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Boven Birth Center Cesarean Section Orientation
Beth Kalkman, BSN, RNC-OB
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Overview of Cesarean Section and Perioperative Considerations for the Pregnant Woman
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Anatomy and Physiology of Later Pregnancy
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System Involvement Skeletal Gastrointestinal Reproductive Respiratory
Circulatory Nervous Genitourinary
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Surgical Considerations in Pregnancy
Thromboembolism Anemia Aspiration Hypoxia Hemorrhage Two Patients
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Cesarean Section Education Video
10/3/2013 The Cesarean Section Cesarean Section Education Video
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Skin incision is made, then the subcutaneous (sub-q) tissue
down to the fascia is incised.
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Cutting through rectus fascia
(in this case, with cautery) Separating Abdominal muscles with fingers
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Opening the peritoneum
Stretching the Abdominal Wall
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Uterine incision is made
Amniotic membranes are ruptured Uterine incision is stretched laterally
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Surgeon reaches in to identify and lift the presenting
part out of uterus through the abdominal incision
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Head is delivered by hand
10/3/2013 Head is delivered by hand Kiwi can and is used in OR as well as vaginal births. or, by vacuum assistance
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The trunk and lower extremities follow
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.
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Removal of placenta and amniotic membranes
Exploration of uterus to insure complete Removal of tissue Uterine incision is closed in one or two layers
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Fascia is closed Skin is closed with suture, staples, or glue
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Family is Transferred to Recovery
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Wound Classification System
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
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Readings: Nunny, R. (2008) Providing perioperative care for pregnant women. Nursing Standard, 22(47),
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The Boven Birth Center Operating Room
10/3/2013 The Boven Birth Center Operating Room To provide a safe, clean environment for obstetric surgical patients and hospital personnel What is our goal
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Culture of Safety Origin of Governing Documents
10/3/2013 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) To that end, we need to abide by It’s about creating a culture of safety. Culture of Safety
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Operating Room Suite Divided into three designated areas.
Determined by the activities that take place in each area Unrestricted Semi-restricted Restricted
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Unrestricted All areas where street clothes may be worn.
Area where surgical and non-surgical personnel interface
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Semi-restricted: Scrub attire and caps are required.
Storage of clean and sterile supplies and instruments Corridors leading to restricted area
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Restricted Surgical procedures are performed
and sterile items are stored. All areas where scrub attire, caps, and masks are required and traffic is limited. Restricted
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Semi-restricted Restricted Unrestricted Semi-restricted Semi-restricted
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Readings: Preparation and Maintenance of BBC Operating Room 25.2.5.6
Preparation and Maintenance of the Operating room Environment Recommended Practices for Traffic Patterns in the Perioperative Practice Setting. Holland Hospital Policies and Procedures AORN Perioperative Standards and Recommended Practices
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Roles and Responsibilities of the Surgical Team
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Sterile Team Members(Scrubbed)
Primary Surgeon Assistant Surgeon Scrub Technician Non-Sterile Team Members Circulator Anesthesiologist Infant Nurse Infant Provider
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Scrub Technician: 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
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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)
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Circulating Nurse 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
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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)
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Culture of Safety: What is it?
10/3/2013 Culture of Safety: What is it? Reporting Flexible Learning Wary Just Reporting: Speak up. Discuss “errors and near misses.” Flexible: Speed up. Can’t just say, “we never did it that way before.” “be aware that practices will change as ebp evolves.” We practice based on what we know to be best practice currently knowing that things could change. Learning: Seek knowledge. Be inquisitive. Wary: Expect the unexpected. Be alert. Just: Not blaming. Accountability to acceptable and unacceptable behavior. Knowing what to do and choosing not to do it is different than not knowing right from wrong to begin with. Jean Watson’s Theory on Human Caring. It’s about Caring, It’s about the Patient.
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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)
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10/3/2013 You are a team!!!! What does being a team mean? Trust needs to be established. Credibility of every team member ( each person knowing what they are doing and why). Helpful and supportive. Friendly and open relationship.
