187CHAPTER 18
Obstetric Emergency: Postpartum Hemorrhage1
A. IMPLEMENTATION OF SIMULATION-BASED PEDAGOGY IN YOUR INDIVIDUALIZED TEACHING AREA
Experiences for the obstetric and pediatric clinical areas are becoming difficult to acquire for students, as increasing numbers of students compete for a small number of slots, and constraints on the numbers of students allowed in clinical settings continue to rise. In British Columbia, most of the family birthing units limit the number of students allowed to six and most health authorities require a 1:6 faculty/student ratio. In addition, students need to rotate through at least two areas—postpartum and intrapartum (labor and delivery)—which adds to the complexity of scheduling and student education. Students require preparation for assessments and skills required by these areas.
At present, simulation-based pedagogy has been implemented in this area with the use of an intermediate-fidelity pregnant human patient simulator (HPS) to demonstrate Leopold maneuvers; fundal height measurement; infant positioning in utero (e.g., for placement of external fetal monitors and to monitor the birth process); and, in some cases, to simulate the birth process (Cooper et al., 2012; Ferguson, Howell, & Parsons, 2014; Fox-Young et al., 2012; Gardner & Raemer, 2008). Other uses for this model could include the demonstration and practice of obstetric emergencies such as shoulder dystocia, prolapsed umbilical cord, placenta previa, and abruptio placentae. As postpartum hemorrhage (PPH) constitutes an obstetric emergency and remains a major cause of maternal morbidity and mortality in high- and low-resource countries (Chalouhi, Tarutis, Barros, Starke, & Mozurkewich, 2015), using a simulator offers an ideal opportunity for students to practice their skills in simulated PPH. The scenario presented in this chapter was modified and used at the University of British Columbia (UBC) School of Nursing (SoN) since January 2015. Student preparation requires readings, videos, and evidence-based practice protocols for PPH.
B. EDUCATIONAL MATERIALS AVAILABLE IN YOUR TEACHING AREA AND RELATED TO YOUR SPECIALTY
The UBC SoN has several rooms set up for simulation. The simulation lab was run over a 3-hour period with two faculty members and groups of six students exposed to the simulation at a time. 188The PPH scenario takes place in the acute care area (a room set up like a patient room in hospital on a family birthing unit) using a medium-fidelity HPS (Laerdal’s VitalSim Anne®). The faculty communicated with students directly and responded as the voice of the patient from behind curtained areas using the remote to effect vital sign (VS) changes. Students were requested to prepare for the simulation by completing a number of readings available on their learning management system. The readings included: Campbell and Daley (2013); Davidson, London, and Ladewig (2012a, 2012b); Hall (2014); and Leduc and colleagues (2009); see References and Further Reading.
C. SPECIFIC OBJECTIVES FOR SIMULATION USAGE WITHIN A SPECIFIC COURSE AND THE OVERALL PROGRAM
As PPH continues to be the leading cause of maternal death globally (Leduc et al., 2009; Rath, 2011), with one woman dying every 4 minutes (Rath, 2011), using simulation to educate health care professionals about teamwork in managing PPH should be a priority (Dolea, AbouZahr, & Stein, 2003; World Health Organization, 2010). This scenario aimed to assess nursing students’ abilities to conduct thorough postpartum assessments, recognize abnormal findings, and act to determine a plan of action to enhance patient safety and emotional stability. The previous version of this scenario was designed as an in-class, advanced-level simulation for American third-year baccalaureate or first-year associate degree nursing students in their second semester. At UBC SoN, Canadian students exposed to the simulation were in an advanced course: Nursing Practice with Childbearing Families, offered in their fourth term of a five-term accelerated BSN program. The students in the UBC program had completed a medical–surgical course and an introductory course: Professional Nursing Practice with Childbearing Individuals and their Families. Students interested in pursuing a career in maternal-child nursing could select the advanced course from a number of specialty courses.
