In my 30-plus years in perioperative nursing, one of the most common mistakes I've seen is inappropriate gowning. Here's a refresher on the correct way to gown a member of the surgical team.[1]

• Hand the team member a towel to dry her hands by placing the opened towel on her hands without touching the skin of the team member.
• Unfold the surgical gown with as little handling of the gown as possible. Gravity will open the gown; all you need to do is give it a slight shake.
• Hold up the surgical gown for the team member by putting your hands on the outside of the gown around the shoulder area, cuffing your hand under and outside the neck of the gown. This creates a protective cuff for your sterile gloved hands and provides a barrier between you, the unsterile skin and the team member's scrub attire.
• The team member should hold her arms out for the gown and place them into the sleeves.
• At this point, the scrub person should let go of the gown and the circulating nurse should pull it up from the inside of the gown to tie or assist with the wraparound device of the gown.
• If the circulating nurse is caring for the patient and not available immediately to tie the gown, the team member may hold her arms up and the scrub may help get the sleeves on by handling the mid-point of the sleeve, not coming in touch with the stockinette cuff or the team member's hands.
• The team member has to wait until someone can tie the gown, because the neckline could fall down and contaminate the rest of the gown.
• The team member can now don gloves, taking care to cover the gown's stockinette cuff. (The material's in contact with perspiring skin and will be contaminated, so consider the stockinette cuff an unsterile zone once it's over the user's skin.)

The gown is considered sterile from the level of the OR field to the mid-chest of the gowned team member. The neckline and shoulders are considered contaminated with perspiration - that's why the scrub nurse's hands in "What's Wrong With This Picture?" shouldn't be above his or the surgeon's shoulders.[2] The hands of any gowned team member should always be in front and above the waist. If you have nothing to hold, place your gloved hands on top of each other on your abdomen. The back of the gown (even if it's a wraparound), under the arms and below the level of the OR field (the OR patient) aren't considered sterile. The back of the gown isn't considered sterile because we're unable to see it at all times - if you can't vouch for what it may have touched, the rule of the OR is to err on the side of caution. The area under the arms sweats and creates moisture, which is a contaminant. It is an all-too-common practice that I see: gloved hands under arms and drapes.

References
1. AORN Standards and Recommended Practices. 2004.
2. Fortunato, Nancymarie. Berry and Kohn's Operating Room Technique. 2000. Mosby, Inc.