Perimortem Cesarean Delivery Protocol Checklist Form
Clinical checklist for emergency perimortem cesarean delivery: readiness, decision, timing, and execution steps.
Date and time of maternal cardiac arrest
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Patient gestational age (weeks)
*
Team leader identified and present
*
Yes
No
Decision to proceed with perimortem cesarean delivery documented
*
Yes
No
Time from arrest to incision (minutes)
*
Incision performed
*
Yes
No
Uterine entry achieved
*
Yes
No
Fetus delivered
*
Yes
No
Maternal resuscitation continued throughout procedure
*
Yes
No
Checklist completed and reviewed by team leader
*
Checklist reviewed and acknowledged
Submit Checklist
Should be Empty: