433CHAPTER 37
Placental Abruption After Motor Vehicle Accident: An Interprofessional Simulation
A. IMPLEMENTATION OF SIMULATION-BASED PEDAGOGY IN YOUR INDIVIDUALIZED TEACHING AREA
Central to providing nursing care to pregnant women is the reminder that for low-risk women the goals are empowerment and support of a natural, physiological birth. Having a physiological perspective recognizes that birth is a normal, developmental process in which women benefit from holistic care with as little intervention as possible. This underpinning is at the core of the maternal and newborn nursing curriculum.
However, nurses must also be prepared to quickly recognize and react should an obstetric emergency occur, in order to safeguard maternal and fetal well-being. During obstetric emergencies seconds of time matter. To ensure that the new graduate nurses are poised to provide care in all contexts of birth, they must practice caring for women in emergent scenarios. In the clinical setting, if an obstetric emergency occurs, students become observers and passive learners, given the high-stakes situation in which maternal and fetal lives are at risk. However, in simulation scenarios, students can become actively engaged in making clinical decisions and gain confidence in recognizing the signs and symptoms of obstetric emergencies.
In the case of a placental abruption, both maternal and fetal well-being depend on the ability of RNs, certified registered nurse anesthetist (CRNAs), anesthesiologists, certified nurse midwives (CNMs), and obstetricians (OBs) working together efficiently as a team to identify and treat the situation with emergent delivery of the infant. Placental abruption, when the placenta detaches from the wall of the uterus before the birth of the infant, has many possible underlying causes, including vasospasm related to maternal hypertension or cocaine use, abdominal trauma related to a motor vehicle accident, direct trauma to the abdomen (accidental or purposeful such as in intimate partner violence [IPV]), or other forms of injury during pregnancy (Oyelese & Ananth, 2006). The textbook presentation of a rigid, board-like abdomen with dark-red vaginal bleeding does not always occur if the abruption is partial or concealed, which results in subtler signs and symptoms (Oyelese & Ananth, 2006; Tikkanen, 2011; Tikkanen, Nuutila, Hiilesmaa, Paavonen, & Ylikorkala, 2006). Educating the students to assess pregnant women with pain, bleeding, or symptoms indicating a placental abruption is imperative to maternal and fetal survival.
Student recognition of an obstetric emergency is important, as is the necessity for clear and concise communication with all members of the health care team during this emergency. In the obstetric setting, this involves the RNs, CRNAs, CNMs, and OBs. This high-stakes scenario requires students to quickly assess a pregnant woman and to recognize a placental abruption, as well as to communicate these findings with the health care team. The goal is to get the patient into the 434operating room (OR) for a cesarean birth as quickly as possible, maintaining patient(s) (mother and infant) safety, and using therapeutic communication with the patient and family members.
The International Nursing Association for Clinical Simulation and Learning simulation Standard IX: Simulation Design (Lioce et al., 2015) is at the core of pedagogy in the development of scenarios for meaningful simulation experiences at the authors’ institution. We ensure each participant has a clear plan of what their role will be before entering the simulation environment. Furthermore, we foster a read-through of the scenario to identify key risk factors (in this case a motor vehicle accident [MVA] involving a pregnant patient), to discuss the anticipated patient signs and symptoms, and to outline potential nursing care that the patient may necessitate. This purposeful prebriefing with the course faculty lead and the simulation director is conducted to allow for maintenance of professional integrity and for active and observational learning (Gloe et al., 2013).
B. EDUCATIONAL MATERIALS AVAILABLE IN YOUR TEACHING AREA AND RELATED TO YOUR SPECIALTY
Preoperative Area
Our simulation suite is equipped with a high-fidelity medical surgical room that doubles as a labor and birth (L&B) suite, a pediatric care area, or a long-term care space with a designated control room. A standardized patient (SP) enhances fidelity and humanism in the simulation. A control room with a one-way mirror is adjacent to the simulation room. The control room houses audiovisual equipment, which allows for live streaming of the simulation into the classroom. The use of the new Laerdal LLEAP software is used to control vital signs (VS) of the SP via a patient monitor. A tablet is used to display an electronic fetal heart rate (FHR) using iSimulate, an application that is available for download on an Apple mobile device. A landline is used to communicate to the provider when necessary.