Student Learning Activities
• Review and practice normal postpartum assessment (text, videos, online materials)
• Review risk factors for postpartum complications (text, evidence-based-protocols, references)
• Review medications: pain, oxytocics, standard orders for postpartum medications (up-to-date pharmaceutical resources in your country)
D. INTRODUCTION OF SCENARIO
Setting the Scene
The setting is a hospital room on a postpartum unit of a tertiary-level institution. The students receive a report from the night nurse, an obstetric resident is available on call, and the infant is in the room being held by the father.
Technology Used
The medium-fidelity HPS is a female: genitalia are in place on this HPS, running manually, with initially normal vital signs (VS) (blood pressure [BP]: 100/70 mmHg, pulse [P]: 80 beats/minute, respiratory rate [RR]: 16 breaths/minute, temperature [T]: 36.9°C), but these are not visible on the monitor, and the pulse oximeter is not in place. The patient has a saline lock from IV antibiotics in labor for positive status for group B streptococcus (strep). She is wearing a pad with gauze panties that are soaked through with two grapefruit-sized clots (paste and food coloring). A boggy uterus displaced to the right is present in the medium-fidelity HPS using a fundal model. A wristband identifies the patient as “Mrs. Matilda Price.” Stethoscopes, gloves, and a pulse oximeter are placed nearby for student use, as well as intravenous (IV) fluids (1,000 mL normal saline), a large-bore intravenous canula, IV tubing, blood transfusion set, 189suture materials, Foley catheter, packing materials, and blood products (Leduc et al., 2009; Perinatal Services BC [PSBC], 2011). Clean perineal pads, gauze panties, and a pericare bottle are nearby. Routine and as-needed (PRN) medications are also available (PSBC, 2011).
Objectives
1. Apply physiological knowledge to detect PPH.
2. Demonstrate critical and systematic thinking to manage PPH.
3. Incorporate all family members in the management of PPH to support emotional well-being.
4. Use empirical evidence to support approaches to managing PPH.
5. Work collaboratively with other members of the health care team to manage PPH.
Description of Participants
Mrs. Matilda Price, a 39-year-old First Nations woman of Coast Salish and Snohomish descent. Obstetric history: gravida 5, term 3, preterm 1, abortions 1, living 4. Augmentation of labor with Pitocin occurred and membranes were ruptured on Sunday morning. Had a vacuum-assisted delivery of 9 lbs. 8 ounces (4,309 g) male on Sunday at 4:30 a.m.; long labor—difficult delivery, pushed for longer than 1 hour. Midwife Robinson is on call for care of Mrs. Price, who is a clinic patient.
E. RUNNING OF THE SCENARIO
Before the simulation, students were requested to review readings available through the learning management system and provided with the patient history. Students were oriented to the simulation room and the HPS, shown the location of medications and supplies, and provided an opportunity to ask questions and clarify the situation. They were given report and told Mrs. Price is diaphoretic, with falling BP. Students were to identify the risk factors from the patient history and respond to the VS by performing a postpartum check, including information about the onset, duration, and amount of blood loss (PSBC, 2011). On assessing the fundal height and tone they found a boggy and displaced fundus, as well as lochia soaking the pad with two grapefruit-sized clots. Priority care involves calling for help, running IV fluids with 20 IU oxytocin, and performing bimanual fundal massage (PSBC, 2011). They should start oxygen by mask at 8 to 10 L/minute and monitor O2 saturation. They would also insert a Foley catheter, to monitor urine output, recheck the fundal location, and continue bimanual uterine massage if still boggy, prepare a second line of uterotonic drugs, and anticipate laboratory studies (PSBC, 2011). They should recognize the potential for blood transfusions and surgery, dependent on the cause of the bleeding
F. PRESENTATION OF COMPLETED TEMPLATE
Title
Obstetric Emergency: PPH
Focus Area
Nursing 422: Nursing Care of the Childbearing Family, specialty clinical course in obstetrics for fourth-term nursing students in an accelerated baccalaureate program.
