Purpose of the tool: The Postpartum Hemorrhage In Situ Simulation tool provides a sample scenario for labor and delivery (L&D) staff to practice teamwork, communication, and technical skills in the unit where they work. Upon completion of a
Postpartum Hemorrhage In Situ Simulation, participants should be able to do the following: Who should use this tool: Simulation facilitators How to use this tool: This tool should be used in connection with “Facilitation Instructions for Conducting In Situ Simulations” to prepare, conduct, and debrief in situ simulations in L&D units. Simulation facilitators can adapt, modify, and further tailor this
sample scenario to meet the training needs of their unit staff or resources available in their facility. Other resources: Additional scenarios related to obstetric hemorrhage are available from the California Maternal Quality Care Collaborative: https://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit Note: The information
presented in this document does not necessarily represent the views of AHRQ. Therefore, no statement in this document should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services. Outside resources identified do not represent an endorsement of those resources and do not reflect the position of AHRQ or the Federal Government. This document provides a sample scenario
for an in situ simulation for postpartum hemorrhage. This document contains the following: Refer to the document titled "Facilitation Instructions for Conducting In Situ Simulations" for general guidance and
instructions regarding presimulation planning, presimulation briefing, simulation assessment, and simulation debriefing. During the simulation, participants are encouraged to practice the use of protocols, checklists, or cognitive aids the unit has developed or adapted for use in evaluating and treating postpartum hemorrhage. This simulation requires people to play the roles of the patient and the patient’s support person: In addition, the following props (i.e., simulated equipment and materials) are required: The content of this simulation is divided into four parts: Clinical Context, Triggers, Distractors, and Expected Behaviors. The Clinical Context is provided at the beginning of the simulation in the form of a patient handoff and introduces that simulated patient and her clinical history. The handoff is followed by a series of Triggers and Distractors, events or actions that introduce new information and shape the context of the clinical
response. The simulation facilitator introduces the Triggers and Distractors throughout the course of the simulation. A set of Expected Behaviors is also provided for the Clinical Context and each set of Triggers and Distractors. The Expected Behaviors offer a list of ideal actions that the clinical team might take in response to each set of events in the simulation with particular regard to those that foster effective teamwork and communication. The Expected Behaviors can also serve as a tool
to use in evaluating the performance of the simulation participants. Clinical Context The facilitator provides the clinical context to person in the role of nurse. This can be done using a verbal report and handoff from one nurse to another nurse during change of shift. "Welcome to your shift. Your patient for this evening is Elena Gonzalez, a 32-year-old G4P4 who vaginally delivered a 4,309-gm term male infant 45 minutes ago. She had an
uncomplicated prenatal course, and her only medications during pregnancy were prenatal vitamins." "Her membranes ruptured at home 48 hours prior to delivery, and she was admitted to L&D about 2 hours ago in active labor. Her labor progressed quickly, and she delivered an hour later. The placenta was delivered spontaneously within 5 minutes. Her estimated blood loss was 400 ml. She had a second-degree perineal laceration that was repaired under local anesthesia. No type and cross
[T&C] was done. She has no known allergies." "Her most recent vital signs 10 minutes ago were as follows: Pulse 88, BP 124/70, Resp Rate 20, Temp 37.1 Celsius, O2 Saturation 97% on room air. I just helped her back from the bathroom, where she accidentally pulled out her IV. She’s doing well; the baby’s father is at the bedside. The kitchen is sending her up a dinner tray." Expected behavior/performance (not in any particular order): Trigger #1 Patient volunteers information to assessing nurse: "I don’t feel good. I feel sick to my stomach. My head is spinning. I am really crampy. Can I have something for pain?" Clinical information provided on cards (one at a time) in response to assessment actions taken by team. For example, after team measures blood pressure (BP), the BP value is
provided to team on a card. Pulse 100 Uterine fundus is boggy at 3 cm above umbilicus. Patient is lethargic but intelligible. Patient has pain in lower abdomen and area around vagina. Hospital gown soaked with blood, perineal pads saturated with blood, blood on bed linens. The facilitator may provide answers to team as needed to help maintain the flow of the simulation.
Symptoms and bleeding should continue while the team attempts various measures to address. Distractors Partner appears anxious, is rocking crying baby in its crib. Partner asks nurse for water and pain medication for patient. Baby is crying at intervals. Partner asks patient to breastfeed baby. Partner asks questions, does not hear answers, does not understand medical jargon. Partner is very verbal. Expected
behavior/performance (not in any particular order): Trigger #2 Partner or patient continues to pour more simulated blood on blue underpad at intervals. Patient will begin to have deteriorating vital signs. Patient will become more lethargic, but is still
responsive. The facilitator may provide answers to team as needed to help maintain the flow of the simulation. Symptoms and bleeding should continue while the team attempts various measures to address. Clinical information provided on cards (one at a time) in response to assessment actions taken by team. For example, after team takes BP, the BP value is provided to team on a card. Pulse 115 Uterine fundus is boggy at 3 cm above umbilicus. Patient is moaning and less able to speak. The facilitator may provide answers to team as needed to help maintain the flow of the simulation. Symptoms and bleeding should continue while the team attempts various measures to address. Distractors Partner continues to ask questions and is very verbal. Partner acts agitated at discussion of blood transfusion. Expected behavior/performance (not in any particular order): Trigger #3 After blood has been hung, the patient should gradually become nonresponsive. The facilitator may provide answers to team as needed to help maintain the flow of the simulation. Symptoms and bleeding should continue while the team attempts various measures to address. Facilitator ends the simulation after no further opportunities for teamwork and communication are
apparent. Expected behavior/performance (not in any particular order):
Postpartum Hemorrhage Simulation Assessment Tool (Optional)This tool provides a list of expected behaviors in response to the Clinical Context and each set of Triggers and Distractors in the simulation and can be used as a tool in evaluating the performance of the simulation participants. Trigger 1: Patient Reports Feeling Ill and Hemorrhage Identified
Trigger 2: Patient Continues to Bleed and Vital Signs Begin To Deteriorate
Trigger 3: Patient Becomes Nonresponsive
Clinical Context, Triggers, and Distractors Formatted for Printing SeparatelyThe Clinical Context, Triggers, and Distractors used in this simulation scenario are provided on the next several pages in a format suitable for printing on cardstock in preparation for facilitating this in situ simulation using printed cards. The printed cards can be handed to the simulated patient or participating staff members at appropriate intervals during the simulation. Clinical Context: "Welcome to your shift. Your patient for this evening is Elena Gonzalez, a 32 year-old G4P4 who vaginally delivered a 4,309-gm term male infant 45 minutes ago. She had an uncomplicated prenatal course, and her only medications during pregnancy were prenatal vitamins." "Her membranes ruptured at home 48 hours prior to delivery, and she was admitted to L&D [labor and delivery] about 2 hours ago in active labor. Her labor progressed quickly, and she delivered an hour later. The placenta was delivered spontaneously within 5 minutes. Her estimated blood loss was 400 ml. She had a second-degree perineal laceration that was repaired under local anesthesia. No type and cross [T&C] was done. She has no known allergies." "Her most recent vital signs 10 minutes ago were as follows: Pulse 88, BP [blood pressure] 124/70, Resp Rate 20, Temp 37.1, O2 Saturation 97% on room air. I just helped her back from the bathroom, where she accidentally pulled out her IV [intravenous line]. She’s doing well; the baby’s father is at the bedside. The kitchen is sending her up a dinner tray." Trigger #1 Patient: "I don’t feel good. I feel sick to my stomach. My head is spinning. I am really crampy. Can I have something for pain?" Clinical information to be provided to team in response to their assessment after Trigger #1 Pulse 100 Uterine fundus is boggy at 3 cm above umbilicus. Patient is lethargic but intelligible. Patient has pain in lower abdomen and area around vagina. Hospital gown soaked with blood, perineal pads saturated with blood, blood on bed linens. Distractors (Trigger #1)
Trigger #2 Support person or patient continues to pour more simulated blood on pad at intervals. Patient will begin to have deteriorating vital signs. Patient will become more lethargic, but is still responsive. Clinical information to be provided to team in response to their assessment after Trigger #2 Pulse 115 Uterine fundus is boggy at 3 cm above umbilicus. Patient is moaning and less able to speak. Distractors (Trigger #2)
Trigger #3 After blood has been hung, the patient should gradually become nonresponsive. Page last reviewed May 2017 Page originally created April 2017 Internet Citation: Sample Scenario for Postpartum Hemorrhage In Situ Simulation. Content last reviewed May 2017. Agency for Healthcare Research and Quality, Rockville, MD. Which position should be used for assessment of the fundus?Position patient flat in bed with head comfortably positioned on a pillow. d. If the procedure is uncomfortable, patient may flex legs. RATIONALE: Having the patient void assures that a full bladder is not causing any uterine atony.
Where does the nurse expect to feel the fundus?Immediately after delivery, the upper portion of the uterus, known as the fundus, is midline and palpable halfway between the symphysis pubis and the umbilicus. By approximately one hour post delivery, the fundus is firm and at the level of the umbilicus.
Where would you expect to assess uterine fundus in a patient who is 2 days postpartum?If I'm two days postpartum, the fundus is probably two centimeters below the umbilicus. And then, at day six, the fundus is halfway between the umbilicus and the symphysis pubis.
When doing a health assessment at which location would the nurse expect to palpate the fundus in a woman on the second postpartum day?At 16 weeks gestation, the fundus of the uterus can be palpated at the midpoint between the umbilicus and the pubic symphysis. At 20 weeks gestation, the fundus can be palpable at the level of the umbilicus.
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