12.04 Circumcision of the Newborn, Assisting With Procedure - Pediatric Primary Care Clinics
Category: UWHC Departmental Policy
Policy Number: 12.04
Effective Date: May 28, 2014
Section: Clinic Specific (Ambulatory)
To guide Pediatric Primary Care Registered Nurses (RNs) and Medical Assistants (MAs) to assist with circumcision of
Employ Universal Protocol and obtain consent using Signed Consent for Operation, UWH Form #9139, and
document in Health Link under the UWHC Universal Protocol flow sheet.
Papoose board or other newborn immobilizer board covered with sheet or infant blanket
Circumcision tray, obtained from Central Supply
Povidine iodine 10%
Signed Consent for Operation (UWH Form #9139)
Portable exam light
1 ml syringe with 22 gauge needle
Lidocaine 1% without Epinephrine
Scalpel Blade #10
A. Verify infant identification with parent/legal guardian by name, medical record number and/or birthdate,
as final timeout for Universal Protocol.
B. Remove infant's diaper in the front and tuck back under the infant’s bottom, place infant on board and
apply Velcro restraints or other straps as indicated, utilizing blanket to pad infant at pressure points as
needed. Remain with infant at all times. Document any changes in status or interventions while using
C. Open circumcision tray, position lamp toward penis; open sterile glove package, and assist physician as
D. Prepare for physician: povidine iodine 10% to clean incision site, sterile water to remove iodine after
procedure, and alcohol to prep skin for injection of lidocaine for dorsal penile nerve block.
E. Observe extremities during procedure for color, mobility and pressure points at sites of restraint. Offer
pacifier or other comfort measures as able.
F. Patient/parent instructions post-procedure per provider or standard per below:
1. Apply petroleum jelly with each diaper change.
2. Observe for bleeding and signs of infection including purulent drainage or spreading
redness. Note that redness with yellow crusting on the circumcision site is normal.
V. CARE OF EQUIPMENT
A. Rinse the non-disposable equipment and send back to Central Supply.
B. Reorder circumcision tray and any needed resupplies.
C. See Ambulatory Policy 12.06-Papoose Board-Pediatrics Clinics for papoose board cleaning.
UWHC Administrative Policy 4.17 – Informed Consent
Ambulatory Policy 12.06 – Papoose Board – Pediatrics Clinics
VII. REVIEWED AND APPROVED BY
Karen Hillery, MD, Pediatric Clinics
Pediatric Clinic Managers
Ambulatory Policy and Procedure Committee
Deborah D. Tinker, MSN RN, CENP, Director, Ambulatory Nursing