Beth Kalkman, BSN, RNC-OB
• Skeletal
• Gastrointestinal
• Reproductive
• Respiratory
• Circulatory
• Nervous
• Genitourinary
• Thromboembolism
• Anemia
• Aspiration
• Hypoxia
• Hemorrhage
• Two Patients
Cesarean Section Education Video
Skin incision is made, then the subcutaneous (sub-q) tissue
down to the fascia is incised.
Cutting through rectus fascia
(in this case, with cautery)
Separating Abdominal muscles with
fingers
Opening the peritoneum
Stretching the Abdominal Wall
Uterine incision is made
Amniotic membranes are ruptured
Uterine incision
is stretched laterally
Surgeon reaches in to identify and lift the presenting
part out of uterus through the abdominal incision
Head is delivered by hand
or, by vacuum assistance
The trunk and lower extremities follow. After the
cord is clamped, the baby is suctioned and handed to
the newborn team. Collection of the cord blood
sample follows.
Removal of placenta and amniotic membranes
Exploration of uterus to insure complete
Removal of tissue
Uterine incision is closed in one or two
layers
Fascia is closed
Skin is closed with suture,
staples, or glue




Class I: Clean wound: Gastrointestinal (GI),
genitourinary(GU), or respiratory track is
not entered.
Class II: Clean contaminated: The GI, GU, or
respiratory track is entered under
planned, controlled means.
Class III: Contaminated Wound: Gross
contamination is present but obvious
infection is not present.
Class IV: Dirty or infected: old traumatic wound
with dead tissue or an infection process is
present

Nunny, R. (2008) Providing perioperative care for
pregnant women. Nursing Standard, 22(47),
40-44.

To provide a safe, clean environment
for obstetric surgical patients and
hospital personnel
Origin of Governing Documents
• Holland Hospital Policies
• Association of periOperative Registered
Nurses (AORN)
• Association of Women’s Health, Obstetric,
and Neonatal Nursing (AWHONN)
• Association of Surgical Technologists (AST)
Culture of Safety
Operating Room Suite
Divided into three designated areas.
Determined by the activities that take
place in each area
• Unrestricted
• Semi-restricted
• Restricted
Unrestricted
• All areas where street clothes
may be worn.
• Area where surgical and nonsurgical personnel interface
Semi-restricted:
• Scrub attire and caps are required.
• Storage of clean and sterile supplies
and instruments
• Corridors leading to restricted area
Restricted
• Surgical procedures are performed
and sterile items are stored.
• All areas where scrub attire, caps,
and masks are required and traffic
is limited.
Semi-restricted
Semi-restricted
Semi-restricted
Unrestricted
Restricted

Preparation and
Maintenance of BBC
Operating Room
25.2.5.6

Preparation and
Maintenance of the
Operating room
Environment 25.8.4.21
Holland Hospital Policies
and Procedures

Recommended
Practices for Traffic
Patterns in the
Perioperative Practice
Setting.
AORN Perioperative Standards
and Recommended Practices
• Sterile Team Members(Scrubbed)
• Primary Surgeon
• Assistant Surgeon
• Scrub Technician
• Non-Sterile Team Members
•
•
•
•
Circulator
Anesthesiologist
Infant Nurse
Infant Provider
• Preparing the Sterile Field
• Selecting appropriate instruments and supplies
• Scrubbing, donning gown and gloves
• Maintaining integrity and sterility of the sterile
field
• Knowledge of the procedure and anticipation
of the surgeon’s needs
• Providing instruments, sutures, and
supplies to the surgeon
• Preparing sterile dressings
• Implementing procedures that contribute
to patient safety
• Cleaning and preparing instruments for
sterilization
(Spry, 2009, p.7)
• Managing and implementing activities outside
the sterile field
• Emotional support to patient prior to and during
induction of anesthesia
• Performing ongoing patient assessment
• Documenting patient care
• Obtaining appropriate surgical supplies and
equipment
• Creating and maintaining a safe environment
• Administering medications
• Implementing and enforcing policies and
procedures that contribute to patient safety
• Preparing and disposing of specimens
• Communicating relevant information
(Spry, 2009, p. 7)
Culture of Safety: What is it?
• Reporting
• Flexible
• Learning
• Wary
• Just
It’s about Caring,
It’s about the Patient.
Surgical Conscience:
“An inner commitment to adhere strictly to
aseptic practice, and to correct any violation,
whether or not anyone else is present or observes
the violation“
(Spry, 2009, p.101)
You are a team!!!!

