PAS Check List

Multi-Disciplinary Team

Maternal mortality and morbidity are reduced when women with PAS deliver in a tertiary care hospital with a multidisciplinary care team present who have experience in managing the risks and challenges presented by PAS.

• Silver, R.M., et al., Center of excellence for placenta accreta. Am J Obstet Gynecol, 2015. 212(5): p. 561-8.

A typical MDT may include;

• Imaging expert (fetal medicine specialist and/or radiologist)

• Experienced obstetrician (often maternal-fetal medicine specialist)

• Anaesthesiologist with expertise in complex obstetric cases

• Surgeon experienced with complex pelvic surgery (often a gynaecological oncologist)

• Urologist (with experience of open urological surgery especially ureteric re-implantation)

• Neonatologist

• Interventional Radiologist*

* Although the SAC technique does not routinely use of prophylactic balloon occlusion, the availability of embolization in the event of massive haemorrhage remains important.

In many centres, the members of the team meet before the planned surgery and discuss the plan for the particular woman. The minutes of the MDT are then circulated to the MDT and all those involved in the case (e.g. cell salvage and theatre teams) as it forms the basis of the surgical plan (see below).

Example Surgical plan

A detailed plan for the surgery should be circulated to the entire team several days before the surgery is scheduled. This contains a step by step guide to the intended plan of management on the day including type of incision, and intended management strategy (surgical or conservative). It is generated on a case by case basis and includes any extra steps specific to the patient (e.g. plan to have bowel surgeon present to divide pre-existing bowel adhesions).

The surgical plan also has all the extra equipment that might be needed listed on it and a checklist for all the standard equipment (e.g. Wertheim's tray, ureteric slings, magnetic instrument tray) to help the scrub staff to ensure everything required is ready on the day of surgery. This is then filed in the patient notes as a record of the MDT process.

Pre-surgery team briefing (WHO meeting)

All members of the team introduce themselves and their designated role. The clinical details of the case should be summarised and presented by the team leader on the morning of surgery. The anaesthetic, operating, theatre, cell salvage and midwifery teams should re-cap their management plans and are given the opportunity to confirm availability of all required equipment and ask any questions.

In addition, we also routinely use a 0-degree laparoscope and stack to facilitate the safe and aseptic intra-operative recording of each procedure. This used for both documentation and educational purposes.

The 'Helicopter'

An important additional role within a PAS team is that of the ‘Helicopter’. This is a senior member of the obstetric team who is regarded as being 'in charge' of the whole theatre team. They do not 'scrub' or take any clinical role in the surgery. The ‘Helicopter’ remains in the theatre at all times and is responsible for:

• Monitoring human factors throughout the procedure including maintaining situational awareness throughout the case.

• Ensuring good communication between all members of the team at all times.

• Checking and reporting to the operating team the estimated PV loss at regular intervals following delivery of baby.

• Ensuring there is no theatre overcrowding.

• They are responsible for all escalation to the relevant teams should intra-operative assistance be required.

Closed Theatre

Only staff with a designated role in the surgery are allowed in theatre and a maximum of 2 observers (usually trainees) who need to obtain permission to attend in advance of the case. Such strict measure are taken as an infection control measure and to avoid over-crowding as the delivery itself is routinely performed under epidural anaesthesia with the woman awake.

‘Theatre cruising’ (in and out during the procedure) should be strictly forbidden for everyone no matter how senior they are.