Obstetrical Simulator Curriculum

1
Obstetrical Simulator Curriculum

• Sarah Price, MD
• Amanda Pauley, MD
• MU Dept. of Obstetrics and GynecologyJCESOM
  Academy of Medical Educators

2
(No Transcript)
3
Abstract/Purpose

• The infrequent and high-stakes nature of
  obstetric emergencies requires physicians to
  respond quickly and proficiently to a complex and
  high-stress situation, a situation they have
  likely had little opportunity to experience. We
  planned to create a realistic simulation to
  prepare physicians at our institution to manage
  these situations. Shoulder dystocia, vaginal
  breech extraction, postpartum hemorrhage, and
  forceps assisted vaginal delivery can all be
  obstetrical emergencies that require immediate
  recognition and a well-coordinated response.
  Simulation education provides an opportunity to
  learn and master simple as well as complex
  technical skills needed in emergent situations.
  This simulation training will have an enormous
  impact on human performance and improve safety
  for both the mother and infant.

4
Methods

• A curriculum was written for each of four
  potential obstetrical emergencies including
  vaginal breech delivery, shoulder dystocia,
  postpartum hemorrhage, and forceps assisted
  vaginal delivery. Each emergency has a sample
  case presentation as well as a checklist of
  knowledge and skills that physicians are expected
  to know when they are on the simulator.

5
Vaginal Breech Delivery

• 32yo G3P2002 at 38 0/7 weeks gestation presents
  to triage complaining of contractions. Her
  pregnancy has been uncomplicated. Her two
  previous deliveries were vaginal deliveries
  without complication. She is placed on the
  monitor and the fetal heart tracing is
  140s/moderate variability/accels/no decels. She
  is contracting every 2-3 minutes and is very
  uncomfortable with contractions. Upon cervical
  examination, she is noted to be dilated to 5cm,
  80 effaced, and -2 station. However, it does not
  feel as though the vertex is presenting. Bedside
  US confirms breech presentation. The patient
  refuses 1LTCS.

6
Shoulder Dystocia

• -H Call for help-E Evaluate for episotomy-L
  Legs (McRoberts Maneuver)-P Suprapubic pressure
  to disengage the anterior shoulder-E Enter
  internal rotation maneuvers (Rubin, Wood
  screw)-R Remove posterior arm-R Roll patient
  over

7
Postpartum Hemorrhage

• Call for nursing help
• Ask for a second iv- at least 18 gauge
• Assess vital signs including heart rate, blood
  pressure and pulse oximetry at least every 5
  minutes
• Start i.v. crystalloid bolus
• Assess for atony
• Assess for lacerations
• Assess for retained products
• Repair lacerations and remove retained products
  if these are found
• Perform uterine massage
• Place Foley catheter
• Notify anesthesia
• Begin/increase pitocin administration
• Methergine 0.2mg i.m- may repeat up to 3 total
  doses
• Hemabate 0.25mg- may repeat up to 8 total doses
  in 24 hours
• Cytotec 800mcg per rectum
• Place Bakri balloon and inflate with 180-200cc
  saline
• Type and cross for 4 units packed RBCs
• Notify blood bank if there is a life-threatening
  hemorrhage
• If medical management fails, to OR with plan for
  possible hysterectomy

8
Forceps Assisted Vaginal Delivery

• Indications for Operative Vaginal Delivery
• No indication for operative vaginal delivery is
  absolute. The following indications apply when
  the fetal head is engaged and the cervix is fully
  dilated.
• Prolonged second stage
• Nulliparous women lack of continuing progress
  for 3 hours with regional anesthesia, or 2 hours
  without regional anesthesia
• Multiparous women lack of continuing progress
  for 2 hours with regional anesthesia, or 1 hour
  without regional anesthesia
• Suspicion of immediate or potential fetal
  compromise.
• Shortening of the second stage for maternal
  benefit.

9

• Studies have shown that learning retention rates
  are significantly higher with hands on training
  as in simulation laboratories.

10
Future Plans

• Our plans are to continue to educate our
  residents regarding these obstetrical
  emergencies, but also to involve our nursing and
  anesthesia staff. Studies have shown that
  teamwork reduces clinical errors and improves
  patient outcomes. Therefore, we will conduct
  drills with our simulator to assist in team
  training.