Responsibilities of the
Circulating Nurse
25.8.4.7

Surgical Assistants in
the Operative Room/
Boven Birth Center

Guidance Statement:
Creating a Patient
Safety Culture
25.8.4.38
Holland Hospital Policies
AORN Perioperative Standards
and Recommended Practices
Microorganisms that cause disease
Can you name a few?
• MRSA
• E-Coli
• Pseudomonas
• Strep
Sources of Infection
• Endogenous: From the patient’s own body
• Exogenous: Outside the body
Nosocomial Infections: Hospital Acquired Infections (HAI)
• 1 in 20 patients
Surgical Site Infections (SSI)
• 1-3 in 100 patients
The Patient-Internal Factors
• Lifestyle Choices
• Nutritional Status
• Age
• Existing Disease
• Acute Illness
External Factors-presence
of others
• Movement
• Talking
• Attendance
• Security
Surgical attire
• Laundered by facility-approved laundry service
• Replaced daily or when soiled
• Loose fitting tops are tucked in
• Non-scrubbed personnel – long jackets buttoned
or closed.
**Personal clothing that extends beyond the neck or
sleeves of the scrub attire are not worn.**
What Else?
• Doors kept closed
• Personnel kept to a minimum
• Room is Cleaned before, during, and after
cases
Personal Protective Equipment

Traffic Patterns in the
Operating Room

25.8.4.32

Cesarean section,
Personnel in
Attendance 25.2.1.5
Holland Hospital Policies

Recommended Practices
(RP) for Traffic Patterns in
the Perioperative Practice
Setting
RP for prevention of
Transmissible Infections
in the Perioperative
Practice Setting
AORN Perioperative Standards
and Recommended Practices
The single most important step
in the prevention of infection
The Targets: Microorganisms
Transient : Accumulate during activities of the day.
Found on the surface of hands
Resident : More permanent dwellers. Found in the
deeper layers.
Methods:
• Hand Washing
Washing with soap and water for at least
15 seconds
• Antiseptic Hand Wash
Hand wash performed with a product
Intended to decrease the resident and
transient flora
• Antiseptic Hand Rub
An alcohol containing agent which is applied
to the hands to decrease the resident and
transient flora
• Surgical Hand Antisepsis Wash or rub performed before surgery to
eliminate transient microorganisms and
significantly reduce resident organisms.
Condition and cleanliness:
• Natural fingernails: < ¼ inch long
• No rings, watches, or other jewelry
up to elbows.
• Free of damage
Performing the Surgical Hand Scrub

Surgical Scrub Attire
and Hand Hygiene
10.1.181
Holland Hospital Policies

RP for Hand Hygiene in
the Perioperative
Setting
AORN Perioperative Standards
and Recommended Practices

The practices by which contamination
from microorganisms is prevented
( Spry, 2009, p. 95)
Aseptic: The absence of all disease
causing microorganisms.
Synonym:
Sterile
Modes of Contamination:
• Airborne: Transmitted through the air
small particles
• Droplet: Sneezing, Talking, Coughing
slightly larger particles
• Contact: Touching
• Direct: Touching infected patient
• Indirect: Touching something in contact with
Patient
Methods to Prevent
Contamination
• Surgical Attire
• Personal Protective Equipment
(PPE)
Principles of Asepsis
1. Scrubbed persons function within a sterile
field
2. Sterile drapes are used to create a sterile field
3. All items used within a sterile field must be sterile
4. All items introduced onto a sterile field should be
opened, dispensed, and transferred by methods
that maintain sterility and integrity.
Continued. . .
5. A sterile field should be maintained and monitored
constantly
6. All personnel moving within or around a sterile
field should do so in a manner to maintain the sterile
field
7. Policies and procedures for maintaining a sterile field
should be written, reviewed annually, and readily
available within the practice setting.
Maintaining the Sterile Field

