Step-by-Step Guide: How To Fold A Surgery Gown For Aseptic Packaging

Folding a surgical gown correctly ensures that perioperative staff can don the garment under strict sterile conditions without risking accidental contamination of the exterior barrier. According to ANSI/AAMI ST79 guidelines, the gown must be folded using an accordion or book-fold technique with the inside surfaces exposed, allowing the scrubbed team member to grasp the collar and unfurl the garment cleanly. Mastering how to fold surgery gown units guarantees uniform steam penetration during processing and rapid, sterile presentation in the operating theatre.

Pre-Sterilization Inspection and Setup

Proper preparation of surgical gowns within the Central Sterile Supply Department (CSSD) directly impacts surgical site infection (SSI) rates and sterilization efficacy. Before performing any fold sequence, technicians must verify fabric integrity, barrier performance ratings, and cleanliness under optimized lighting conditions.

Required Materials and Tools

• Inspected Surgical Gown: Reusable woven textile (microfilament polyester) or multi-layer disposable SMS (Spunbond-Meltblown-Spunbond) polypropylene conforming to ANSI/AAMI PB70 liquid barrier standards (Level 1 through Level 4).
• Illuminated Inspection Table: High-intensity light table generating a minimum of 1,500 lux to detect fabric micro-pinholes, seam degradation, or residual organic debris.
• Absorbent Hand Towel: Standard Huck or terry cloth towel (typically 40 cm x 60 cm) placed within the package for scrubbed hand drying prior to donning.
• Internal Chemical Indicators (CI): Type 4, 5, or 6 multi-variable chemical indicator strips compliant with ISO 11140-1 to verify steam or ethylene oxide (EtO) penetration.
• Sterilization Wrap: Double-layer non-woven barrier wrap (polypropylene SMS) sized appropriately for the folded gown bundle (typically 60 cm x 60 cm or 75 cm x 75 cm).
• Autoclave Indicator Tape: Process indicator tape engineered for specific sterilizer modalities (steam or hydrogen peroxide gas plasma).

Technical Prerequisites and Operational Metrics

• Environment: CSSD preparation and packaging area maintaining ISO Class 8 cleanroom conditions, positive air pressure, 35–60% relative humidity, and ambient temperatures between 18°C and 23°C (65°F to 73°F).
• Standard Compliance: Strict adherence to ANSI/AAMI ST79 (Comprehensive guide to steam sterilization) and ISO 11607 (Packaging for terminally sterilized medical devices).
• Processing Benchmark: Standardized manual folding duration target of 60 to 90 seconds per gown, ensuring uniform mechanical density for steam air removal and moisture evacuation.

Step-by-Step Aseptic Surgical Gown Folding Protocol

Executing a standardized surgical gown fold ensures that the garment opens smoothly when pulled downward by the scrubbed clinician, preventing the exterior sterile field of the gown from coming into contact with non-sterile attire or unscrubbed skin.

Step 1: Surface Alignment and Micro-Pinhole Inspection

1. Spread the surgical gown completely flat across the illuminated inspection table with the front (chest and abdominal area) facing downward and the open back panel facing upward.
2. Smooth out all fabric wrinkles along the seams using clean, gloved hands to eliminate air pockets that impede steam distribution.
3. Perform a 100% surface inspection by passing the fabric over the light table. Check critical zones—specifically the chest and forearm reinforcement panels—for tears, fraying, thread separation, or structural thin spots. Reject any gown failing visual inspection.
4. Ensure all neck ties, waist ties, and card-transfer mechanisms are completely untangled and laid parallel to the long axis of the gown body.

Warning: Never process reusable surgical gowns with damaged liquid-barrier seams or unpatched punctures larger than 1 mm. Sub-standard barrier layers compromise ANSI/AAMI PB70 compliance and expose surgical teams to bloodborne pathogen strike-through.

Step 2: Sleeve Inversion and Internal Positioning

1. Position the left and right sleeves flat against the inside back panels of the gown.
2. Fold each sleeve lengthwise toward the central longitudinal axis of the gown, ensuring the stockinette wrist cuffs are situated approximately 10 to 15 cm below the neckband.
3. Keep the stockinette cuffs completely flat and un-bunched. The cuffs must remain inside the fold envelope so that the clinician can easily access them during the closed-glove or open-glove donning technique.
4. Smooth the armhole seams outward to maintain a uniform rectangular footprint across the central torso panel.

Pro-Tip: Align sleeve cuffs straight toward the bottom hem rather than crossing them over the chest cavity. Straight placement reduces bulk in the center of the package, permitting flat stacking inside the sterilization chamber and preventing localized superheating of dense fabric folds.

Step 3: Longitudinal Side-Panel Accordion Folding

1. Grasp the outer edge of the right side panel (including the right back closure overlap).
2. Fold the right panel inward toward the center line in an accordion (Z-fold) style, creating a fold width of approximately 15 to 20 cm.
3. Repeat the process for the left side panel, bringing the left outer edge inward using an identical 15 to 20 cm accordion fold so that both lateral margins meet neatly along the spine line of the garment.
4. Verify that the inner neckband tag and neck ties remain fully visible at the top edge of the newly formed longitudinal column. The exterior chest surface of the gown must now be completely shielded on the inside of the fold structure.

Step 4: Vertical Bottom-to-Top Accordion Roll

1. Position yourself at the bottom hem of the longitudinally folded gown.
2. Begin folding the bottom hem upward toward the neck collar using a tight, uniform accordion (Z-fold) pattern with fold increments of 12 to 15 cm.
3. Continue the upward accordion fold, pressing down gently on each layer to expel trapped atmospheric air, until the entire length of the gown is collapsed into a compact, rectangular package.
4. End the fold sequence directly at the collar, ensuring that the inside surface of the neckband and the internal shoulder contact points sit flatly on the very top of the folded stack.

