5Surgical Considerations in Pregnancy ThromboembolismAnemiaAspirationHypoxiaHemorrhageTwo Patients
6Cesarean Section Education Video 10/3/2013The Cesarean SectionCesarean Section Education Video
7Skin incision is made, then the subcutaneous (sub-q) tissue down to the fascia is incised.
8Cutting through rectus fascia (in this case, with cautery)Separating Abdominal muscles withfingers
9Opening the peritoneum Stretching the Abdominal Wall
10Uterine incision is made Amniotic membranes are rupturedUterine incisionis stretched laterally
11Surgeon reaches in to identify and lift the presenting part out of uterus through the abdominal incision
12Head is delivered by hand 10/3/2013Head is delivered by handKiwi can and is used in OR as well as vaginal births.or, by vacuum assistance
13The 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.
14Removal of placenta and amniotic membranes Exploration of uterus to insure completeRemoval of tissueUterine incision is closed in one or two layers
15Fascia is closedSkin is closed with suture, staples, or glue
17Wound 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
18Readings:Nunny, R. (2008) Providing perioperative care for pregnant women. Nursing Standard, 22(47),
19The Boven Birth Center Operating Room 10/3/2013The Boven Birth Center Operating RoomTo provide a safe, clean environment for obstetric surgical patients and hospital personnelWhat is our goal
20Culture of Safety Origin of Governing Documents 10/3/2013Origin of Governing DocumentsHolland Hospital PoliciesAssociation of periOperative RegisteredNurses (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
21Operating Room Suite Divided into three designated areas. Determined by the activities that takeplace in each areaUnrestrictedSemi-restrictedRestricted
22Unrestricted All areas where street clothes may be worn. Area where surgical and non-surgical personnel interface
23Semi-restricted: Scrub attire and caps are required. Storage of clean and sterile supplies and instrumentsCorridors leading to restricted area
24Restricted Surgical procedures are performed and sterile items are stored.All areas where scrub attire, caps, and masks are required and traffic is limited.Restricted
26Readings: Preparation and Maintenance of BBC Operating Room 22.214.171.124 Preparation and Maintenance of the Operating room EnvironmentRecommended Practices for Traffic Patterns in the Perioperative Practice Setting.Holland Hospital Policies and ProceduresAORN Perioperative Standards and Recommended Practices
28Sterile Team Members(Scrubbed) Primary SurgeonAssistant SurgeonScrub TechnicianNon-Sterile Team MembersCirculatorAnesthesiologistInfant NurseInfant Provider
29Scrub Technician: Preparing the Sterile Field Selecting appropriate instruments and suppliesScrubbing, donning gown and glovesMaintaining integrity and sterility of the sterilefieldKnowledge of the procedure and anticipationof the surgeon’s needs
30Providing instruments, sutures, and supplies to the surgeon Preparing sterile dressingsImplementing procedures that contribute to patient safetyCleaning and preparing instruments for sterilization(Spry, 2009, p.7)
31Circulating Nurse Managing and implementing activities outside the sterile fieldEmotional support to patient prior to and duringinduction of anesthesiaPerforming ongoing patient assessmentDocumenting patient careObtaining appropriate surgical supplies andequipment
32Creating and maintaining a safe environment Administering medications Implementing and enforcing policies and procedures that contribute to patient safetyPreparing and disposing of specimensCommunicating relevant information(Spry, 2009, p. 7)
33Culture of Safety: What is it? 10/3/2013Culture of Safety: What is it?ReportingFlexibleLearningWaryJustReporting: 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.
34Surgical Conscience: “An inner commitment to adhere strictly to aseptic practice, and to correct any violation,whether or not anyone else is present or observesthe violation“(Spry, 2009, p.101)
3510/3/2013You 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.