Surgical Scrub Attire
and Hand Hygiene
10.1.181
Holland Hospital Policies

Recommended
Practices for Surgical
Attire
AORN Perioperative Standards
and Recommended Practices
The use of specific actions and activities
to prevent contamination and maintain
sterility of identified areas during
operative or other invasive procedures
“First, do no harm”
Basic:
• Clean scrub attire
• Surgical Head Covers
• Personal Protective Equipment
More Advanced:
• Sterile Gowns
• Sterile Gloves
• Creating and Maintaining a Sterile Field
Sterile drapes, gowns, and gloves
are intended to create a barrier
Are your gowns, gloves, and supplies
free from damage???
Sterile Gowning and Gloving
Sleeve cuffs
Are Unsterile once
Hands have passed
through
Gown is considered
sterile from the chest
to the level of the sterile
field
Gown sleeves are sterile
from two inches above
the elbow to the cuff
Neckline
Axillary regions
Shoulders
Are ALL Unsterile
Gloving yourself or
Gloving another. . .
It’s all going to take some time
I recommend Practice,
Practice, Practice!!!
Sterile Field:
:
The area . . . surrounding a body site that
has been prepared for an invasive procedure
covered by sterile drapes or sterile attire.
• working areas
• Furniture
• Personnel
Preparing the Sterile Field

Surgical Draping
25.8.4.10
Holland Hospital Policies

Recommended
Practices for Sterile
Technique
AORN Perioperative Standards
and Recommended Practices
Goal:
Reduce the risk of post operative surgical
site infection
• Removing debris, soil, and transient microorganisms
• Reduce resident microbial count
• Inhibit rapid rebound growth of microorganisms
Hair Removal
Research indicates that preoperative shaving
increases the risk of surgical site infections
**Patients should be instructed NOT to shave surgical
site the day before or day of surgery**
So, what are our options?
• With Clippers
• Only at the operative site
• Outside of the OR
• Only if necessary
Antisepsis:
The prevention of sepsis
by preventing or inhibiting the growth of
resident and transient microbes
Basics of Skin Preparation
For our patients:
Umbilicus is cleaned
with cotton-tipped
applicator

Skin Preparation of
Patients 25.8.1.23
Holland Hospital Policies

Recommended
Practices for
Preoperative patient
skin antisepsis
AORN Perioperative Standards
and Recommended Practices
PREPROCEDURE
SIGN-IN
TIME-OUT
SIGN-OUT
CHECK-IN
In Holding Area
Before Induction of Anesthesia
Before Skin Incision
Before the Patient Leaves the Operating Room
Patient/patient representative
actively confirms with Registered Nurse
(RN):
RN and anesthesia care provider confirm:
Initiated by designated team member
RN confirms:
Identity □ Yes
Procedure and procedure site □ Yes
Consent(s) □ Yes
Site marked □ Yes
□ N/A
by person performing the procedure
Confirmation of: identity, procedure,
procedure site and consent(s) □ Yes
Site marked □ Yes □ N/A
by person performing the procedure
All other activities to be suspended (unless a lifethreatening emergency)
Patient allergies □ Yes □ N/A
RN confirms presence of:
History and physical □ Yes
Preanesthesia assessment
□ Yes
Diagnostic and radiologic test results □
Yes
□ N/A
Blood products
□ Yes
□ N/A
Any special equipment, devices, implants
□ Yes
□
Include in Preprocedure check-in as per
institutional custom:
Beta blocker medication given (SCIP) □
Yes
□ N/A
Venous
thromboembolism prophylaxis ordered
(SCIP) □Yes
□ N/A
Normothermia measures (SCIP) □ Yes
□ N/A
N/A
Difficult airway or aspiration risk?
□ No
□ Yes (preparation confirmed)
Risk of blood loss (> 500 ml)
□ Yes □ N/A
# of units available ______
Anesthesia safety check completed
□ Yes
Briefing:
All members of the team have discussed
care plan and addressed concerns
□ Yes
Introduction of team members □ Yes
All:
Confirmation of the following: identity,
procedure, incision site, consent(s)
□ Yes
Site is marked and visible □ Yes
□ N/A
Relevant images properly labeled and
displayed □ Yes
□ N/A
Any equipment concerns?
Anticipated Critical Events
Surgeon:
States the following:
□ critical or nonroutine steps
□ case duration
□ anticipated blood loss
Anesthesia Provider:
□ Antibiotic prophylaxis within one hour
before incision □ Yes
□ N/A
□ Additional concerns?
Scrub and circulating nurse:
□ Sterilization indicators have been
confirmed
□ Additional concerns?
Name of operative procedure
Completion of sponge, sharp, and instrument
counts □ Yes
□ N/A
Specimens identified and labeled
□ Yes
□ N/A
Any equipment problems to be addressed? □ Yes
□ N/A
To all team members:
What are the key concerns for recovery and
management of this patient?
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April 2010
Caution!!!!!
Our Prepping agents are flammable
until completely dry
Place the dispersive pad as close to surgical
site as possible to surgical site
• Dry, clear (hairless) skin
• Well-vascularized
• Once placed, do not lift and re-place.


