MULTIPROFESSIONAL OBSTETRIC EMERGENCIES TRAINING Martina Gisin December 2012
May 28, 2015
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