Vaginal Prep

Position the patient in the lithotomy position before beginning the prep. Regardless of what antiseptic agent you will be using, prepare the supplies ahead of time and follow these steps:  

• Perform hand hygiene according to your site-specific policy.   
• Prepare the material for the sterile set-up that will be opened onto a prep stand. If a sterile prep kit is not utilized, open the following contents: 
  • Towels
  • Small basin(s)
  • Sponge sticks
  • 4 x 4 sterile radiopaque sponges¹
• Expose the area to be prepped (with the patient in lithotomy position). 
  • If performing only a vaginal prep, expose the patient’s vagina, perineum, anus, and inner aspects of the thighs.
  • If the vaginal prep is to be completed with an abdominal prep, expose the patient from the nipple line to mid-thighs.
• Ensure that the prepped area is large enough to allow for drape shifting and extension of the surgical incision (if used in combination with abdominal surgery).
• Don sterile gloves (nonscrubbed team members).²
• Place a fluid-resistant pad under the patient’s buttock.^1,2 (Remember to place your sterile gloved hand into the cuff of the prep pad to prevent contact with the patient’s skin.) 
  • If an abdominal prep will be completed, pooling towels will be applied on each side of the patient’s abdomen to ensure that the antiseptic agent does not accumulate underneath the patient.² 

Performing Vaginal Prep Only 

1. Use a sterile applicator (foam sponge or sponge stick with radiopaque gauze) moistened with the selected antiseptic agent.
2. Starting at the pubic area, move downward over the vulva and perineum.³
3. Discard the applicator after passing over the anus.³
4. Use a new sterile applicator to apply the antiseptic agent over the inner aspects of the thigh, starting from the labia majora outward, using an up-and-down motion and separate applicators for each thigh.³
5. Using new sterile applicators, repeat steps 1 to 4 as many times as necessary to achieve complete coverage and comply with recommended application time according to the selected agent's manufacturer’s instructions for use (IFU). 
6. Next, insert a new sterile applicator (e.g., foam sponge stick or sponge stick with radiopaque gauze) moistened with the selected antiseptic agent into the vagina. Using a circular motion cleanse the vaginal vault and cervix.³
7. On completion, a dry sterile foam sponge stick or sponge stick with radiopaque gauze may be inserted into the vagina to absorb excess prep solution.⁴
8. Carefully remove the fluid-resistant pad and any linen that may have absorbed the antiseptic solution to avoid contaminating the prepped area.  

Performing Vaginal Prep Combined with Abdominal Prep 

• AORN recommends that the vaginal prep be performed first (refer to the above steps 1-8), followed by an abdominal prep.^1,2
• Refer to the abdominal skin prep Procedure Quick Tips article for the steps on completing an abdominal prep. 
• For the abdominal prep, use a separate prep set-up, perform hand hygiene, and don new sterile gloves. After the abdominal prep is completed, it is recommended to use a sterile applicator to apply the antiseptic at the border of the abdominal and vaginal prep at the pubis.5 

Prepping Agents for Vaginal Preps 

Povidone-iodine is the preferred preoperative skin antiseptic for vaginal antisepsis if not contraindicated for the patient (eg, allergy).⁶ When povidone-iodine is contraindicated, chloroxylenol 3% (PCMX) is the only other preoperative skin antiseptic approved by the U.S. Food and Drug Administration for vaginal antisepsis.⁷ 

If povidone-iodine or chloroxylenol 3% is contraindicated, sterile saline and baby shampoo have been suggested as alternatives for vaginal preps.^2,8,9 

The American College of Obstetricians and Gynecologists indicates that off-label use of 4% chlorhexidine gluconate is a safe and effective alternative for vaginal preps when povidone-iodine is contraindicated;^2,8,10 however, this contraindicates the manufacturer’s IFU to not use this product in the genital area.¹¹ 

The above antiseptic agents should be removed after surgery to prevent irritation to the skin, unless otherwise indicated by the manufacturer’s IFU.² 

