Brief Summary of Closing Tray Process for Cesarean Section 1. Opening and Closing trays are opened and counted at the beginning of the case. 2. The Closing tray set up and gowns/gloves for the changeover are aseptically covered and set aside. 3. The case proceeds as usual until the uterus and or peritoneum is closed. Final, full instrument, lap and sharp counts are done. 4. Everyone at the OR table steps away as the light handles are removed, cautery tip and suction tips removed and unplugged. 5. Gowns and gloves are aseptically removed, with new sterile gowns and gloves aseptically donned. 6. A new drape is applied to the surgical field, with new light handles, cautery, and suction if needed. New, sterile, pre-counted closing instruments are moved to the field and the case proceeds from this point as usual.
Opening Process prior to case start: 1. Hand hygiene, Apply mask 2. Place dry good kits, and instrument trays on tables/stands (outlined in fig 1-6) 3. Open OB Dry goods pack on main large OR table (fig 1, 9, 15) Fig 1 Large Table Mayo for gown, then opening instruments Fig 2 Mayo for Sterile Closing instrum ents Fig 3 Case Cart that new sterile instruments were brought into room in and dirty instruments will leave in: Gowns and Gloves for change over here. Fig 4 Ring Standopen inst Fig 5 Ring Stand - Basin 4. Open the OB Closing Dry Pack on the case Cart (fig 4, 11) (Leave the cover drape on this as your gowns and gloves for closing will end up here) 5. Place Basin in ring stand, and open. (fig 5) 6. Place and open sterile scrub gown here with gloves for this person. (fig 2, 12) 7. Open all other packs as outlined above. (fig 14) 8. Scrub per standard; re-enter OR. 9. Don sterile gown and gloves from Mayo stand in (Fig 2) 10. Prep large table (fig 15) A. Move sterile instrument tray from ring stand (fig5) to Large Table (fig 1) B. Push aside ring stand (fig 5) 11. Apply mayo cover to Mayo stand (fig 2) 12. Set Sterile instrument tray for closing on Mayo in (fig 2) 13. Apply Mayo stand cover and Sterile towels to closing Mayo stand. (Fig 3) 14. Closing instrument tray moved and set up on the mayo stand (the metal tray can be used to hold the instruments or it may be set up as pictured) (fig 3, 12) Fig 6 15. Opening instrument tray will be opened and set up on OR table and mayo stand as usual (fig 2, 16) 16. Sutures up to and including the peritoneum will be opened onto the opening table or dropped into the basin, but then placed on the opening table. (fig 15) 17. Sutures will be placed on the Closing Mayo table for the fascia through skin. (fig 17) 18. Set up all other equipment and instrumentation as preferred. 19. Place smallest Basin from basin set on the closing Mayo stand for fundal/uterine lochia expression. (fig17) 20. Leave gowns on case cart with Sterile pack sheet as barrier, from the closing dry pack. (fig 14, 19) Set gloves for Assist, LPN/tech, and surgeon on ring stand next to gowns. Since the order of people coming to be regowned is unpredictable, just lay them out so they are reachable. Also keep the sterile towels here for those with damp hands. (Fig, 21)
