Surgical Considerations in Pregnancy Surgical Considerations in Pregnancy 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),
To provide a safe, clean environment for obstetric surgical patients and hospital personnel
Origin of Governing Documents Association of periOperative Registered Nurses (AORN) Association of Women’s Health, Obstetric, and Neonatal Nursing (AWHONN) Holland Hospital Policies Culture of Safety Association of Surgical Technologists (AST)
Divided into three designated areas. Determined by the activities that take place in each area Operating Room Suite Unrestricted Semi-restricted Restricted
Unrestricted All areas where street clothes may be worn. Area where surgical and non- surgical personnel interface
Scrub attire and caps are required. Semi-restricted: Storage of clean and sterile supplies and instruments Corridors leading to restricted area
Surgical procedures are performed and sterile items are stored. All areas where scrub attire, caps, and masks are required and traffic is limited. Restricted
Holland Hospital Policies and Procedures Preparation and Maintenance of BBC Operating Room Preparation and Maintenance of the Operating room Environment AORN Perioperative Standards and Recommended Practices Recommended Practices for Traffic Patterns in the Perioperative Practice Setting.
Sterile Team Members(Scrubbed) Primary Surgeon Assistant Surgeon Scrub Technician Non-Sterile Team Members Circulator Anesthesiologist Infant Nurse Infant Provider
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
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)
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
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!!!!
Holland Hospital Policies Responsibilities of the Circulating Nurse Surgical Assistants in the Operative Room/ Boven Birth Center AORN Perioperative Standards and Recommended Practices Guidance Statement: Creating a Patient Safety Culture
Pathogenic Microorganisms: Pathogenic Microorganisms: Microorganisms that cause disease Can you name a few? MRSA E-Coli Pseudomonas Strep
Sources of Infection Nosocomial Infections: Hospital Acquired Infections (HAI) 1 in 20 patients Surgical Site Infections (SSI) 1-3 in 100 patients Endogenous: From the patient’s own body Exogenous: Outside the body
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.**
Doors kept closed Personnel kept to a minimum Room is Cleaned before, during, and after cases What Else?
Personal Protective Equipment
Holland Hospital Policies Traffic Patterns in the Operating Room Cesarean section, Personnel in Attendance AORN Perioperative Standards and Recommended Practices Recommended Practices (RP) for Traffic Patterns in the Perioperative Practice Setting RP for prevention of Transmissible Infections in the Perioperative Practice Setting
The single most important step in the prevention of infection
Transient : Accumulate during activities of the day. Found on the surface of hands Resident : More permanent dwellers. Found in the deeper layers. The Targets: Microorganisms
Hand Washing Antiseptic Hand Wash Antiseptic Hand Rub Surgical Hand Antisepsis Methods: 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.
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
Holland Hospital Policies Surgical Scrub Attire and Hand Hygiene AORN Perioperative Standards and Recommended Practices RP for Hand Hygiene in the Perioperative Setting
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.
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. Continued...
Maintaining the Sterile Field
Holland Hospital Policies Surgical Scrub Attire and Hand Hygiene AORN Perioperative Standards and Recommended Practices Recommended Practices for Surgical Attire
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 sleeves are sterile from two inches above the elbow to the cuff Gown is considered sterile from the chest to the level of the sterile field 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
Holland Hospital Policies Surgical Draping AORN Perioperative Standards and Recommended Practices Recommended Practices for Sterile Technique
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**
With Clippers Only at the operative site Outside of the OR Only if necessary So, what are our options?
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
Holland Hospital Policies Skin Preparation of Patients AORN Perioperative Standards and Recommended Practices Recommended Practices for Preoperative patient skin antisepsis
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 □ 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? _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ 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.
Holland Hospital Policies Electrosurgery Surgical Fire Prevention and Fire Response AORN Perioperative Standards and Recommended Practices Recommended Practices for Electrosurgery
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 BBC C-Section Instruments 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)
Retractors Large (2) Small (2) Richardsons 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. Blue indicates radiopaque Material (xray detectable) Raytecs or xrays Lap sponges
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.
Holland Hospital Policy Surgical Counts AORN Perioperative Standards and Recommended Practices Recommended Practices for Prevention of Retained Surgical Items
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), Spry, C. (2009). Essentials of perioperative nursing (4th ed.). New York, NY: Jones and Bartlett.