Checklist for Hysteroscopy and D&C

The pdf form of the Checklist for Hysteroscopy and D&C may not contain the latest changes below.

Preoperative Checklist
(Please indicate   - Done,   X - Not done,   NA – Not applicable)


 * 1) ____ Inform patient about possible complications, cervical laceration, uterine perforation, bleeding, infection, inability to visualize, heart failure due to fluid overload,  thermal energy problems, interruption of pregnancy, and the need for further surgery or treatment to address any complications (prevent unrealistic expectations)
 * 2) ____ Test for pregnancy preoperatively within 48 hours of surgery in any reproductive age woman (prevent interrupting an intrauterine pregnancy)
 * 3) ____ Avoid procedures in the luteal phase of menses in women without sterilization or using effective contraception (prevent interrupting an intrauterine pregnancy)
 * 4) ____ Preoperatively, culture for G.C. and Chlamydia if any discolored cervical mucous (prevent infection)

Intraoperative Checklist

 * 1) ____ Check weighted speculum and other instruments for excessive heat (prevent thermal injury)
 * 2) ____ Determine version and flexion position of the uterus (prevent uterine perforation)
 * 3) ____ Do not sound uterus until after endometrium is visualized (prevent inability to visualize)
 * 4) ____ Use graduated dilatators to dilate cervix to internal uterine os to size of hysteroscope or curette (prevent cervical lacerations)
 * 5) ____ Avoid contaminating intrauterine instruments with vaginal blood and secretions (prevent infection)
 * 6) ____ Place downward traction on cervical tenaculum to straighten out cervical-uterine axis (prevent uterine perforation)
 * 7) ____ Avoid excess downward traction on cervical tenaculum (prevent cervical lacerations)
 * 8) ____ Introduce instruments into the uterus in the midline sagittal plane (prevent excessive bleeding from lateral lacerations)
 * 9) ____ Avoid excessive cephalad pressure with dilator or hysteroscope or other instruments (prevent uterine perforation)
 * 10) ____ If instrument penetration is suspicious for uterine perforation, discontinue procedure (prevent bowel, bladder or omental injury)
 * 11) ____ Visualize endometrium when inserting hysteroscope into the uterine cavity so as not to disturb the endometrium (prevent inability to visualize endometrium)
 * 12) ____ Maintain intrauterine pressure of distension media at or below the patient’s mean arterial pressure (prevent cardiac overload)
 * 13) ____ Keep track of distension fluid used and returned to be less than 250 ml discrepancy (prevent cardiac overload)
 * 14) ____ Keep procedure less than 45 minutes if possible (prevent cardiac overload)
 * 15) ____ Use instruments for ablation according to manufacturers’ instructions (avoid thermal injury)
 * 16) ____ Check tenaculum site on cervix after removal (prevent excessive bleeding)

Signature: _________________________ Attending:_____________________ Date:______

Global Evaluation: |Initial learning|       |Needs work|       |Progressing|      |Good for level|        |OK on own|