Surgical Safety Checklist for Cesarean Delivery- SMFM Special statement

In every surgery, there are myriad opportunities for errors of omission and failures of communication. Surgical safety checklists, such as the one developed by the World Health Organization (WHO), have been shown to reduce serious perioperative complications and death by 30% to 40% when implemented across a wide range of hospital settings. Use of a checklist reduces the chance of neglecting routine items such as antibiotic prophylaxis and sponge, instrument, and needle counts. Pausing to identify the patient and the planned procedure reduces the chances of wrong-patient, wrong-site, or wrong-procedure surgeries and other "Never Events." Performing a checklist during and after surgery enhances communication between team members and gives all participants a chance to speak up if something appears to have been overlooked.

Cesarean delivery is even more complex than other types of surgery because there are two patients (mother and fetus/newborn), each with separate care teams and health and safety considerations. Thus, additional coordination and communication are needed to ensure the safety of both patients.

In this Special Statement, Combs CA & team presented sample operating room surgical safety checklists appropriate for most cesarean deliveries in the United States and other high-resource countries. They also present an alternative checklist for time-critical emergency cesarean deliveries in which there is no time to safely perform the standard checklist and a sample preoperative checklist that can be used before moving the patient to the operating room. Finally, they present some suggestions for the implementation of the checklists at individual facilities.

Sample standard operating room checklists for cesarean delivery are adapted from the WHO surgical safety checklist. Both checklists are divided into three sections representing distinct time points: (1) Briefing occurs before initiation of anesthesia; (2) Time-out occurs before skin incision; and (3) Debriefing occurs after completion of the final counts.

In the larger sample checklist, most items are written as questions for a designated team member to ask other team members. This format is intended to guide providers to double-check each other's work and to encourage dialog. It is also intended to keep all individuals engaged throughout the process. On certain items, the patient and their partner (if present) are asked to participate, thus including them in the safety process. If general anesthesia is to be used or the patient is heavily sedated, the patient will be unable to participate, so other team members will need to check wrist bands against the paperwork and the stated planned procedure.

The smaller sample checklist eliminates the question-answer format and removes some items. This briefer format may be preferred by some facilities.

A sample ancillary checklist is intended to be completed in the preoperative area before moving the patient to the operating room. These steps are often completed by a single nurse rather than an entire team, so the items are not phrased as questions but rather presented as a simple task list. In many hospitals, the items on this checklist are scattered across various formats, including paper forms, electronic health records, tablet computer applications, and fetal heart monitoring systems.

In a small percentage of cases, a time-critical emergency necessitates that surgery must start without delay. In such cases, there is no time to complete the preoperative checklist or the standard cesarean surgical safety checklist. To minimize the chances of omitting key items, authors presented a sample checklist for emergency cesarean deliveries. This checklist assigns tasks to the labor and delivery (L&D) or circulating nurse to complete as time permits, minimizing the burden on the surgeon and anesthesiologist. The checklist is intended to "catch up" on items that may have been overlooked because the Briefing and Timeout sections of the standard cesarean checklist were not performed. In most cases, the emergency will have been resolved by the time of closing; therefore, authors recommend performing the full Debriefing section of the standard cesarean checklist in addition to a few items unique to emergency cases (eg, x-ray to rule out retained materials and a reminder to place sequential compression devices postoperatively to prevent venous thromboembolism).

Each checklist is designed using common checklist design principles, such as non-serif typeface with upper case and lower case letters, black text on a white background, avoidance of color, and inclusion of a version date. A key principle is including only those items that are likely to be overlooked. Thus, they did not include such items as gowning and gloving of the operating personnel, placement of bladder catheter, antiseptic skin preparation, and patient draping.

Suggestions for Implementation:

How a facility implements a surgical safety checklist is critical to its success. Studies demonstrating reduced morbidity and mortality with the use of a surgical safety checklist included detailed implementation programs involving extensive staff engagement and education.

A recent review concluded that the implementation of a surgical safety checklist is "a complex and challenging process that requires effective leadership, clear delegation of responsibilities from each professional, collaboration between team members, and institutional support".

Helpful general guidance on the implementation of checklists and other quality and safety projects is given in documents by the American College of Obstetricians and Gynecologists, the Society for Maternal-Fetal Medicine and the Council for Patient Safety in Women's Healthcare.

"The first step in the implementation of a surgical checklist is to assemble a team of relevant stakeholders. The team should be led by clinical "champions" who have a passion for the project and can communicate the rationale for the checklists and roll-out process. We recommend that both a nurse and a physician champion be engaged in the cesarean delivery checklists because nurses and physicians will perform the checklist together. Additional members of the team should include obstetricians (surgeons), L&D nurses, anesthesiologists, other operating room personnel, a neonatologist, a neonatal nurse, and a representative from the hospital's administration. An expert in the hospital information system should be included if the team wishes to incorporate one or more of the checklists into the electronic health record (EHR). In teaching hospitals, residents and fellows should be included. Including a patient advocate may help the team better understand the patient perspective."

The implementation team must first consider whether to introduce dedicated cesarean delivery checklists or use a nonspecific surgical safety checklist such as the WHO checklist. If dedicated checklists are chosen, the team must decide whether to use a question-answer format, a brief format or a hybrid format incorporating elements from both. The choice of format should seek to achieve a balance between completeness and usability. Whatever format is chosen, each facility should be encouraged to adopt a single cesarean delivery operating room checklist to ensure uniformity among providers, not two different checklists.

The team should next consider where the checklists will be physically located. Authors envision the standard cesarean delivery checklist as a wall chart posted in the operating rooms on the L&D unit, the preoperative checklist as a paper form in the patient chart, and the emergency checklist as a laminated sheet to be kept in a convenient location in the operating room where it can be retrieved as needed. Individual hospitals may customize how these materials are used and where they are kept. Hospitals may also choose whether to store the checklists as part of a patient's medical record or use them only as cognitive aids to ensure that all the tasks are done.

Extensive customization of checklist items is encouraged. SMFM does not consider that the mere inclusion of an item on our sample checklists makes that item mandatory. Teams should feel free to add, delete, or substitute items as needed to be consistent with their local practice.

Several items that should already be completed during the Briefing are repeated in the Time-out section on both checklists. These include identification of the patient and planned procedures, hemorrhage risk assessment, and blood product availability. Authors assume that only the anesthesiologist and L&D nurse will perform the Briefing, whereas the Time-out requires the presence of the entire operating team. Some hospitals may require the presence of the surgeon during the Briefing portion, in which case they can remove the redundant items from the Time-out portion.

Once the team has decided on the items to include on their checklists, they should test the usability and feasibility by conducting "table read" dry runs with roles acted out by appropriate personnel on the team. Once the team is satisfied, a few more dry runs should be done involving personnel not on the team. These rehearsals will teach the team how easy or difficult it is for people with minimal training to use the materials. If there are "sticking points" where users are not clear about the intent of an item or the action required, the wording of the checklist item should be modified to clarify the issue. After these preliminary tests, the revised materials can be put into production.

In preparation for a "go-live" start, educational notices and announcements should be made to all personnel who will use the checklists, including obstetricians, nurses, anesthesiologists, other operating room personnel, neonatologists, and nursery staff. Appropriate venues for such notices can include department meetings, staff meetings, grand rounds, in-service training sessions, and e-mail "blasts." Authors recommend at least one announcement a few weeks in advance with a clearly stated start date and a follow-up announcement on the day before the "go-live" date.

After the "go-live" date, the team should listen carefully to all feedback received and must be open to making changes as needed. Any barriers to usage need to be identified and promptly addressed. The team should reconvene soon after the implementation and consider whether any modifications are needed immediately. Thereafter, the champions should remain engaged and encourage feedback from all users. The team may need to meet periodically to evaluate whether there have been any changes to the standard of care that would require updating the checklists. When a checklist is revised, the version date should be revised, and all older versions should be discarded.

Attention to these implementation steps should increase engagement of all users and increase the rate of utilization, thereby improving the rate of completion of the many critical steps that contribute to safe cesarean surgery.

Source: Patient Safety and Quality Committee, Society for Maternal-Fetal Medicine, Combs CA, Einerson BD, Toner LE, SMFM Special Statement: Surgical Safety Checklists for Cesarean Delivery, American Journal of Obstetrics and Gynecology (2021),

doi: https://doi.org/10.1016/ j.ajog.2021.07.011.