Prepping with Povidone-Iodine Scrub and Paint  

Povidone-iodine paint 10% alone or povidone-iodine scrub 7.5% followed by povidone-iodine paint 10% can be used for prepping.² If prepping with 10% povidone-iodine paint only, perform above steps 1-8. After completing the steps, allow the prepped area to air dry for two minutes.¹²

If prepping with povidone-iodine scrub 7.5% followed by povidone-iodine paint 10%, start with the povidone-iodine scrub 7.5% and follow the above steps 1-5 and then use a sterile towel to blot the scrub solution. Next, use the povidone-iodine paint 10% and follow the above steps 1-8. Allow the povidone-iodine paint 10% to air dry for two minutes.¹² 

Prepping with Chloroxylenol 3% 

When prepping with chloroxylenol 3%, follow the above steps 1-7. This prep can air dry or be blotted with a sterile towel. 

Special Considerations 

Use povidone-iodine with caution with breastfeeding women and patients susceptible to iodism (eg, patients with burns or thyroid disorders, pregnant or lactating patients).^2,3  An allergy to seafood does not indicate an allergy to iodine.^2,3 

If a urethral catheter is going to be inserted after the vaginal prep, remove prepping gloves, perform hand hygiene, and don new sterile gloves before inserting the catheter. 

References 

1. Guideline Essentials Quick View patient skin antisepsis. AORN. Accessed February 24, 2023. https://www.aorn.org/docs/default-source/aorn/essentials/skin-antisepsis/files/quickview_patientskinantisepsis_2021.pdf 
2. Guideline for preoperative patient skin antisepsis. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2022:623-680. 
3. AORN. Preoperative Skin Antisepsis [DVD]. Woodbury, CT: CineMed, Inc; 2015. 
4. Phillips N, Hornacky A. Chapter 26: Positioning, prepping, and draping the patient. In: Berry and Kohn’s Operating Room Technique. 14th ed. St. Louis: Elsevier; 2021.
5. Wood A. Abdominal-perineal dual preps [Clinical Issues]. AORN J. 2015;101(1):149-157. 
6. Skeith AE, Morgan DM, Schmidt PC. Vaginal preparation with povidone-iodine or chlorhexidine before hysterectomy: a propensity score matched analysis. Am J Obstet Gynecol. 2021:225(5):560.e1-560.e9. doi:10.1016/j.ajog.2021.08.035
7. Cahn J, Wood A. Iodine allergy [Clinical Issues]. AORN J. 2018;107(2):259-267. 
8. Amstey MS, Jones AP. Preparation of the vagina for surgery. A comparison of povidone-iodine and saline solution. JAMA. 1981;245(8):839-841. 
9. Lewis LA, Lathi RB, Crochet P, Nezhat C. Preoperative vaginal preparation with baby shampoo compared with povidone iodine before gynecologic procedures. J Minim Invasive Gynecol. 2007;14(6):736-739. 
10. ACOG Practice Bulletin No. 195: Prevention of infection after gynecologic procedures. Obstet Gynecol. 2018;131(6):e172-e189. doi:10.1097/AOG.0000000000002670
11. Hibiclens – chlorhexidine gluconate solution. DailyMed. Updated December 21, 2021. Accessed February 24, 2023. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=8b37a721-79bb-4051-95a7-fcb4edebfcb7
12. Scrub Care povidone iodine topical paint. DailyMed. Updated November 22, 2022. Accessed February 24, 2023. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=fbe92fa9-273c-45be-a46d-437587507bee

 AORN Resources 

AORN members can access:  

• Patient Skin Antisepsis | AORN Guideline Essentials  
• Guideline Quick View: Patient Skin Antisepsis - AORN Journal
• Key steps to prepare for preoperative patient skin antisepsis - AORN Journal

If your facility subscribes to eGuidelines+, you can access: 

• Skin Prep at a Glance | AORN eGuidelines+
• Patient Skin Antisepsis Guideline | AORN eGuidelines+