The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Instruments - Sterilizing and Setup

Subsections on this page:

• Sterilization of Instruments
• Instrument and Birth Kit Setup
• Baby Warmer

Sterilization of Instruments

Sterilization -vs- Disinfection - A Reference Guide to the Difference Between

Disinfectants Smoke & Mirrors? - The Real Story - A good discussion of the different types of hard surface germicides, their relative effectiveness and side effects.

Reprocessing Methods for Equipment Used in the Prehospital1 Health-Care Setting - CDC Guidelines for Sterilization

Infection Control in the Physician's Office from The College of Physicians & Surgeons of Ontario

Fun reading about sterilizing equipment for making beer.

Our sterilizer is breaking down. We are looking at ways to avoid having to sterilize speculums. One place I worked simply cleaned the specs carefully and dropped them into a bleach solution overnight, rinsed them in the morning and used them.

Running specs through a dishwasher with sufficiently hot water and a good detergent would fill the bill, too. When you think about it, your goal is not to make and keep the specs sterile, but to kill pathogens and to meet aesthetic considerations (as well as to satisfy the lawyers, OSHA, etc.)

We have tried plastic spec: the staff loves them (less work), many patients hate them (they click loudly and pinch, in spite of great care, more often) and we don't like the expense (you have to buy them, then pay to dispose of them through your biohazardous trash system). The folks that sell surgical supplies love them, too. We do use them for a satellite clinic, for logistical reasons, but have never learned to love them.

We do the bleach method. Scrub the speculum really well and let it sit in bleach for 20 minutes and rinse it off. Seems to work fine.

When I arrive at a birth, I soak the umbilical scissors, blunt-sharps (for poss emergency epises that never happen) and two cord clamps (I use re-usable metal ones) in a cold-sterile solution (Amerse). After the birth, I clean the instruments, and the cycle repeats.

I am experimenting with different ways of handling the sterilization of instruments for homebirths, and I'd love to hear how others handle it. Previously, I cleaned them (I use an instrument-cleaning soap followed by a soak in instrument milk), packed in sterilization wrapper and at home, after the birth, baked in oven with a pot of water underneath for a couple hours til the sterilization bar turned brown. I was finding this hard on my instruments to be subjected to the dry heat, and if I had a lull between births, I questioned the sterility of the instruments, the packaging would get little rips in it, the wrappers are expensive to waste.

So lately, I've been doing a cold-sterilization technique taught me by a doctor that feels safer for my instruments and more time-efficient. I'd love feedback anyone has on cold-sterilization methods. I clean the instruments as above. When I arrive at a birth, I soak the umbilical scissors, blunt-sharps (for poss emergency epises that never happen) and two cord clamps (I use re-usable metal ones) in a cold-sterile solution (Amerse). After the birth, I clean the instruments, and the cycle repeats.

Though I am still experimenting with ideas, the cold-sterile technique seems more desirable so far, feels like a "fresher" sterilization...what do the other homebirth midwives do...what do the hospital midwives think about acceptable methods of sterilization for OOH births (no autoclave, no pressure cooker)?

Do you consider your instruments contaminated until they have been soaked in Amerse? Do you handle them with gloves?

I have a box of Amerse packets, and it says at a 1:32 dilution it kills "pathogenic bacteria and fungi such as S. aureus, S. choleraesuis, Ps. aeruginosa, M. tuberculosis (effective in 10 minutes at 20 deg. C) and C. albicans. Amerse is virucidal against influenza A2 (Hong Kong) Herpes simplex I and II, Type 2 Adenovirus and Vaccinia on hard, inanimate, surfaces in 10 minutes at 20 deg. C."

What about HIV and hepatitis? This has been my concern about using this product and considering the instruments sterile.

There is a product carried by Cascade called Wavecide that is called a sterilant, however it must be used full strength and is very expensive. It is effective against HIV.

In "Practical Skills Guide for Midwifery" the suggested cold Chemical sterilization method is:

With gloved hands, scrub equip. with soap and rinse. Measure 4 parts water to 1 part Cidex, soak 10 min., rinse and allow to dry, package and label to indicate sterilization and date.

Seems to me the rinse & allow to dry part renders them non-sterile.

Soap and water will kill HIV. Hep is nasty and tough though, and needs heat or chemicals I think.

Yeah, I agree with your concern. Why rinse and air dry?

I like simple heat processing -- if you wrap and sterilize then you never touch the instruments again.

Or -- I can just boil again at birth and IF THE PAN IS KEPT COVERED then the instruments will still be sterile

(don't know how many times I've seen folks boil instruments and leave them to sit for hours in an uncovered pan - - - or boil them and then dump them into a separate container with (usually, nasty old betadine) and then let them sit uncovered for hours! If you boil your instruments then just let them sit there with the lid on!

