Newborn Circumcision


Newborn Circumcision Consent Form

Parent Information

Newborn Circumcision Parent Information Handout


Gomco circumcision clamps:

Mosquito forceps, curved (2 pair)

Mosquito forceps, straight (1 pair)

Iris scissors, straight (1 pair)

18 gauge 1.5 inch needle (1)

27 gauge 1.5 inch needle (1)

Safety pins (2 pins)

15 Blade disposable scalpel (1)

ChloraPrep 3 ml stick (1)

1% Lidocaine (withOUT epinephrine) (1 vial)

EMLA Cream (1 tube), if EMLA cream is not available, then 2% Lidocaine hydrochloride jelly is acceptable replacement

Petroleum ointment (Vaseline) (1 tube)

Circumstraint papoose board (1 board) + Leg Straps (1 pair) 

Exam-room sheet (1 sheet), or baby blanket (2 blankets)

Nitrile exam gloves (1 pair)

Sterile gloves (2 pair)

Plastic sterile drape with fenestration (1)

Blue sterile drape (1 drape)

Sterile 2x2 gauze (5)

Sterile 4x4 gauze (5)

Alcohol swabs (4)

1 ml syringe (1)

Xeroform sterile petrolatum gauze dressing (1 package)

Sweet-ease® Sugar Water (1)

Bulb suction device (1)

Pre-Procedure Preparation

Sterile Area:

In sterile fasion, place Gomco, sterile gauze, scalpel, safety pins, and all sterile surgical equipment (hemostats, scissors, etc...) on a blue sterile drape.

Non-Sterile Area:

In the 1 ml syringe, draw up 1 ml of 1% lidocaine WITHOUT epinephrine.  Label the syringe with the contents (write: 1% lido w/o epi).  Keep all remaining equipment unopened in the non-sterile area.  Prepare the Papoose board with the leg restraints.  Have the Sweet-ease and bulb suction at the head of the board for easy access.

Procedure Note


Parents of infant were counseled on the procedure, and all questions answered.  Parents voiced their desire to proceed with the circumcision.  Infant was placed on the Papoose board, legs secured with restraining straps, and infant's upper torso and upper extremities were secured by swaddling with a baby blanket.  Timeout performed.  After cleansing skin with alcohol swab, 1 mL of 1% lidocaine without epinephrine was injected with a 27 gauge needle in a combination dorsal penile/ring block. Surgical site was sterilized with ChloraPrep and draped in sterile fashion.  The foreskin was grasped at 3 and 9 o'clock with the curved mosquito hemostats.  The preputial opening was stretched and the synechial adhesion were broken with a straight hemostat.  The midline foreskin was clamped for 30 seconds, then a midline dorsal slit was made.  The bell-shaped plunger was placed over the glans covering the entire glans. The shaft skin below the corona remained relaxed and supple. The plate of the clamp was applied at the level of the corona. Once in proper alignment the clamp was tightened and a circumferential incision was made with a cold knife. The clamp was left in place for 5 minutes to allow for clotting and coagulation to occur. The clamp was then removed and iodoform gauze was placed at the crush line. Good cosmesis and hemostasis was obtained.  Size of Gomco: _.  Amount of bleeding: < 1mL.  Complications: none.

The infant was observed after the procedure, no further bleeding was noted.  One time dose of 10 mg/kg oral baby acetaminophen (160 mg/ml concentration) was given.  Handout on circumcision care given to parent, all questions answered.  Infant allowed to return to care of parents with return precautions.