Scenario Description
The students arrive at 07:00 for clinical experience at a tertiary-level institution in a postpartum unit. They are assigned to care for Mrs. Matilda Price, a clinic patient being overseen by Ms. Robinson, midwife. The 190infant is under the care of Dr. Lavoy, a pediatrician, and at present is in the mother’s room. The night nurse gives the following report:
Patient: Mrs. Matilda Price
Age: 39 years
DOB: As decided to configure the rest of the scenario
Allergies: No known drug allergies (NKDA)
History: Admission at 24 00 hours. Gravida 5, term 3, preterm 1, abortions 1, living 4 counting new 9-pound, 8-ounce (4,309 g) male born at 04:30. Breastfeeding: infant latched after delivery but is being held by the father because the mother is feeling very groggy and dizzy. Children at home are 6, 4, and 2 years old, two girls and a boy, respectively, being cared for by a grandparent.
Delivery history: Augmentation of labor with oxytocin and membranes ruptured artificially at 00:30. On admission had labored for 5 hours at home and per vaginal exam was 4-cm dilated and partially effaced. Vacuum-assisted delivery; after labor (9.5 hours)—difficult delivery, pushed more than 1 hour. At 2400, VS were as follows: BP: 100/70 mmHg, P: 80 beats/minute, RR: 16 breaths/minute, T: 36.9°C, hemoglobin (hgb): 12.0 g/L, and hematocrit (hct), 35%. The patient has a saline lock from IV antibiotics in labor for group B strep—positive status (received amoxicillin 1 amp ×3), 18-gauge needle is in place. Her fundus has been firm, midline, one fingerbreadth above umbilicus; lochia rubra, moderate amount; and the report indicated that episiotomy with 4th-degree laceration was intact when transferred to floor.
When students enter room, this is what they find:
• Monday morning at 07:00 VS: BP: 65/45 mmHg, P: 120 beats/minute, RR: 21 breaths/minute, T: 36.8°C
• Fundus: Boggy and displaced to right of umbilicus
• Lochia: Bright red, pad soaked with two grapefruit-sized clots
• Episiotomy with fourth-degree laceration: R-2, E-2, E-3, D-3, A-1 = 11; no signs of cervical lacerations, hematoma, or other problems
• Patient complains of dizziness, color is pale, and slight diaphoresis noticed on forehead
• Patient is not hungry and is very teary; lab values: group B strep positive, venereal disease research laboratory (VDRL) neg, HIV neg, white blood cell (WBC): 80,000, hgb: 9.7, hct: 30% (14% change from admission), blood type O+ (two units crossmatched and on hold)
• Father is present and holding the baby
PATIENT INFORMATION
Admission Date: TBD
Today’s Date: Same as admission
Name: Matilda Price
Gender: F
Age/DOB: 39 years
Allergy Status: No known allergies
Previous Medical History (brief summary): No previous chronic illnesses or recent surgeries
Personal/Social History (brief summary if required): Married G5 T3 P1 A1, 4 children
History of Present Illness: Vaginal delivery of a 4,309-g male infant at 04:30 hours. Labor started at 19:00 previous evening. Labor was augmented with oxytocin and membranes were ruptured artificially at 24:00. First stage: 8 hours. Second stage: 90 minutes. Third stage: 30 minutes. A right-medio-lateral episiotomy was performed. Patient had active management of third stage with oxytocin 10 IU administered intramuscularly after delivery of the anterior shoulder. At final postdelivery check, her indicators were: BP: 100/70 mmHg, P: 80 beats/minute, RR: 16 breaths/minute, T: 37.2°C, hgb: 120 g/L, hct: 0.35 volume fraction. Her fundus was firm at 1 fingerbreadth above umbilicus. She voided 50 mL. Her episiotomy was intact and her lochia was moderate rubra.
Presenting Symptoms: Diaphoretic, increased capillary refilling time, cool and clammy extremities, anxiety, tachycardia (120 beats/minute), tachypnea (21 breaths/minute), oliguria, fundus boggy and displaced to right, lochia bright red with two grapefruit-sized clots, episiotomy intact, and no signs of hematoma (e.g., vaginal pressure and pain).
Diagnostics (relevant test results): Lab values not yet available.
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