Personally, I felt the purchase of a small pressure cooker very worthwhile. It also is capable of creating some delicious meals too!

As far as protecting your wrappers from tears in between births I do the following:

After the pressure cooker, because there is some moisture, I place them in a very low temp oven until the pkg is totally dry. Then I immediately place them into a large zip-lock bag, squeeze all the air out & seal it. This protects them then from any moisture & tears. I also have found using this method, that instead of purchasing the fancy instrument wrap paper, I just use brown grocery bags - much cheaper & they work just as well. I double layer the wrap just as I did using the real stuff.

I have been using Amerse off and on for about 2 years and really like it. I still heat sterilize a set of instruments that I carry around for births where the head is crowning when I get there. I just started having a packet of Amerse added to my kits.

I still use my original set of instruments that I bought in 1981.......I've added to them.....a second set of hemostats and scissors, one of those nifty curved cord cutting scissors and the cord bander. It's hard to tell the difference between the old hemostats and the ones that are about 8 years old. Buy good stuff, take good care of it and it lasts forever.

I generally don't sterilize instruments at clients home. Often don't even use instruments. I have parents purchase scissors in their birth kits and give instructions on sterilizing them. I use sterile plastic cord clamps (also in kit) and their scissors to cut the cord. I carry two sets of sterile instruments (steam sterilized)consisting of two curved hem. and scissors. I also carry two sets of suturing instruments (sterile, of course).

Don't worry about cold sterilization for HIV.....almost anything kills it, even soap and water. What you do need to worry about is HepB (hepatitis) which is a very very hardy virus. It can be cultured off surfaces weeks or months later. This can be taken care of by bleach soaking.

Household bleach 1 part to 10 parts water is effective against the hepatitis virus. This is what we used in the hospital to clean the insides and outsides of the hemodialysis machines.

At our Miami Center we use cold sterilant after a short bleach soak followed by heat sterilization.

Right now I'm really happy with steam sterilization with a pressure cooker, thanks to all who answered my questions on this list about it.

Instrument and Birth Kit Setup

We set up all the "important" stuff on a cookie tray, covered by a chux pad. The sterilized instruments go underneath, the bulb syringe, pit, meth, (we hide these because they make the mom nervous) herbs, opened 4 x 4s, some gloves

Use a gardening basket to carry essentials. In the center of the basket she keeps gloves and gauze, in the little side pockets all around are the bulb syringe, deLee, a squeeze bottle of olive oil, another of betadine scrub, cord clamps, blood tubes, syringes and needles, and homeopathics. It has handles and she puts it right in her big bag (a zipper sports bag) and it comes out and goes in with minimum trouble. She sits it right on the bed next to her, and everything is at hand. Things don't spill out 'cause the side pockets have elastic.

I use a Rubbermaid sweater box. I stock it with everything I need for a birth, gloves, gauze, deLee, instruments, etc.

I switched to a large heavy duty plastic box (called action packer). i can put an enormous amount of "stuff" in it (lots of extras and seldom needed things), and everything stays where it's put! -- it doesn't fall all over inside like the "bags" did -- and anyone opening the box can easily find things... It has a sturdy, lockable lid -- strong enough to stand or sit on. I carry my "essentials" - all the things I (might) need for the actual birth in a medium sized cosmetic-type box (though a tackle box also works well); this fits quite nicely in the big box. The other surprising advantage to this box is that it's exactly the height for a birth stool! Found out by accident once (mom wanted something to sit on and the ready made birth stool was way too low for comfort) --tossed a chux on the box and we were ready!

I recently picked up a portable lap table made for children. It has built in pockets on the sides and a large flat top surface - just about cookie sheet size (which is what I've usually used). It's made of one piece molded plastic; easy to clean; shaped like a rectangular box with the long back and front and the bottom removed. I'm stoked about the side pockets.

I have everything necessary for the birth preset in my (Rubbermaid sweater box) birth box. The heating pad, towels and hat go on the lid and are warmed for the birth. After the birth I restock my birth box from the birth kit they ordered.

I use four Tupperware boxes to organize my birth bag. One for let's run in and catch a baby. Everything you really need to do a birth. The next is all the suturing equipment. The third is the newborn box with the scale, tape measure, etc. This is a smaller one. The fourth is extra stuff. Works really well.

Baby Warmer

Another trick is to have the heating pad set on warm in a pillow case with the receiving blankets and a cookie sheet in it. This makes for a nice place to work on the baby in case you have to have the baby flat for open airway purposes. If you need to transfer apart from Mom's body for any reason, then just unplug the heating pad, put the baby on top of the pillowcase-cookie sheet setup, wrap with a wool or solar blanket (not too tightly if you think you'll need access to baby's body). Should stay warm for awhile!