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Readings: 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 Holland Hospital Policies AORN Perioperative Standards and Recommended Practices
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Infection Control in the Perioperative Setting
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Pathogenic Microorganisms:
Microorganisms that cause disease Can you name a few? MRSA E-Coli Pseudomonas Strep
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Sources of Infection Endogenous: From the patient’s own body
10/3/2013 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 From the CDC: In 2002, the estimated number of HAIs in U.S. hospitals, adjusted to include federal facilities, was approximately 1.7 million: 33,269 HAIs among newborns in high-risk nurseries; 19,059 among newborns in well-baby nurseries According to Spry (2009), Most SSIs develop from the patient’s own flora—or bacteria from her own skin. However, if left alone and in their own environment, the bacteria don’t cause infection. So what changed things?
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The Patient-Internal Factors
Lifestyle Choices Nutritional Status Age Existing Disease Acute Illness
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External Factors-presence of others
Movement Talking Attendance Security
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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.**
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What Else? Doors kept closed Personnel kept to a minimum
10/3/2013 What Else? Doors kept closed Personnel kept to a minimum Room is Cleaned before, during, and after cases Trash double bagged, soiled instruments contained and removed. OR suite cleaned with bactericidal disinfecting agent, damp dusting, damp mopping, clearn sponge buckets and plastic inserts replaced. Walls, doors, and lights may need to be wiped down. Special Note: During cases, if a spill occurs: it gets cleaned immediately without disrupting the case.
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Personal Protective Equipment
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Readings: Traffic Patterns in the Operating Room 25.8.4.32
Cesarean section, Personnel in Attendance Recommended Practices (RP) for Traffic Patterns in the Perioperative Practice Setting RP for prevention of Transmissible Infections in the Perioperative Practice Setting Holland Hospital Policies AORN Perioperative Standards and Recommended Practices
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Hand Hygiene The single most important step
in the prevention of infection
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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.
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Methods: Hand Washing Antiseptic Hand Wash Antiseptic Hand Rub
Surgical Hand Antisepsis Washing with soap and water for at least 15 seconds Hand wash performed with a product Intended to decrease the resident and transient flora An alcohol containing agent which is applied to the hands to decrease the resident and transient flora Wash or rub performed before surgery to eliminate transient microorganisms and significantly reduce resident organisms.
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Condition and cleanliness:
Natural fingernails: < ¼ inch long No rings, watches, or other jewelry up to elbows. Free of damage
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Performing the Surgical Hand Scrub
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Readings: Surgical Scrub Attire and Hand Hygiene 10.1.181
RP for Hand Hygiene in the Perioperative Setting Holland Hospital Policies AORN Perioperative Standards and Recommended Practices
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Aseptic Practice The practices by which contamination from microorganisms is prevented ( Spry, 2009, p. 95)
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Aseptic: The absence of all disease
causing microorganisms. Synonym: Sterile
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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
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Methods to Prevent Contamination
Surgical Attire Personal Protective Equipment (PPE)
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Principles of Asepsis Scrubbed persons function within a sterile field
Sterile drapes are used to create a sterile field All items used within a sterile field must be sterile All items introduced onto a sterile field should be opened, dispensed, and transferred by methods that maintain sterility and integrity.
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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.
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Maintaining the Sterile Field
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Readings: Surgical Scrub Attire and Hand Hygiene 10.1.181
Recommended Practices for Surgical Attire Holland Hospital Policies AORN Perioperative Standards and Recommended Practices
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Sterile Technique 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”
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Basic: More Advanced: Clean scrub attire Surgical Head Covers
Personal Protective Equipment More Advanced: Sterile Gowns Sterile Gloves Creating and Maintaining a Sterile Field
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Sterile drapes, gowns, and gloves
are intended to create a barrier
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Are your gowns, gloves, and supplies free from damage???
10/3/2013 Visually inspect your surgical drapes, gowns, gloves, and supplies before using them!! Are your gowns, gloves, and supplies free from damage???
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Sterile Gowning and Gloving
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Neckline Axillary regions Shoulders Are ALL Unsterile 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
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Gloving yourself or Gloving another. . . It’s all going to take some time I recommend Practice, Practice, Practice!!!
