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Cesarean Section: Circulating Nurse

  Procedure for the circulating nurse

Preoperative

  1. Perform hand hygiene.
  2. Verify the patient's identity using two patient identifiers in accordance with institutional policy.
  3. If possible, have the support person accompany the patient to the OR and remain close to her. If the support person is unavailable, the circulator will need to provide emotional support to the patient as appropriate.
  4. Inform the patient of what is happening and provide support.
  5. Assist with placement of regional anesthesia as indicated.
  6. Perform hand hygiene, position the patient for placement of an indwelling catheter, open the catheter kit, and apply sterile gloves.
  7. Insert the indwelling catheter and position the drain tube of the indwelling catheter under the patient's leg. If a catheter is already in place, confirm its patency and the color and amount of urine currently in the drainage bag, then place the bag near the head of the table for the anesthesiologist to continue monitoring.
  8. Gather the used catheterization kit and discard it in the appropriate receptacle. Remove gloves and discard in appropriate receptacle. Perform hand hygiene.
  9. Apply antiembolism stockings or SCDs per institutional policy.
  10. Position the patient supine on the operating table with a roll under the right hip or the bed tilted to the left, cover the lower extremities and upper torso with blankets (warmed, if possible), and apply a safety strap across the patient's upper thighs. Confirm that bony prominences are cushioned.
  11. Connect the dispersive pad (grounding pad) for the electrocautery device as close to the surgical site as possible, avoiding bony prominences. (This is usually the anterior thigh area.) If excess hair is noticed in the area, remove it before placing the pad.
  12. Place the padding around the area of skin to be prepared for incision to prevent the pooling of solutions under the patient. This padding should be removed after preparation is complete and before sterile drapes are applied.
  13. Perform surgical counts of sponges, sharps, and instruments per institutional policy and procedure and AORN. A count is conducted before the start of the procedure and before closure of the uterus, peritoneum, and skin incision. A count is also performed when a change in surgical staff takes place.
  14. Use wide tape to hold excess abdominal fat (pannus) upward, pulling it away from the area of the skin incision, if applicable.
  15. Perform hand hygiene, open the abdominal preparation kit, and apply clean or sterile gloves, as indicated. (Many institutions are now using chlorhexidine gluconate solutions that come in prepared sponge sticks that do not require sterile gloves for application.)
  16. Perform a sterile abdominal skin preparation with preparation solution per institutional policy after determining whether the patient has any allergies to preparation solution. An abdominal scrub is performed just before sterile draping. The direction of the scrub is circular, from the center of the operative area outward and from the pubic area downward to each upper thigh.
  17. Remove gloves and discard in proper trash receptacle. Perform hand hygiene.
  18. Continue to monitor FHR until abdominal sterile preparation has been started or, if internal fetal monitoring is being used, until abdominal preparation is complete. Notify the practitioner if the FHR falls below 100 BPM.

Intraoperative

  1. Call or participate in a "time out" before initiating an invasive procedure in accordance with institutional policy.
  2. After the surgeon drapes the patient for surgery, connect the suction tubing from the operating field to a suction canister and check for proper function.
  3. Connect the electrocautery dispersive pad (grounding pad) and electrocautery pen to the electrocautery machine and adjust the settings per practitioner and institutional policy.
  4. Call for the neonatal resuscitation team/team member if he or she is not already present.
  5. Call for the support person if he or she is not already in the room.
  6. If the practitioner requests a vacuum extractor or forceps, have this equipment in the room and place it onto the sterile field per sterile technique.
  7. Record times of delivery for the infant and the placenta.
  8. Remove gloves and discard in proper trash receptacle. Perform hand hygiene and apply clean gloves.
  9. Label specimens obtained (e.g., placenta, fallopian tube segments, umbilical cord blood, arterial or venous umbilical cord blood for gases), per institutional policy, in the presence of the patient after patient identification. If bilateral tubal ligation is performed during the cesarean section, collect the segments of the right and left tubes in different containers and label them correctly.
  10. Set aside specimens on the appropriate dirty field for delivery to the laboratory after the procedure has been completed or call for staff to take specimens requiring immediate delivery to the lab (e.g., blood gases).
  11. Remove gloves and discard in proper trash receptacle. Perform hand hygiene and apply clean gloves.
  12. Add additional sponges, sharps, and instruments to the operating field as requested. Count additions with the scrub person and add them to the count sheet.
  13. Bring any medications, irrigation fluids, or surgical supplies that are requested to operating field, using sterile technique.
  14. Monitor conditions in the OR. Any break in sterile technique must be reported and corrected.
  15. Perform surgical counts of sponges, sharps, and instruments per institutional policy before closure of the uterus, peritoneum, and skin incision. A count is also conducted when a change in surgical staff takes place.
  16. Notify the practitioner immediately if the surgical count is not correct.
  17. Remove gloves and discard in proper trash receptacle. Perform hand hygiene and apply clean gloves.

Post Operative

  1. If the support person is not allowed or chooses not to be present, the nurse should stay in communication with him or her and deliver progress reports when possible.
  2. Verify whether the infant is being transferred to the nursery or will remain with the patient to be cared for in a family-centered environment.
  3. After wound closure, provide the necessary dressings and assist the anesthesia provider during emergence if the patient was under a general anesthetic.
  4. Remove the grounding pad and check for skin integrity.
  5. Assist in massaging the uterine fundus and cleaning the patient before moving her safely to a bed or stretcher with the use of a roller or transfer device.
  6. Remove gloves and discard in proper trash receptacle. Perform hand hygiene and apply clean gloves.
  7. Alert the nurses caring for the patient after surgery in the PACU.
  8. Accompany the patient to the postanesthesia recovery area. Once in the PACU, the perioperative nurse reports patient status and surgical outcomes to the perianesthesia nurse.
  9. Remove gloves and discard in proper trash receptacle. Perform hand hygiene.
  10. Document the procedure in the patient's record.
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