36Readings: Responsibilities of the Circulating Nurse 126.96.36.199 Surgical Assistants in the Operative Room/ Boven Birth CenterGuidance Statement: Creating a Patient Safety CultureHolland Hospital PoliciesAORN Perioperative Standards and Recommended Practices
38Pathogenic Microorganisms: Microorganisms that cause diseaseCan you name a few?MRSAE-ColiPseudomonasStrep
39Sources of Infection Endogenous: From the patient’s own body 10/3/2013Sources of InfectionEndogenous: From the patient’s own bodyExogenous: Outside the bodyNosocomial Infections: Hospital Acquired Infections (HAI)1 in 20 patientsSurgical Site Infections (SSI)1-3 in 100 patientsFrom 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 nurseriesAccording 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?
41External Factors-presence of others MovementTalkingAttendanceSecurity
42Surgical attire Laundered by facility-approved laundry service Replaced daily or when soiledLoose fitting tops are tucked inNon-scrubbed personnel – long jackets buttonedor closed.**Personal clothing that extends beyond the neck orsleeves of the scrub attire are not worn.**
43What Else? Doors kept closed Personnel kept to a minimum 10/3/2013What Else?Doors kept closedPersonnel kept to a minimumRoom is Cleaned before, during, and after casesTrash 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.
45Readings: Traffic Patterns in the Operating Room 188.8.131.52 Cesarean section, Personnel in AttendanceRecommended Practices (RP) for Traffic Patterns in the Perioperative Practice SettingRP for prevention of Transmissible Infections in the Perioperative Practice SettingHolland Hospital PoliciesAORN Perioperative Standards and Recommended Practices
46Hand Hygiene The single most important step in the prevention of infection
47The Targets: Microorganisms Transient : Accumulate during activities of the day.Found on the surface of handsResident : More permanent dwellers. Found in thedeeper layers.
48Methods: Hand Washing Antiseptic Hand Wash Antiseptic Hand Rub Surgical Hand AntisepsisWashing with soap and water for at least15 secondsHand wash performed with a productIntended to decrease the resident andtransient floraAn alcohol containing agent which is appliedto the hands to decrease the resident andtransient floraWash or rub performed before surgery toeliminate transient microorganisms andsignificantly reduce resident organisms.
49Condition and cleanliness: Natural fingernails: < ¼ inch longNo rings, watches, or other jewelry up to elbows.Free of damage
51Readings: Surgical Scrub Attire and Hand Hygiene 10.1.181 RP for Hand Hygiene in the Perioperative SettingHolland Hospital PoliciesAORN Perioperative Standards and Recommended Practices
52Aseptic PracticeThe practices by which contamination from microorganisms is prevented( Spry, 2009, p. 95)
53Aseptic: The absence of all disease causing microorganisms.Synonym: Sterile
54Modes of Contamination: Airborne: Transmitted through the airsmall particlesDroplet: Sneezing, Talking, Coughingslightly larger particlesContact: TouchingDirect: Touching infected patientIndirect: Touching something in contact withPatient
55Methods to Prevent Contamination Surgical AttirePersonal Protective Equipment(PPE)
56Principles of Asepsis Scrubbed persons function within a sterile field Sterile drapes are used to create a sterile fieldAll items used within a sterile field must be sterileAll items introduced onto a sterile field should beopened, dispensed, and transferred by methodsthat maintain sterility and integrity.
57Continued. . .5. A sterile field should be maintained and monitoredconstantly6. All personnel moving within or around a sterilefield should do so in a manner to maintain the sterilefield7. Policies and procedures for maintaining a sterile fieldshould be written, reviewed annually, and readilyavailable within the practice setting.
59Readings: Surgical Scrub Attire and Hand Hygiene 10.1.181 Recommended Practices for Surgical AttireHolland Hospital PoliciesAORN Perioperative Standards and Recommended Practices
60Sterile TechniqueThe 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”
61Basic: More Advanced: Clean scrub attire Surgical Head Covers Personal Protective EquipmentMore Advanced:Sterile GownsSterile GlovesCreating and Maintaining a Sterile Field
62Sterile drapes, gowns, and gloves are intended to create a barrier
63Are your gowns, gloves, and supplies free from damage??? 10/3/2013Visually inspect your surgical drapes, gowns, gloves, and supplies before using them!!Are your gowns, gloves, and suppliesfree from damage???
