Patient positioning is an important patient safety concern that must be performed appropriately to avoid injuring the patient. Patient positioning during surgery is a skill that is rarely taught but we expect students to know. During the course of a routine surgical case, the resident or faculty may verbalize what they are doing while positioning the patient, but the student does not necessarily participate in the active process.
NOTE: This entire module is also available in PDF Format.
This clinical skills module provides a standardized framework for teaching the importance of and the principles behind patient positioning.
Following participation in this module, students should demonstrate the following learning outcomes:
Practice makes perfect. The residents and faculty can model the positioning and verbally explain what they are doing and why on the gynecology services. However, we all learn best by doing. Therefore, it is recommended to model the behavior on the first case and then have the student direct the positioning of the patient on the second case. This will allow the student to troubleshoot the issues and verbalize their thinking during the process. After the student has completed this module and been able to practice positioning the patient, use the checklist to confirm competency. This could be done in the operating room, with a simulated patient or a simulation manikin. The students could consider positioning each other. However, the lithotomy position may pose some psychological concerns for the students due to the vulnerability of the position and should only be done with caution and with permission gained in a way that feels safe and non-directive for the students.
Patient positioning for gynecologic procedures should be introduced in the third year. However, it would be important to include this training in the fourth-year sub-internship and/or ob-gyn boot camp in preparation for residency.
Describe the goal of patient positioning for surgery:
The goal of surgical positioning includes the following:
Describe the most common positions for patients in routine gynecologic procedures:
Review the technique for patient positioning in surgery:
General safety measures for the supine position:
*Special Note for Obstetric Patients
When placed in the supine position, the uterus of the pregnant female patient compresses the vena cava and aorta obstructing the blood flow, which can result in undesired physiological consequences for the female and fetus. To avoid this compression during Caesarean delivery, the patient should be tilted to the left approximately 15 degrees by either “airplaning” the table or placing a wedge under the patient’s right hip.
General safety measures for lithotomy position:
Review the risks if surgical positioning is done incorrectly:
Protect the nerves and reduce the risk for temporary or permanent injury when positioning the patient. Nerves are vulnerable to injury by traction and pressure. The nerves most commonly injured are the ulnar, common peroneal and brachial plexus. See the checklist below for a description of the nerve injuries and their origins.
How to avoid certain nerve injuries:
The instructor tells the student about the patient:
38-year-old female G3 P2 who presented with pelvic pain and vaginal bleeding. She has a 4-cm ectopic pregnancy in the right adnexa. After counseling about the options of surgery versus methotrexate, the patient has decided on surgery. You plan to do a laparoscopy.
The instructor asks the following:
This checklist is designed for laparoscopy but could easily be modified for a laparotomy.
Demonstrate accurate patient positioning for surgery:
|Describe the most common positions for patients in routine obstetrical and gynecologic procedures|
|Describes the goal of patient positioning for surgery|
|Describes the risks if surgical positioning is done incorrectly|
|Describes the appropriate steps in patient positioning in surgery|
|Lateral Aspect of Knee|
|Identify nerve at risk (common peroneal)|
|Describe consequence of injury (decreased sensation on lateral lower leg, dorsal foot, foot drop)|
|Describe correct position to avoid injury (knee toward opposite shoulder, no pressure on lateral aspect)|
|Identify nerve at risk (ulnar)|
|Describe consequence of injury (decreased sensation and weakness in fourth and fifth digits)|
|Describe correct position to avoid injury (elbow padded, arm pronated, avoid hyperextension)|
|Identify nerve at risk (femoral and lateral femoral cutaneous)|
|Describe consequence of injury (sensory deficit of thigh, weakness of hip flexion, knee extension)|
|Describe correct position to avoid injury (no hyperflexion of hip, limit abduction and external rotation)|
|Position buttocks at edge of bed, no sacral pressure|
|Make sure patient centered on bed|
|Make sure arms are tucked|
|Position arms so they are pronated, thumbs up or thumbs in|
|Check that there is no hyperflexion or hyperextension of elbow|
|Check that there is no hyperflexion or hyperextension of wrist|
|Check that arms are padded|
|Check that fingers are safe|
|Make sure that lithotomy leg rest clips at level of the greater trochanter or anterior superior iliac spine|
|Position heels snug in the boot, weight of patient’s leg on the heel, heel at back of boot|
|Make sure that ankle, knee, hip, umbilicus, opposite shoulder all in alignment|
|Make sure there is no pressure on posterior calf|
|Make sure there is no pressure on lateral aspect of leg|
|Make sure there is no hyperflexion or hyperextension of hips|
|Make sure there is no hyperflexion or hyperextension of knees|
|Be sure to limit abduction and external rotation|
The provided checklist can be used for performance assessment.
We recommend that the patient positioning during surgery be introduced to students during the third‐year clinical clerkship in obstetrics and gynecology. The training/practice session can be conducted in the operating room or as a part of the objective structured clinical examination followed by immediate performance assessment using the checklist. Continued practice should be encouraged during the clerkship. This will allow the student to better integrate into the surgical team and assist the residents and faculty in a knowledgeable way.