Step 5: Towel Placement and Chemical Indicator Integration

1. Select a freshly laundered, lint-free absorbent hand towel folded into a matching rectangular dimension (approximately 15 cm x 20 cm).
2. Position the hand towel directly on top of the folded gown package adjacent to the exposed neckband.
3. Place an internal Type 5 or Type 6 chemical indicator strip flat between the top fold layer of the gown and the hand towel, ensuring it is positioned centrally to accurately capture sterilant penetration.
4. Confirm that when the outer sterile wrap is opened in the surgical suite, the hand towel and neckband are the immediate, primary contact surfaces exposed to the scrubbed professional.

Step 6: Sterilization Envelope Wrap Securing

1. Centrally position the assembled gown stack on a square sheet of sterile barrier wrapping material laid out in a diamond orientation.
2. Bring the bottom corner of the wrap over the gown assembly, completely covering it, and fold the tip back onto itself to create an accessible release tab.
3. Fold the right and left lateral corners inward over the package in sequence, each time creating a folded pull-tab extended outward for non-contaminating opening.
4. Draw the top corner down over the entire bundle, tucking the remaining material under the lateral folds while leaving a single pull-tab visible.
5. Secure the wrapped envelope using two strips of autoclave process indicator tape, clearly marking the pack with the load number, sterilizer ID, operator initials, and expiry date.

Surgical Gown Material Standards and Sterilization Specifications

Selecting the correct folding geometry depends on fabric composition, density, and liquid-barrier classification. The table below outlines key technical metrics across standard surgical gown materials compliant with ANSI/AAMI PB70 and ASTM F2407 standards.

Common Packaging Failures and Field Fixes

Standardizing gown folds prevents procedural delays and maintains barrier performance. Below are common failure modes encountered during surgical gown preparation along with their technical root causes and remedies.

• Failure Scenario: Gown Inversion during Unfurling (Garment drops exterior-first when lifted)

  
  
  
  • Root Cause: The gown was accordion-folded from the neck down to the hem rather than from the hem up to the neck, placing the hem on top of the stack.
  • Actionable Fix: Reverse the folding direction during Step 4. Ensure the final fold leaves the inside collar tags and internal shoulder seams exposed on the top face of the folded block.

• Failure Scenario: Wet Packs Post-Sterilization (Residual moisture inside gown folds)

  
  
  
  • Root Cause: Over-compressing the fabric layers during vertical accordion folding, combined with insufficient dry-time parameters in the autoclave chamber.
  • Actionable Fix: Maintain a relaxed Z-fold pattern with minimum 12 cm fold widths to allow free condensate drainage and steam circulation. Increase steam cycle drying times by 10-minute increments for Level 3 and Level 4 heavy laminates.

• Failure Scenario: Cuff Contamination During Donning (Stockinette cuffs exposed to non-sterile wrap exterior)

  
  
  
  • Root Cause: Sleeves were folded outward toward the lateral edges of the gown rather than tucked inward along the torso spine.
  • Actionable Fix: Re-align sleeves during Step 2 so that stockinette cuffs sit completely within the internal body fold envelope, at least 10 cm interior to the outer edges.

• Failure Scenario: Steam Penetration Failure (Unchanged Chemical Indicator Strip)

  
  
  
  • Root Cause: Chemical indicator placed deep inside a dense roll fold without adequate clearance for air evacuation.
  • Actionable Fix: Transition from roll-folding to a strict flat accordion (Z-fold) layout. Place the Type 5/6 indicator flat between the top gown layer and the drying towel, ensuring optimal contact with incoming sterilant gases.

Frequently Asked Questions

Why is the accordion fold preferred for surgical gowns over a standard roll fold?

The accordion Z-fold configuration allows trapped air within heavy protective fabrics to evacuate rapidly during the vacuum phases of steam sterilization. Additionally, when a scrubbed clinician lifts an accordion-folded gown by the collar, gravity smoothly unfurls the garment downward without requiring manual unrolling, preserving strict aseptic presentation.

Where should the surgical hand towel be placed within the folded gown package?

The hand towel must be placed on top of the folded gown package directly adjacent to the inside collar surface. This structural placement ensures that when the outer sterile wrap is opened by a circulating nurse, the scrubbed surgeon or technologist can pick up the hand towel first to dry their hands without touching or contaminating the underlying surgical gown.

What is the main difference in gown folding for open-glove versus closed-glove donning?

For closed-glove donning, the sleeve cuffs must remain completely enclosed within the internal body of the gown fold to keep hands protected inside the sleeve during gloving. For open-glove techniques, the sleeves are folded so that the stockinette cuffs are immediately visible and positioned for direct hand protrusion upon unfurling.

How many times can a reusable surgical gown be refolded and re-sterilized?

Reusable surgical gowns typically maintain their ANSI/AAMI barrier rating for 50 to 75 processing cycles, depending on fabric composition and laundering chemistry. CSSD technicians must track laundering logs and visually inspect gowns on a light table after every fold sequence to verify liquid resistance and seam integrity.

Can disposable single-use gowns be refolded and autoclaved if opened by mistake?

No. Single-use disposable gowns manufactured from SMS polypropylene or film laminates are validated for single-sterilization cycles only. Re-sterilizing opened single-use gowns can degrade the polymer structure, melt internal thermal seams, and compromise liquid barrier performance compliant with ASTM standards.

Upgrade Your Sterilization and CSSD Protocols

Standardizing gown preparation protocols ensures consistent aseptic performance across all surgical specialties. Implement these evidence-based folding practices within your Central Sterile Supply Department to protect staff, streamline operating room turnaround times, and maintain full compliance with ANSI/AAMI ST79 standards.