21. The initial count for the opening and closing instruments will be completed. This should be led by the Scrub/Tech/LPN and Circulator as a CONCURRENT count. 22. The closing table/tray/stand will be covered with a sterile Drapes/towels, and placed out of the way of traffic. (fig 19, 20) 23. Closing Table is moved aside into a location contamination likely will not occur. Segregate closing items where they can be observed, but not contaminated. 24. Team Briefing during TIME OUT (fig 28) 25. The case/surgical procedure will proceed as usual. If a tubal is to be performed this occurs prior to utilization of the closing tray. 26. Tech/LPN Announce closing UTERUS COUNT Once the first Uterine suture line is done, the cavity is closed and therefore a count or final count may occur. 27. After the Uterus is closed: the Tech, Assist, Circulator and Surgeon will: a. Complete Uterus closing count if not already done, tubal will be completed at this point if needed. Final Count will be at Uterus or peritoneum, whichever occurs last. (fig 25) b. Full Instrument, Lap and Sharp count after Peritoneum if closed. (if not closed, no count required for this level/layer) This will be a full and complete instrument count. (fig 25) c. Blot surgical incision site dry d. Move the Operative Table (opening instrument table) aside e. Remove Light handles f. Remove Cautery Tip and place in sharps per standard, cord and set up optional at this point. (it will be covered by drapes) g. Remove Suction tip per standard, tubing optional at this point. h. Circulator remove cover from gowns, gloves and drape case cart. (fig 20, 21) i. Remove Gown and Gloves Aseptically (to do this, circulator may grab gown at shoulder and pull to tear back, or Surgeon, Tech, Assist may cross arms in front of themselves and pull down on the shoulders or pull at the waist, to pull the gown away from their arms and skin) j. Re-gown always k. Re-glove always (Hand hygiene only if contaminated) If aseptic technique is broken, then that person needs to go out and re-scrub in. (Ensure Sterile towels are available with the gowns and gloves for providers/techs who have moist/damp hands.) l. Circulator, scrub or assist may remove the Cover Drapes from Mayo stand. m. Circulator to assist with Gown backs, and spinning. n. Circulator Ensure all laps from the OR table are in the Lap bag for final counts. (fig 23) o. Circulator Turn the Count bag holder now for the closing tray laps. (Fig 23) p. Re-drape surgical field, directly over opening drapes. Replace light handles. q. Bring the Closing table/mayo stand to the patient r. Recount if needed s. Circulator Be sure you take ALL laps from the Opening sterile field and complete the lap bags. 28. New Cautery CIRCULATOR- Plug in the new Cautery. Plug in new suction if needed. 29. Place clear tube tape over the wires/tubes to prevent falling/dropping 30. Tech - Replace light handles 31. Complete closure of fascia and skin 32. Lap and Sharp Count after Fascia (fig 25) 33. Final full Closing Instrument Tray, instrument, Lap, Sharp count, at skin closure (fig 25) 34. Remove Ioban Drape, slow and low, supporting incision with Sterile Towel or Lap. 35. Dry the incisional area as needed 36. Apply dressings aseptically, per protocol 37. Team debriefing (includes anesthesia, OR staff, surgeon, PA, students, guests) (counts correct, evaluate process, suggestions, procedure card changes, PPH risk, specimen disposition, QBL, wound class, etc.) (fig 28) 38. RN circulator documents counts per standard and routine. Fig 7, Case cart
Fig 8. Case cart with Sterile instruments, basin and packs in it Fig 10, Mayo Stand with Sterile opening instrument tray Fig 9, Large Table with Sterile Dry Pack on it.
Fig 11, Case Cart with Closing Sterile Pack on it Fig 13, View of tables with pack and instruments on them, ready to open. Fig 12, Ring stands with closing instruments and basin, ready to be opened. Fig 14, View of table with open packs and instruments Fig 15, Large Table set up
Fig 16, Opening Mayo Stand Set up Fig 18, Back work table, lap counter, large basin for laps, and extra ring stand set aside. Fig 17, Closing Mayo Stand Set Up.
Fig 19, Complete Set up, ready for case to begin.
