INFANT CIRCUMCISION AND EARPEARCING

1. PRESENTED BY
SAMBO ,NICKY MARIAH
RN,RM,RPON,BNSC,PGDE,MSc

2. 1. Theatre And Labour Room Preparation
2. Use and care of equipment
3. Trays and trolleys for theatre procedures
4. Male circumcision(plastibell and conventional
methods)
5. Ear piercing

3.  Ensure good lightening
 Ensure non slippery floor
 Have a mini autoclave machine
 Have instrument for suturing
episiotomy/destructive procedures
 Have containers for cold sterilization prn
 Have suctioning /oxygen apparatus
 Have charts for both mother and baby
 Have weighing scales for both mother and
baby

4.  2 x Tissue forceps
 4 x Sponge holding forceps
 2 x Allis Tissue Forceps
 2 x Mayo tissue Scissors
 1 x stitch scissors
 10 x Artery Forceps (size 1&2)
 6 x Kelly Forceps 14cm Straight 06
 6 x Kelly Forceps 14cm Curved
 4 x Tissue Dissection Forceps (toothed and non-tooth)
 2 x Needle Holder
 2 x Scalpel Handle #3 and 4
 6 x Green-Armytage Forceps
 1 x Doyen Retractor
 2 x Kelly Retractor
 4 x Backhaus Towel Forceps
 1 x Instrument Tray with cover
 1 large bowl with 2 kidney dishes and 2 gallipots

5.  An experienced team will gather as many
supplies as possible before a C-section.
 Here is a non-exhaustive checklist.
 Anesthesia Team
 Paperwork (records, forms)
 Complete list of pre-calculated drug dosages
 Various syringes and needles
 Various endotracheal tubes
 Laryngoscope
 Spinal pack

6.  Surgical blades
 Scrubbing supplies
 Gauze and lap sponges at least two
 Sterile towels
 Suction (machine, hose and tip) Warm
irrigation fluids
 Towels on the floor to help cleaning up
 Suture material
 Retractor
 Urethrel catheter and urine bag

7.  Neonatal stethoscope
 Neonate sized mask attached to small Ambu bag
 Heating pads
 Oxygen source for babies
 Bulb syringes or “snot sucker”
 Umblical clamp to tie off umbilicus
 Comfy box or laundry basket for the newborns-
Diapers
 Warm towels
 The RM is responsible for cleaning, restocking
and confirming function of the resuscitation
trolley ; O2 cylinders or pipe .

8.  identification bracelet
 Maternal notes
 Yellow antenatal co-operation card
 Delivery details – including time, gender and
admission details.
 The Baby’s own sticker : Baby of ‘Mother’s
Full Name’ Baby’s Date of Birth
 Baby’s APGAR scores and physical
examination

9.  Cleaning,
 Inspection and lubrication
 Disinfecting and
 Sterilising are the three levels of instrument
care

10. 
Cleaning removes dirt, debris and biological
material from surgical instruments. surgical
instruments could be cleaned manually or
mechanically using water and detergents or
an enzymatic cleaner

Particular attention needs to be paid to box
locks, hinges, ratchets and serrations.

11.  Final rinsing with demineralised water is
required.
 then thorough drying.
 The use of tap water / normal Saline will
cause instrument discolouration and staining,
and can also commence the process of
corrosion.
 When cleaning instruments manually, wear
gloves, a plastic apron, eye protection and a
face mask.

12.  Use soft plastic cleaning brushes to scrub the
instruments. Do not use steel wool, wire
brushes or other abrasive materials that could
scratch the finish or dull your instruments. Be
sure to brush out all crevices, teeth and
grooves. Rinse each instrument thoroughly
under running water. Open and close hinged
instruments under running water to
thoroughly rinse.

13. 
Careful inspection is required to ensure
instruments are clean, dry, in good condition
and fit for purpose. If there is any concern
that an instrument will not perform as
expected it should be removed from use and
sent for service.

14. 
To prevent instruments with box locks,
hinges and any moving parts from ”freezing”
they need to be lubricated regularly.. The
lubricant has to be surgical grade and water
soluble. Do NOT use a silicone spray as this
will render the instrument unsterile. Apply
lubricant after cleaning and before sterilizing.