Electrosurgery 25.8.4.11
Surgical Fire Prevention
and Fire Response

Recommended
Practices for
Electrosurgery
25.8.4.37
Holland Hospital Policies
AORN Perioperative Standards
and Recommended Practices
BBC C-Section Instruments
Routine Instruments
Stat Instruments
2
4
2
2
4
2
2
4
6
1
1
1
2
2
1
2
4
2
2
1
1
1
1
1
Long Sponge Sticks
Short Sponge Sticks
Towel Clamps
Towel Clips
Babcock Forceps
Allis Forceps
Kocker Forceps
Crile Forceps
Kelly Forceps
Needle Holder
Short Needle Holder
Straight Scissors
Large Richardson Retractors
Small Richardson Retractors
DeLee Retractor
Knife Handles
Short Sponge Sticks
Kocker Forceps
Crile Forceps
Needle Holder
Straight Scissors
Curved Mayo Scissors
Curved Metenbaum Scissors
Bandage Scissors
Forceps
2 Adsons with Teeth
2 Toothed Forceps
1 Russian Forceps
1 Singley Bowel Forceps
1 Smooth Forceps
1 Debakey Forceps
1 Ferris Smith
60
Sponge Sticks ( Also known as
Ringed Forceps)
2 - Long
8 - Short
Towel Clamps(2)
Towel Clips(2)
Babcock (4)
Allis (2)
Kockers (4)
Crile and Kelly
Hemostats(4 of
each)
Scissors
Bandage
Curved Mayo
Straight Mayo (2)
Curved Metzenbaum
Forceps (Also known as Pick-ups)
Adson with Teeth (2)
Toothed Forceps (2)
Russian Forceps
Singley Bowel Forceps
Smooth Forceps
Debakey Forceps
Ferris Smith
Retractors
Richardsons
Large (2)
Small (2)
Delee
And Two Knife Handles
Purpose: To prevent retained surgical items (RSI)
in patients undergoing surgical or other invasive
procedures.
RSIs are “Never Events”
They should NEVER happen!
Primary responsibility of the
RN circulator and the
perioperative team
• Prompt
• Standardized
• Documented
• Deliberate
What needs to be counted?
• Soft Goods
• Sharps
• Needles
• Instruments
Radiopaque: Visible upon
xray.
Lap sponges
Raytecs or xrays
Blue indicates radiopaque
Material (xray detectable)
Procedure: Aloud,concurrently,
and visually observed
Order of location:
• Surgical Site
• Mayo Stand
• Back table
• Off the field
Order of items:
• Sponges (as packaged)
-xrays and laps
• Sharps
-needles, blades,
bovie tips
• Instruments
Soft items that do not contain
radiopaque material(white towels,
dressings) should never be on the
sterile field at any time.

Surgical Counts 25.8.4.8
Holland Hospital Policy

Recommended
Practices for Prevention
of Retained Surgical
Items
AORN Perioperative Standards
and Recommended Practices
You have the foundational
knowledge to start perfecting
your hands-on role in providing
great care to our patients!
Association of Women’s Health, Obstetric, and Neonatal Nurses
(AWHONN). (2011). Perioperative care of the pregnant woman.
Washington, DC: Author.
Association of periOperative Registered Nurses (AORN). (2012).
Perioperative standards and recommended practices (2012 ed.).
Denver, CO: AORN.
Nunney, R. (2008). Providing perioperative care for pregnant women.
Nursing Standard, 22(47), 40-44.
Spry, C. (2009). Essentials of perioperative nursing (4th ed.).
New York, NY: Jones and Bartlett.