65Neckline Axillary regions Shoulders Are ALL Unsterile Sleeve cuffs Are Unsterile onceHands have passedthroughGown is consideredsterile from the chestto the level of the sterilefieldGown sleeves are sterilefrom two inches abovethe elbow to the cuffNecklineAxillary regionsShouldersAre ALL Unsterile
66Gloving yourself orGloving another. . .It’s all going to take some timeI recommend Practice,Practice, Practice!!!
67Sterile Field: : The area . . . surrounding a body site that has been prepared for an invasive procedurecovered by sterile drapes or sterile attire.working areasFurniturePersonnel
80Introduction of team members □ Yes All: PREPROCEDURECHECK-INSIGN-INTIME-OUTSIGN-OUTIn Holding AreaBefore Induction of AnesthesiaBefore Skin IncisionBefore the Patient Leaves the Operating RoomPatient/patient representativeactively confirms with Registered Nurse (RN):RN and anesthesia care provider confirm:Initiated by designated team memberAll other activities to be suspended (unless a life-threatening emergency)RN confirms:Identity □ YesProcedure and procedure site □ YesConsent(s) □ YesSite marked □ Yes □ N/A by person performing the procedureRN confirms presence of:History and physical □ YesPreanesthesia assessment □ YesDiagnostic and radiologic test results □ Yes □ N/ABlood products □ Yes □ N/AAny 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/ANormothermia measures (SCIP) □ Yes □ N/AN/AConfirmation of: identity, procedure, procedure site and consent(s) □ YesSite marked □ Yes □ N/A by person performing the procedurePatient allergies □ Yes □ N/ADifficult airway or aspiration risk?□ No□ Yes (preparation confirmed)Risk of blood loss (> 500 ml)□ Yes □ N/A# of units available ______Anesthesia safety check completed□ YesBriefing:All members of the team have discussed care plan and addressed concernsIntroduction of team members □ YesAll:Confirmation of the following: identity, procedure, incision site, consent(s) □ YesSite is marked and visible □ Yes □ N/ARelevant images properly labeled and displayed □ Yes □ N/AAny equipment concerns?Anticipated Critical EventsSurgeon:States the following:□ critical or nonroutine steps□ case duration□ anticipated blood lossAnesthesia 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 procedureCompletion of sponge, sharp, and instrument counts □ Yes □ N/ASpecimens identified and labeled □ Yes □ N/AAny equipment problems to be addressed? □ Yes □ N/ATo all team members:What are the key concerns for recovery and management of this patient?__________________________________________________________________ _________________________________ _________________________________ _________________________________ _________________________________April 2010
98Surgical Counts Purpose: To prevent retained surgical items (RSI) in patients undergoing surgical or other invasiveprocedures.RSIs are “Never Events”They should NEVER happen!
99Primary responsibility of the RN circulator and theperioperative teamPromptStandardizedDocumentedDeliberate
100What needs to be counted? Soft GoodsSharpsNeedlesInstruments
101Radiopaque: Visible upon xray. Lap spongesRaytecs or xraysBlue indicates radiopaqueMaterial (xray detectable)
102Procedure: Aloud,concurrently, and visually observed Order of location:Surgical SiteMayo StandBack tableOff the fieldOrder of items:Sponges (as packaged)-xrays and lapsSharps-needles, blades,bovie tipsInstruments
103Soft items that do not contain radiopaque material(white towels,dressings) should never be on thesterile field at any time.
104Readings: Surgical Counts 184.108.40.206 Recommended Practices for Prevention of Retained Surgical ItemsHolland Hospital PolicyAORN Perioperative Standards and Recommended Practices
105Thanks 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!
106References: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.