Intraoperative Area
CAE’s METIman is used as the high-fidelity human patient simulator (HPS) in our state-of-the-art simulated OR. A placental abruption case was originally developed by Anka Roberto and a CRNA doctoral student in 2014 using the 2013 International Nursing Association for Clinical Simulation and Learning (INACSL) simulation standards. The scenario was piloted in 2014 twice before its implementation. The simulation presented in this chapter was then further augmented and edited by both authors as they began to jointly run the simulation in 2015. Laerdal’s PROMPT Birthing Simulator Infant is used during the delivery process. Laerdal’s SimBaby is used to exemplify neonatal resuscitation in the immediate postnatal phase. Simulated blood products are used to allow for students to understand the process that takes place for an intraoperative blood transfusion as well as a blood warming unit. A Draeger ventilator is used to allow a rapid sequence induction (RSI) to take place to provide general anesthesia.
Postoperative Area
In the simulation room an SP playing the role of the father is used to allow for therapeutic communication techniques to take place with audiovisual capabilities.
C. SPECIFIC OBJECTIVES FOR SIMULATION USAGE WITHIN A SPECIFIC COURSE AND THE OVERALL PROGRAM
The overarching objective of this simulation is to promote interprofessional education (IPE) between DNP nurse anesthetist students and BSN students. These students will be working together in the clinical setting and the teamwork between these two cohorts is critical, especially in 435the fast-paced, labor and birth (L&B) setting. Furthermore, recognizing the signs and symptoms of a placental abruption, an obstetric emergency, and quickly and safely generating a plan of care among the health care team is critical to the life of the patient and her neonate.
This scenario was initially designed for Maternal and Newborn Nursing (NS314) as a flipped-classroom, advanced-level simulation. Students enrolled in this course were either second-term, third-year students or first-term, fourth-year baccalaureate students. These students take a medical–surgical course concurrently and have completed pathophysiology, pharmacology, therapeutic skills, and physical assessment courses. This scenario takes place toward the end of the semester, when the students have already had the bulk of their exposure to the maternal and newborn clinical areas. They all have had at least one experience in L&B, the neonatal intensive care unit (NICU) and postpartum and have assessed a pregnant and/or a postpartum woman as well as a newborn. In addition, before entering the maternal and newborn clinical setting, these students spend a full clinical day in the simulation environment providing postpartum assessments on static patients, as well as practicing both newborn assessment and a neonatal resuscitation on Laerdal’s SimBaby. Anecdotally, the students have shared how this day prepares them for the clinical setting and helps to enhance their skills and confidence to provide excellent patient care in the hospital environment.
The DNP nurse anesthetist students have already completed their obstetric rotation and serve as content experts in this scenario. Before the start of the simulation these students teach the theory portion of the class on the role of anesthesia and the medical pain management options in labor. All nursing programs at Fairfield University strive to promote holistic nursing care, which is delivered safely and efficiently through all members of the health care team working together.
D. INTRODUCTION OF SCENARIO
Setting the Scene
In the emergency department (ED) of the local hospital, a patient (Mia) arrives to be evaluated. Mia is a G1 P0 and presents s/p (status post) an MVA at 37 weeks, 1 day gestation. Mia, with a history of scoliosis, arrives on a stretcher via ambulance in a lot of pain. She has some vaginal bleeding and is incredibly concerned about her baby. Report is given to indicate that the airbags were deployed after she was rear-ended as the driver. The emergency room (ER) RNs promptly assess her to anticipate a transfer to L&B for the imminent delivery of her newborn. Welcomed by the charge nurse, the L&B RNs assess the patient, obtain VS of both mother and fetus, obtain patient medical history (PMHx), start an intravenous (IV) line, send for blood work, and inform the attending CNM or OB/GYN.
