Surgical Privileges Form: Obstetrics & Gynecology
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1 Surgical Privileges Form: Obstetrics & Gynecology Applicant s Name:. License No. (If Any):... Clinical Privileges Request Scope of Practice:. Facility:.. Date:... Privileges Requested (To be completed by the applicant) Recommended (For committee use) Under Supervision Independent Not Recommended (For committee use) OUTPATIENT PROCEDURES 1. Colposcopy 2. Vulvoscopy + vaginoscopy 3. LLETZ 4. Insertion of HRT implant 5. Insertion/removal of inplanon/ norplan implants RADIOLOGY PROCEDURES 1. Hycosyexamination LABOR ROOM PROCEDURES 1. Induction/ Augmentation of labour Page 1 of 8
2 2. Artificial rupture of membranes 3. Application of foetal scalp electrode 4. Foetal blood sampling 5. Cord blood collection for stem cell reservation 6. Normal vaginal delivery 7. Forceps/ Vacuum assisted delivery 8. Episiotomy and repair 9. Repair of 1st and 2nd degree tears 10. External cephalic version 11. Breech assisted delivery 12. Breech extraction 13. Twin delivery OPERATING THEATRE PROCEDURES 1. Manual removal of placenta 2. Repair of cervical tear 3. Cervical cerclage procedures 4. Lower segment caesarean section 5. Dilatation and curettage /removal of products of conception 6. Suction evacuation of the uterus 7. Incision/excision of hymen 8. Excision of vulva/vaginal lesions 9. Incision and drainage of vulval abscess/haematoma 10. Marsupialisation + Excision of bartholin Page 2 of 8
3 11. Total abdominal hysterectomy +/-bilateral salpingooophorectomy 12. Oophorectomy/ ovarian cystectomy 13. Salpingectomy 14. Laparotomy and drainage of pelvic abscess 15. Vaginal hysterectomy +/- salpingo-oophorectomy 16. Diagnostic hysteroscopy 17. Diagnostic laproscopy +/- sterilization 18. Anterior vaginal repair 19. Posterior vaginal repair+/- perineorrhapy 20. Repair of enerocoele 21. Robotic Surgery Please specify: GYNAE/OBS PROCEDURES 1. Microwave endometrial ablation 2. Thermachoice endometrial ablation 3. Other endometrial procedure 4. Hysteroscopic resection of fibroids/ septae 5. Manchester repair 6. Tubal reconstruction/ anastomosis 7. Insertion of uterine balloon 8. Repair of 3rd degree tear Page 3 of 8
4 9. Repair of 4th degree tear 10. Caesarean hysterectomy 11. Abdominal cerclage 12. B Lynch Sutures 13. Surgical management of placenta incerta/accreta 14. Repair of ruptured uterus FETO MATERNAL MEDICINE PROCEDURES 1. Transvaginal/abdominal Obstetric ultrasound examination 2. Detailed anomaly scan (level3) 3. Prenatal diagnosis 4. Foetal screening and assessment 5. Amniocentesis 6. Amnio-infusion/reduction 7. Chorionic villus biopsy Assisted reproduction Procedures 1. Prescribing of gonadotrophins 2. Prescribing of Clomiphene citrate 3. Prescribing of GnRH agonists 4. Intra-uterine insemination 5. Oocyte retrieval (transvaginal/ transabdominal/ transurethral) 6. Laproscopic oocyte retrieval or embryo transfer 7. Transvaginal intra-uterine embryo transfer Page 4 of 8
5 8. Transvaginal aspiration of ovarian cysts Laproscopic Procedures 1. Laparoscopic assisted vaginal hysterectomy +/- oophorectomy 2. Laparoscopic oophorectomy or ovarian cystectomy 3. Laparoscopic salpingectomy or salpingostomy 4. Laparoscopic adhesiolysis 5. Laparoscopic ovarian drilling 6. Laparoscopic ablation of endometriosis 7. Laparoscopic vault suspension 8. Laparoscopic uterine suspension 9. Laparoscopic transaction of uterosacral nerve 10. Laparoscopic lymphadenectomy Urogynae procedures 1. Vaginal repairs involving the use of meshes 2. Sarco-spinous fixation 3. Injection of bulking agents/ Botox 4. Sacro-colpopexy Page 5 of 8
6 5. Ventro-suspension (abdominal) 6. Colposuspension 7. Insertion of TVT (tension-free vaginal tape) 8. Insertion of TOT (Transobturator tape placement) 9. Urethral dilatation 10. Cystoscopy 11. Fenton Repair 12. Le fort procedure 13. Vulval/vaginal reconstructive plastic procedures Gynae Oncology Procedures 1. Laser ablation of preinvasive disease of vulva/ vaginal/cervix 2. Radical hysterectomy 3. Radical vulvectomy 4. Pelvic/Para-aortic and groin node dissection 5. Omentectomy 6. Debulking of ovarian malignancy High Risk Privileges It includes high risk procedures, services, administration of high risk drugs and high risk due to the use of instrumentation or the use of implantable medical devices require skills in implementation, calibration and monitoring. Evidence of training must be provided. These are high risk privileges that the physician were able to maintain/ perform the minima number of times required in the past year INVASIVE FETAL DIAGNOSTIC PROCEDURES 1. Fetal reduction 2. Intrauterine fetal blood sampling. Transfusion and insertion of fetal shunts Page 6 of 8
7 Name of Applicant: MAJOR LAPAROSCOPIC SURGICAL PROCEDURES 1. Laparoscopic hysterectomy 2. Laparoscopic myomectopmy 3. Dissection of severe endometriosis including deep pelvic nodules 4. Pelvic lymph node dissection Additional Privileges Notes: If additional privilege(s) are desired, please indicate this in the space provided above. You must submit along with this application all necessary document(s) to support your request. If documentation is incomplete, your request will not be accepted. By signing below, I acknowledge that I have read, understand, and agree to abide by QCHP standards for privileging. I have requested only those privileges for which by education, training, current experience and demonstrated performance I am qualified to perform and wish to exercise, and I understand that: a) In exercising any clinical privileges granted, I am constrained by QCHP's policies and rules applicable generally and any applicable to the particular situation. b) Any restriction on the clinical privileges granted to me is waived in an emergency situation Page 7 of 8
8 and in such situation my actions are governed by the recognized policies and rules... Applicant s signature (Stamp if any) Date Medical Director (of the facility the applicant Date will perform surgeries in) Stamp & Signature For Committee use only Evaluation Committee Chairman: I have reviewed the requested clinical privileges and supporting documentation for the above-named applicant and I have made the above-noted recommendation(s)... Chairperson s Stamp & signature Date Other Committee Members:.. 1) Name Date.. 1) Name Date Page 8 of 8
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