UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
CLINICAL POLICY AND PROCEDURE
TITLE: Hysteroscopy (Set-up and Clean-up)
Effective Date: June, 2005 Approval: See Authorization
Supersedes Protocol: None Contact: Clinical Staff Education
Reviewed March, 2008 May 2009 Dec 2009 January 2012
PURPOSE: To provide guidelines for the set-up/clean-up of an office hysteroscopy at a
DEFINITION: A visual examination of the cervix, uterine canal, and uterine cavity.
POLICY: The clinical staff will utilize the following guidelines to set-up prior to and
clean-up after an office hysteroscopy.
4 Sterile Drapes 1 Sterile 10cc syringe
Betadine Swab Lidocaine w/ epinephrine
Sterile 4x4’s Needle Extender
1 Under-Buttock Pad 27g 1-1 1/4 “ needle
2 IV tubing 1- 1000cc Lactated Ringers
2 1000cc bottles Sterile Water Sterile gloves for provider
Hysteroscope 3 Sterile Trays
Biopsy Scissors Hysteroscopy Kit
Biopsy Cup Tenaculum
Biopsy Graspers Dilator
1. Check provider’s order and clarify any inconsistencies.
2. Check Metricide 14 solution with monitor sticks. Change solution if expired. Soak the scope and
biopsy instruments in the solution for at least 30 minutes.
3. Wash hands and gather equipment.
NOTE: 1 person needs to be “sterile” while the other handles the non-sterile equipment.
4. The non-sterile person opens a sterile drape; the sterile person then takes it out of the package and
places it across the mayo stand that is on the left side of the table.
5. Using sterile technique place on Mayo stand the following items:
Lidocaine w/epinephrine - filled syringe
6. Place another sterile drape over the top of tray.
7. Using sterile technique unwrap the sterile trays and empty 2 bottles of sterile water into the 3 trays.
8. The non-sterile person opens a sterile 4x4 and hands it to sterile person.
9. Using the 4x4, the sterile person picks up the scope as well as the biopsy instruments and triple rinses
10. The non-sterile person opens another sterile 4x4 and hands it to sterile person. The sterile person then
wipes the instruments dry. They are then placed on the 2nd sterile field.
11. Non-sterile person should open the bag of Lactated Ringers and insert IV tubing and hang for IV pole.
12. Using sterile technique insert IV tubing into proper ports on scope (one for inflow and one for
outflow). Put the opposite end of outflow tube into bag on under-buttock pad.
13. Cover tray with sterile drape.
14. Non-sterile person should wrap BP cuff around IV bag and be sure the IV pole is high enough for fluid
to flow properly.
15. Soak scope and forceps in METRIZYME SOLUTION (Blue) and then wipe with 4x4.
16. Rinse and place in Metricide- 14 for 30 minutes.
17. Rinse, wipe dry with 4x4 and return to proper case.
WRITTEN BY: Ronnie Peterson, R.N., M.S., Clinical Staff Educator
REVIEWED BY: Jill Rockwell, M.A.-TL, Department of Obstetrics and Gynecology
Klaus Diem, MD, Department of Obstetrics and Gynecology
Clinical Associate Professor -Ob/Gyn-General Date
Medical Director Date