Ref: 1252 November 2010

WHO Surgical Safety Checklist:

for maternity cases ONLY
(adapted from the WHO Surgical Safety Checklist)

SIGN IN (to be said out loud after TIME OUT (to be said out loud SIGN OUT (to be said out loud
the arrival of the woman and the before skin incision) before the woman leaves theatre)
midwife)
Has the woman confirmed her identity, Have all team members introduced Practitioner verbally confirms with the team:
procedure and consent? themselves by name and role? Has the name of the procedure and any
additional procedures been recorded?
Caesarean section category? 1 2 3 4 What is the woman’s name?
Has it been confirmed that instruments, swabs
Obstetrician: and sharps counts are correct?
Is the anaesthetic machine and medication
check complete? What additional procedure(s) are planned? Have specimens been labelled?
Are there any critical or unusual steps you want Has blood loss been recorded?
Does the woman have a known allergy? the team to know about?
Obstetrician, Anaesthetist, Midwife:
Are there any conerns about the placental site?
Is there a difficult airway risk? Have the key concerns for recovery and
Anaesthetist: management been discussed?
Are blood products available? Are there any specific concerns? Has post-operative VTE prophylaxis been
prescribed?
Has the appropriate/recent antacid prophylaxis Scrub practitioner:
been given? Have antibiotics been given?
Has the sterility of the instruments been
confirmed? Anaesthetist and theatre team:
Is the resuscitaire checked and ready?
Are there any equipment issues or concerns? Have any equipment problems been identified
Has the neonatal team been called, if needed? that need to be addressed?
Midwife:
Are cord blood samples needed? Midwife:
Is the urinary catheter draining? Has the baby/babies been labelled?
Has the FSE been removed? Have relevant cord bloods been taken, if
PATIENT DETAILS Has VTE prophylaxis been undertaken?
relevant?
Have cord gases been recorded, if required?
Last name:

First name:

Date of birth:
The checklist is for
NHS Number:
maternity cases only www.nrls.npsa.nhs.uk/alerts
Date of procedure:
This modified checklist must not be used for
*If the NHS Number is not immediately available, a temporary number should be used until it is other surgical procedures.

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