The patient will be admitted for emergent cesarean birth because of placental abruption. The anesthetist assesses the patient recommending general anesthesia because of scoliosis of mother and the emergency condition of placental abruption. After obtaining consent, the anesthetist and the CNM/OB/GYN transfer the patient to the OR. The patient will be transferred to an OR table, anesthesia induction RSI occurs. Time-out will be performed, led by the circulating RN. Surgery will start and the scrub RN will ask for supplies. The infant is delivered not breathing, with a decreased heart rate, cyanotic, little movement, and no audible cry. The infant has an Apgar score of 2 at 1 minute. Neonatal nurses provide appropriate neonatal care following Neonatal Resuscitation Program (NRP) guidelines. The infant is resuscitated, stabilized, and brought to the father in the recovery room; the infant’s 5-minute Apgar score is 7.
Technology Used
A classroom with audiovisual capability was used to live stream the recorded simulation into the classroom while the active participants were caring for Mia. The Laerdal LLEAP software is used to control VS of the SP via a patient monitor. A tablet was used to display the electronic FHR using iSimulate. An FHR strip indicating fetal distress was created, in which the FHR drops to 60 beats/minute and does not recover. A landline is needed to call members of the health care team. CAE’s iStan is used in the OR. Laerdal’s PROMPT Birthing Simulator Infant is used during the birthing process. Laerdal’s SimBaby 436is used for neonatal resuscitation in the immediate postnatal phase. A Draeger ventilator was used to allow for an RSI to take place to provide general anesthesia. In addition, a pulse oximeter, blood pressure (BP) cuff, IV start tray, IV tubing, IV fluids (choices of 1,000 mL D5NS [potassium chloride in 5% dextrose and sodium chloride], Ringer, or normal saline [NS]), vials for blood collection for type and cross, Foley catheter, clippers for surgical prep, a pad with vaginal bleeding (red food coloring and water are used to simulate bleeding), O2, face mask, Bicitra, Ancef, and external fetal monitors (toco transducer and external FHR monitor). Routine and as needed (PRN) mediations are available.
Objectives
1. Assess a third-trimester patient with abdominal pain and vaginal bleeding
2. Prioritize assessment of the fetus and identify fetal distress through fetal monitoring
3. Use therapeutic communication techniques with patient and family members
4. Maintain patient safety throughout the intraoperative period
5. Communicate efficiently with interprofessional health care team
6. Provide neonatal support and resuscitation using NRP algorithm
7. Recognize one’s own limitations in skills, knowledge, and abilities to promote safe and efficient care (Interprofessional Education Collaborative [IPEC] Expert Panel, 2011).
The scenario also allows students to practice key elements from the National Council of State Boards of Nursing (2015) National Council Licensure Examination for Registered Nurses (NCLEX-RN®) test plan, including:
Safe and effective care environment: Management of care (advocacy; assignment, delegation and supervision; collaboration with interdisciplinary team; establishing priorities; informed consent), Safety and infection control (accident/error/injury prevention; standard precautions/transmission-based precautions/surgical asepsis); Health promotion and maintenance: (ante/intra/postpartum and newborn care, techniques of physical assessment); Psychosocial integrity: (family dynamics; therapeutic communication); Physiological integrity: Basic care and comfort (nonpharmacological comfort interventions), Pharmacological and parenteral therapies (parenteral/intravenous therapies; pharmacological pain management), Reduction of risk potential (changes/abnormalities in vital signs; laboratory values, potential for alterations in body systems, potential for complications from surgical procedures and health alterations, system specific assessments, vital signs), Physiological adaptation (hemodynamics, medical emergencies, pathophysiology)
For this scenario, the American Association of Colleges of Nursing (AACN; 2008) Essentials of Baccalaureate Education for Professional Nursing Practice items addressed include the following:
Essential I: Liberal Education for Baccalaureate Generalist Nursing Practice, Objectives 2, 7
Essential II: Basic Organization and Systems Leadership, Objectives 1, 7, 8
Essential IV: Information Management and Applications of Patient Care Technology, Objectives 1, 5, 6
Essential VI: Interprofessional Communication and Collaboration for Improving Patient Health Outcomes, Objectives 1, 2, 4, 6
Essential VIII: Professionalism and Professional Values, Objectives 6, 9
Essential IX: Baccalaureate Generalist Nursing Practice, Objectives 3, 5, 12, 21
Description of Participants
Triage RN
Role: As triage RN, you are to maintain patient safety, recognize signs and symptoms of placental abruption, assess patient (Pt.) and fetus (FHR). Obtain past medical history. Make recommendations.
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