Practical obstetric simulation training

MULTIPROFESSIONAL OBSTETRIC

EMERGENCIES TRAINING

Martina Gisin

December 2012

CONTENT Why simulation training ? Evidence Importance of teamwork Importance of communication Training options Multidisciplinary training for obstetric emergencies

in Basel Example: Scenario shoulder dystocia Example: Scenario post partum haemorrhage

WHY ? - 1 Obstetric emergencies are rare – experience

needed

Obstetric emergencies are mostly unexpected - immediate, adequate action is required

High risk situations – medico- legal consequences

Complications in 1 of 12 deliveries

WHY ?- 2

To improve: Maternal and perinatal care Outcomes Teamwork Communication Team roles and responsibilities Situational awareness

SIMULATION TRAINING FOR OBSTETRIC EMERGENCIES-

EVIDENCE

CONFIDENTIAL ENQUIRIES- 1

Potentially preventable:

o 50% of all maternal deaths

o 75% of all intrapartal caused deaths

CONFIDENTIAL ENQUIRIES- 2

Recurrent sources of error:

Not identifying the problem Communication failures Too late or missing reaction Transfer of the patient too late or not Delegate inadequately to an inexperienced assistant Lack of multiprofessional team working

CEMACH 2007, Lewis 2001, CESDI 1996

UK: NATIONAL RECOMMENDATIONS

Annual drill training of all obstetric and midwifery staff

Fire drills to improve management of rare emergency situation : multiprofessional and training of team work

6 monthly CTG training

CEMACH 2007, Clinical Negligence Scheme for Trusts 2007, CESDI 1996

SAFE STUDY

Simulation and Fire drill Evaluation

Department of Health funded:

o Proof of principle study of the effect of individual and team drill of different intensities on the ability of labour ward staff to manage acute obstetric emergencies

o Local vs. centre-based simulation training

o Evaluate ‘teamwork training’Crofts et al. 2006

SAFE STUDY

Main study 6 hospitals 141 staff

96 midwives45 doctors

Own unit Simulation centre

SAFE STUDY - BEFORE TRAINING

o 57% of the participants used basic manoeuvres (McRoberts Manoeuvre and suprapubic pressure)

o 42% of the participants did not achieve to start Mg- sulfat within 10 minutes

o PPH Management was suboptimal

SAFE STUDY CONCLUSIONS

Training verified

Training improved knowledge and performance Team working scores improved after

multiprofessional training Similar improvement between local training units or

simulation centres Improvement on knowledge and skills persist for

1 year

IMPROVEMENTS IN PERINATAL OUTCOME WITH LOCAL

TRAINING

The introduction of obstetric emergencies training courses was associated with a significant reduction in low 5-minute Apgar scores

Draycott et al. 2005

DIAGNOSIS-DELIVERY INTERVAL WITH UMBILICAL CORD PROLAPSE: THE

EFFECT OF TEAM TRAINING

1 day emergency training interprofessional every 2 months Decrease interval decision delivery : 25 minutes versus 14,5

minutes Increase in recommended actions to alleviate cord

compression : 34,7% versus 82,3% No decrease in low pH (5 min) No decrease in transfer to neonatal intensive care No increase in spinal anaesthesia

The introduction of annual training, in accordance with national recommendations, was associated with improved management of cord prolapse.

Siassakos et al. 2009

IMPORTANCE OF TEAMWORK

„TRAIN TOGETHER, WHO WORKS TOGETHER“

MULTIDISCIPLINARY

Anaesthetist

Obstetrician

Midwife

Neonatologist

Haematologist

IMPORTANCE OF COMMUNICATION

Transfer of information and sharing meaning

Communication is often impaired under stress

Effective communication: Give a clear message Use name of staff and allocate appropriate tasks Message should be sent clearly Adequate volume and repeated back Meaning acknowledgement and action performed

TRAINING OPTIONS -1

TRAINING OPTIONS -2

BASEL MULTIPROFESSIONAL OBSTETRIC EMERGENCIES

TRAININGProgramm

8.30 – 9.00 Registratur

9.00 – 10.00 Begrüssung und Einführung

10.00 – 10.30 Kaffeepause + Aufteilung in Gruppen

10.30- 12.45 Training + Simulations-Szenarien:

Präeklampsie

PPH

Schulterdystokie

12.45 – 14.00 Mittagspause

14.00 – 16.15 Training + Simulations-Szenarien:

Fruchtwasserembolie

Reanimation Neugeborenes

Suspektes CTG: VE / FE

16.15 – 17.00 Ende der Fortbildung und Zertifikate

PREPARATION- 1

PREPARATION- 2

EXAMPLE: SCENARIO SHOULDER DYSTOCIA

Key learning points: Antenatal and intrapartum risk factors Understand manoeuvres to effect delivery

during shoulder dystocia Clear and accurate documentation Awareness of potential complications of

shoulder dystocia

CASE SHOULDER DYSTOCIA

Handover midwife:

This is Ms. Brown, pregnant with her first baby. She is having a gestational diabetes. She arrived with regular contractions one week before term.

The labour was without any difficulties up till now. However, the cervix is now fully dilated and she is pushing since 75 minutes.

INITIAL MANAGEMENT OF SHOULDER DYSTOCIA

Prevention Management: Recognition of shoulder dystocia Call for help McRobers’ manoeuvre Suprapubic pressure Evaluate the need for an episiotomy Internal manoeuvres Gaining internal vaginal access Delivery of the posterior arm Internal rotational manoeuvres All fours position Documentation

To avoid: traction and fundal pressure

SCENARIO SHOULDER DYSTOCIA

SCENARIO SHOULDER DYSTOCIA

DEBRIEFING- SCENARIO SHOULDER DYSTOCIA

EXAMPLE: SCENARIO POST PARTUM HAEMORRHAGE (PPH)

Key learning points: To understand the main risk factors and causes of major

obstetric haemorrhage To emphasise the importance of early fluid resuscitation To train the immediate management and treatment of PPH,

including bimanual uterine compression Recall the drug doses and routes of administration for the

treatment of uterine atony To outline mechanical manoeuvres required to control

torrential bleeding To communicate effectively with he woman and the team Document details of management accurately and

CASE PPH- 1

Handover , midwife to midwife:

Ms Miller has delivered 20 minutes ago her first baby. Robert weights 4200 g. She is very tired after a prolonged labour. She is having an intravenously infusion as she has used Oxytocin in labour because of a hypotonic uterine dysfunction and a prolonged second stage of labour. The placenta has been expelled spontaneously and is complete. At the moment, the blood loss is around 400 ml, but it’s still dripping a bit..

Midwife to Ms. Miller: Ms. Miller, I would like to introduce my colleague Ms. Smith.

She will take care from now on.

SCENARIO PPH- 2

INITIAL MANAGEMENT OF MAJOR PPH

Call for help (early involvement of senor staff)

PPH emergency box

Assessment- rapid evaluation (observe for signs of shock)

Stop the bleeding (oxytocics, mechanical measures)

Fluid replacement (rapid fluid resuscitation)

MANAGEMENT OF PPH

DEBRIEFING SCENARIO PPH

BASEL SIMULATION TEAM FOR OBSTETRIC EMERGENCIES

LITERATURE

Crofts JF, Bartlett C, Ellis D, Hunt LP, Fox R, Draycott TJ (2006). Training for shoulder dystocia: a trial of simulation using low-fidelity and high-fidelity mannequins. Obstet Gynecol 108 (6), p. 1477- 1485

Confidential Enquiries into stillbirths and deaths in infancy(1996). Focus group- shoulder dystocia. In 5th annual report London: maternal and child health research consortium, p. 73-79

Draycott T, Sibanda T, Owen L, Akande V, Winter C, Reading S, Whitelawb A (2005). Does training in obstetric emergencies improve neonatal outcome? BJOG 113, p.177–182.

Lewis G, Drife J (2001) Why mothers die 1997- 1999. The fifth report of the Confidential Enquiries into maternal deaths in the United Kingdom. London: RCOG

Lewis G (2007) Saving mothers lives: reviewing maternal deaths to make motherhood safer 2003- 2005. The seventh report of the Confidential Enquiries into maternal deaths in the United Kingdom. London: Cemach

NHS Litigation authority (2007): Clinical negligence scheme for trusts maternity clinical risk management standards. London: NHSLA

Siassakos D, Hasafa Z, Sibanda T, Fox R, Donald F, Winter C, Draycott, T (2009). Retrospective cohort study of diagnosis-delivery interval with umbilical cord prolapse: the effect of team training. BJOG