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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
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Preparing the Sterile Field
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Readings: Surgical Draping 25.8.4.10
Recommended Practices for Sterile Technique Holland Hospital Policies AORN Perioperative Standards and Recommended Practices
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Pre-operative Skin Preparation
10/3/2013 Pre-operative Skin Preparation
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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
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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**
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So, what are our options? With Clippers Only at the operative site
Outside of the OR Only if necessary
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Antisepsis: The prevention of sepsis
by preventing or inhibiting the growth of resident and transient microbes
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Basics of Skin Preparation
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For our patients: Umbilicus is cleaned with cotton-tipped applicator
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Readings: Skin Preparation of Patients 25.8.1.23
Recommended Practices for Preoperative patient skin antisepsis Holland Hospital Policies AORN Perioperative Standards and Recommended Practices
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Safety in the Operating Room
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Surgical Time Out
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Introduction of team members □ Yes All:
PREPROCEDURE CHECK-IN SIGN-IN TIME-OUT SIGN-OUT 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 All other activities to be suspended (unless a life-threatening emergency) RN confirms: Identity □ Yes Procedure and procedure site □ Yes Consent(s) □ Yes Site marked □ Yes □ N/A by person performing the procedure 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 Confirmation of: identity, procedure, procedure site and consent(s) □ Yes Site marked □ Yes □ N/A by person performing the procedure Patient allergies □ Yes □ 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 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? _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ April 2010
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Fire
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Our Prepping agents are flammable
Caution!!!!! Our Prepping agents are flammable until completely dry
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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.
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Readings: Electrosurgery 25.8.4.11
Surgical Fire Prevention and Fire Response Recommended Practices for Electrosurgery Holland Hospital Policies AORN Perioperative Standards and Recommended Practices
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Instrumentation and Surgical Counts
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60 BBC C-Section Instruments Routine Instruments 2 Long Sponge Sticks
4 Short Sponge Sticks 2 Towel Clamps 2 Towel Clips 4 Babcock Forceps 2 Allis Forceps 2 Kocker Forceps 4 Crile Forceps 6 Kelly Forceps 1 Needle Holder 1 Short Needle Holder 1 Straight Scissors 2 Large Richardson Retractors 2 Small Richardson Retractors 1 DeLee Retractor 2 Knife Handles Stat Instruments 4 Short Sponge Sticks 2 Kocker Forceps 2 Crile Forceps 1 Needle Holder 1 Straight Scissors 1 Curved Mayo Scissors 1 Curved Metenbaum Scissors 1 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
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Sponge Sticks ( Also known as Ringed Forceps)
2 - Long 8 - Short
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Towel Clamps(2) Towel Clips(2)
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Babcock (4) Allis (2)
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Kockers (4) Crile and Kelly Hemostats(4 of each)
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Scissors Bandage Straight Mayo (2) Curved Mayo Curved Metzenbaum
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Forceps (Also known as Pick-ups)
Adson with Teeth (2) Toothed Forceps (2)
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Russian Forceps Singley Bowel Forceps Smooth Forceps
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Debakey Forceps Ferris Smith
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Retractors Richardsons Large (2) Small (2) Delee
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And Two Knife Handles
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Surgical Counts Purpose: To prevent retained surgical items (RSI)
in patients undergoing surgical or other invasive procedures. RSIs are “Never Events” They should NEVER happen!
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Primary responsibility of the
RN circulator and the perioperative team Prompt Standardized Documented Deliberate
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What needs to be counted?
Soft Goods Sharps Needles Instruments
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Radiopaque: Visible upon xray.
Lap sponges Raytecs or xrays Blue indicates radiopaque Material (xray detectable)
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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
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Soft items that do not contain
radiopaque material(white towels, dressings) should never be on the sterile field at any time.
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Readings: Surgical Counts 25.8.4.8
Recommended Practices for Prevention of Retained Surgical Items Holland Hospital Policy AORN Perioperative Standards and Recommended Practices
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Thanks for participating in the Cesarean Section Orientation!
You have the foundational knowledge to start perfecting your hands-on role in providing great care to our patients!
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References: 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), Spry, C. (2009). Essentials of perioperative nursing (4th ed.). New York, NY: Jones and Bartlett.
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