15.  Disinfection can be broken down into three
tiers:
 low level disinfection (LLD),
 Intermediate level disinfection (ILD) and
 High level disinfection (HLD).

16.  LLD eliminates all vegetative bacteria (except
tubercle bacilli), lipid viruses, some non-lipid
viruses and some fungi in less than 10
minutes.

17.  ILD destroys tubercle bacilli, mycobacteria,
lipid enveloped and some non-lipid
enveloped viruses and fungus spores.

18.  In addition to killing these microorganisms,
HLD can also kill bacterial spores, though not
in a high number. The CDC recommends a 90
minute soak at 25°C

19.  Chemical disinfection can be used when
instruments will be damaged by heat. Some
chemicals that may be considered include;
 glutaraldehyde 2% for 20 minutes,
 hydrogen peroxide 6%–7.5% for 20–30 minutes,
 peracetic acid 0.2–0.35% for 5 minutes and
ortho-phthalaldehyde (OPA) for 5–12 minutes.
 Chlorine, (bleach )a fast-acting oxidant, is a
widely available and broad-spectrum chemical
germicide.Solution of sodium hypochlorite
(NaOCl),

20.  Steam sterilization is the best method to sterilize
stainless steel instruments.
 Sterilisation kills all microorganisms and spores.
 Autoclaving (saturated steam under high
pressure) is the most common method for
sterilising surgical instruments
 Dry Heat
Dry heat may also be used to sterilise surgical
instruments. Instruments can be placed in
sterilisation trays before putting them in the oven

25.  Def;Circumcision is the surgical removal of
the prepuse (foreskin), that is covering the
glans of the penis. It is an ancient practice
that has its origin in religious rites. Today,
many parents have their sons circumcised for
religious or other reasons.

26.  Circumcision is performed on the eighth day
 Circumcision might not be an option if
certain blood-clotting disorders are present,
premature babies who still require medical
care in the hospital nursery
 Babies born with abnormalities of the penis.
 Circumcision doesn't affect fertility, nor dose
it enhance or detract from sexual pleasure
for men or their partners

29.  A decreased risk of urinary tract infections .
 A reduced risk of some STDS in men.
 Protection against penile cancer and a reduced
risk of cervical cancer in female sex partners.
 Prevention of balanitis (inflammation of the
glans) and balanoposthitis (inflammation of the
glans and foreskin).
 Prevention of phimosis (the inability to retract the
foreskin) and paraphimosis (the inability to
return the foreskin to its original location).
 Circumcision also makes it easier to keep the end
of the penis clean.

30.  The idea of using a tourniquet approach to
infant circumcision is attributed to Dr Cecil J.
Ross who patented steel circumcision rings in
1939. Subsequently, Dr Kariher patented a
plastic ring with a removable handle in 1955.
 Plastibell comes in a sterile package with a
single ligature

31.  Pain
 Uretheral injury
 Penial amputation
 Bleeding and infection at the site of the
circumcision
 Irritation of the glans
 Increased risk of meatitis (inflammation of
the opening of the penis)
 Risk of injury to the penis

33.  Curved Artery Forcepts ------- 3
 Straight Artery Forcept ------- I
 MCIndoe scissors
 Gauze , plastibell( size 1.1,1.2,1.3,1.4 etc)
 Povidone iodine 10%
 Savlone (centrimed)
 Surgical gloves
 Perinial sheet
 Conventional method need needle holder and
a small suture such as vicryl 3/0

34.  Position
 The patient is placed supine, with the legs
astride to expose the penis.
 Cleaning and draping
 The penis and the immediate surrounding
area is prepped with povidone-iodine and
draped with a perineal sheet.

35.  Two artery forceps are applied on either side
of the preputial opening. A curved artery
forcep lubricated with lignocaine gel, is
introduced to dilate the opening and separate
the adhesions between the glans penis and
the prepuce . The artery forcep is turned
upwards and away from the urethral meatus.
This maneuver avoids the risk of injury to the
urethral meatus

37.  The prepuce is everted. This enables the
gland to be cleaned and any adhesions to be
separated.
 The prepuce is freed right to the corona

38.  After separation of the foreskin from the
glans penis, avoiding the frenulum at 6
O’clock, the strainght artery is then used at
12 O’clock to crush the skin to reduce
bleeding by clamping twice then cut to about
1 CM
 with a groove on its back is slipped between
the glans and the prepuce, an initial dorsal
slit is usually needed to allow the bell to be
placed

41.  The prepuce is pulled slightly forward and
suture material is looped around in the
groove and tied tightly
 The suture cuts off the blood supply to the
prepuce distal to the groove, which withers
and drops off in 7-10 days.