Fig 20, Closing mayo stand, with cover in place Fig 21, Cart with closing gowns and gloves, uncovered
Other changes made in OR: Fig 23, New signage on Lap Bags Fig 22, Count sheets adjusted Fig 24, Opening and closing counts on the white board in the OR:
Fig 25 Counts policy update to match new process. The count layers were added into Op-time as defaults for the cesarean case type. If Peritoneum is not closed, then the circulator simply selects X for that row to remove. Example of Counts if Peritoneum is closed by the Surgeon: Example of Counts if there is NOT Peritoneum closure by Surgeon:
Fig 26 Garbage bag (Bedside) ChloraPrep Mayo stand Cover Table Cover 50X90 Suction Tubing Sterile Towels X4 Sterile Gowns X3 Paper Towels Placenta Basin Cesarean Opening Dry Pack will include: Blades X2 Pencil Cautery Cup - Cord Blood collector Light handles Label Sheet Skin Marker (CHG compatible) Sharps Pad/Needle Counter Pitcher 1200 ml Laps 3 Packs (5ea.) Suction Tip Syringe Bulb Syringe Cord blood vial Plastic Clips Organizer tubing/cord Control Syringe 4-Clamp Crile Curved 5 1/2" 4 4-Clamp Carmalt 4 4-Clamp Kocher Straight 4 2 - Babcock 2 4- Sponge Forceps Short 4 4- Clamp Sponge Forceps 4 Clamps SubTotal 22 1-Fbc Needle Holder Small 1 2-Fbc Needle Holder Mayo-Hegar 7 1/4" 2 2-Fbc Needle Holder 8" may be removed completely 2 2-Fbc Needle Holder Heaney 8" 2 Needle Holder SubTotal 7 1-Fbc Scissor Mayo Straight 6 3/4" 1 1-Fbc Scissor Metz Curved 7" 1 1 Mayo Straight 1 1- Bandage 1 Scissor SubTotal 4 2-Towel Clip Plastic 2 Towel Clip SubTotal 2 Opening Instrument Tray 2-Fbc Forcep Tissue W/Teeth 6" Small 2 1-Forcep Debakey Tissue Medium 1 1-Fbc Forcep Russian Small Fbc Forcep 1 1-Russian Medium Fbc Forcep 1 Forceps SubTotal 5 1-Fbc Retractor Roux Medium #2 1 2-Fbc Retractor Army Navy 2 1-Fbc Retractor Richardson 1 1/2" X 2" Small 1 1-Fbc Retractor Richardson 2 X 2 1/2" 1 Fbc Retractor Richardson 2 1/2" X 3" 1 1-Fbc Retractor Malleable Medium 2" Wide 1 1 DeeLee Retractor missing from count sheet, please add 1 Retractor SubTotal 8 2-Handle Knife #3 Handle SubTotal 2 Time Out Hood Time Out Hood Subtotal 1 Count Sheet 1 Cord Blood Container 1 Suction Tip 1 Cautery tip 1
Fig 27 Sterile Gowns X3 Sterile Mayo Table cover Sterile Towels X4 (1 pack) Pediatric Laparotomy Drape with adhesive Laps 1 (5) Pack Sharps Pad Cesarean Closing Dry Pack will include: Pencil Cautery Light handles Plastic Garbage bag Tube Cord Organizer (to help hold the cords/cautery in place) Bedside Bag (plastic) Cesarean Closing Instrument Tray: 4-Clamp Crile Curved 5.5 4 4-Clamp Carmalt 2 4-Clamp Kocher 2 Clamps SubTotal 8 2-FBC Needle Holder Heaney 8 1-Fbc Needle Holder Small 2-FBC Needle Holder Mayo-Hagar 8 Needle Holder SubTotal 5 1-Scissor Mayo Straight 6.75 1-Scissor Metz Curved 7 Scissor SubTotal 2 1-Towel Clip Plastic Towel Clip SubTotal 1 2-Forcep Tissue w/teeth 6 small 1 1-Forcep Russian Small 1 1 Bickle (AKA Ferris-Smith) 1 1-Forcep Russian Med 1 Forceps SubTotal 4 1-Retractor Roux Medium 1 2-Retractor Army/Navy 2 1-Retractor Richardson 1.5X2 1 1-Retractor Richardson 2.5X3 1 Retractor Retractor SubTotal 5 1-500cc Metal Graduate Needs to be ordered/added into the tray Graduate Graduate SubTotal 1 Metal basin Basin Basin SubTotal 1 Count Sheet 1 Cautery Tip Cautery SubTotal 1 Suction Tip 1
Fig 28
Fig 28 Cont.
Fig 29, Education provided to Nursing Circulators: Uterus Defining Layers of the Abdominal Cavity: From inside to out
Peritoneum Fascia = Fascia, deep Thin connective tissue covering or separating the muscles and internal organs of the body. 1= Fascia Layer (inferior and superior) Rectus Muscle Closure 1= Rectus Muscle 2=Peritoneum Layer 1= Uterus 2= Fascia
Fascia is nearly closed Subcutaneous 2= Skin 1=