42.  Its main advantage is low risk of bleeding.
 Plastibell is a single-use-only disposable
device, which prevents reuse and potential
transmission of infection. The glans is
protected during the procedure by the ring,
so there is a reduced risk of injury to the
glans
 It is a rapid procedure which can be done
under clean conditions. No bandage is
required, allowing for easy monitoring for
bleeding or infection.

43.  Glans necrosis and failure of the prepuce to
fall-off are the two main complications of this
technique. Inappropriate bell size and not
tight enough suture over the prepuce are the
main cause of these complications.

46.  It's OK to wash the penis as it heals. For
newborns, change the bandage with each
diaper change, and apply a dab of petroleum
jelly to the tip of the penis to keep it from
sticking to the diaper. Change your baby's
diaper often, and make sure the diaper is
loosely fastened.
 If there's a plastic ring instead of a bandage,
it will drop off on its own — usually within
about a week. Once the penis heals, wash it
with soap and water during normal bathing.

47.  Def.-Ear piercing is one of the oldest forms
of body modification. It occurs when holes are
created on the ear lobes or cartilage to allow the
insertion of decorative ornaments, such
as earrings.
 Ear piercing in children has been around for
centuries as part
of ritualistic and cultural traditions, but
continued to become a worldwide
mainstream fashion statement. Its very common
in India, Brazil, Nigeria and Hispanic countries.

48.  Spots other than the conventional ear lobe
are not meant for piercing during childhood
 Therefore, stick to the lower ear lobe; it is
easier and less painful due to absence of
cartilage in that region and good blood
supply

50.  Advice parent to carry baby’s favorite toys,
pacifier or other interesting stuff to distract
her while piercing. They come handy when
she gets cranky.
 On the day, let child wear buttoned clothes
that can be removed without pulling the dress
over the head. This can mitigate the chance
of an accidental tug at the ears.

51.  Step 1:Disinfects the piercing site by cleaning
it with alcohol or any other skin disinfectant.
To keep things hygienic and professional,
wear surgical gloves.
 Step 2: Piercing can be done through needle-
based piercers or piercing guns. It depends
on what the parent prefers and what the ear
piercing professional recommends. Both
cause a bit of pain but only when the piercing
is in the process that is a few minutes.

52.  Step 3: The holes will then be filled with
gold-post earrings, which act as a
placeholder to prevent the hole from closing.
 Step 4: The disinfectant should be applied to
the piercing site.

53.  Ask parents to apply the disinfectant twice a
day for 14-21 days.
 Need to then shift the earrings from one ear
to another every week for the next six weeks.
 Every time the an earring is removed, clean it
with a cotton swab dipped in a disinfectant.
 Tend the pierced site with clean hands. Wash
and dry hands thoroughly before touching
baby’s ears

54.  Gold is the metal of choice since it is less
likely to cause infections . It does not
exacerbate the existing redness and mild
inflammation.
 An alternative to gold is surgical steel, which
is free of nickel. Gold-plated surgical steel
earrings are also good.

55.  Babies should only wear earrings that fasten
securely in the hole.
 Choose earrings that have a soft fastener at the
rear, which is less likely to prick the baby.
 Choose earrings that are lightweight.
 Never select dangling earrings for baby. Baby
can accidentally tug at them, hurting herself.
 Stay away from earrings with large and sharp
projections at the rear, which may hurt the baby
while sleeping. Tend to the piercing site with
care.

56.  Allergic Reactions :allergies with visible
symptoms, such as an itchy rash, weeping
skin, pain, and in extreme cases, bleeding
and pus, are most often caused by exposure
to nickel and cobalt. present in quality/ cheap
jewelry
 Keloids:are raised, reddened, fibrous growths
that usually occur after surgical procedures
or trauma and can cause significant cosmetic
deformity.

57. Thanks for listening.