Simulation Scenario Pack Shoulder Dystocia

Simulation Scenario Pack – Shoulder Dystocia

Western Sussex Hospitals Trust Simulation Centre

Created by: Julie Turner - Clinical Skills and Simulation Manager Edited by: Miss Alison Crocker – Consultant Obstetrician Sarah Bolger - Practice Development Midwife Dr Keri Ashpole –Consultant Anaesthetist

This document is designed to assist you in delivering the shoulder dystocia simulation scenario. By reading all sections in this document, you will have all the relevant information to run your station.

This scenario was originally designed to be used with a PROMPT trainer pelvis as a hybrid simulation. It is difficult to run this scenario without a pelvis mannequin and most units should have access to this equipment so this requirement has been left in.

This document remains the property of Western Sussex Hospitals Trust PGMC Simulation Centre 2 Created by Julie Turner, Clinical Skills and Simulation lead. www.cmec.info Contents

Rules of simulation 4

Curricular information 5  Education Rationale  Learning objectives

Demographics 6  Simulation plan  Patient details

Station kit requirements 7

Handover 8

Scenario route card 9

Potential issues for each staff group 10

Debrief – generic advice 11

Checklist to guide debrief for shoulder dystocia 13

This document remains the property of Western Sussex Hospitals Trust PGMC Simulation Centre 3 Created by Julie Turner, Clinical Skills and Simulation lead. www.cmec.info Rules

Participant Guidelines for Simulation

1. Whether there is a mannequin or a patient actor for your station, treat them with respect as you would a real patient, and treat the scenario as a real patient interaction as much as possible.

2. Actively participate in the simulation and provide respect, support and encouragement for those around you. This is a team learning experience in a safe, non-threatening environment.

3. Remember that mistakes are puzzles to be solved, not crimes to be punished.

4. Do not discuss the patient’s situation or anyone’s performance outside this room. “What happens in simulation stays in simulation.”

5. Follow safety, quality of life, and infection control standards.

6. Time is limited. Be prepared to change activities as directed.

7. Use the telephone in the scenario to call required help if needed. DO NOT use your hospital’s real emergency number

Precautions for Simulation Mannequins

1. All mannequins are to be operated by trained personnel only.

2. Any special instructions for using the mannequins will be explained to you by the faculty beforehand.

3. Wash hands prior to using the mannequins and use gloves as appropriate when working with the mannequins.

4. Do not perform mouth-to-mouth respirations on the mannequins.

5. Do not place felt tipped markers, ink pens, acetone, iodine, or other staining medications, newsprint or inked lines of any kind on or near the mannequins, as it will stain them.

6. Do not bring food or drink anywhere close to the mannequin.

7. Do not introduce fluids into the torso area without advanced training. At no time are fluids to be introduced into the left (BP) arm.

8. Do not use sharps on mannequins.

This document remains the property of Western Sussex Hospitals Trust PGMC Simulation Centre 4 Created by Julie Turner, Clinical Skills and Simulation lead. www.cmec.info Curricular Information

Educational Rationale:

Independent competence in managing the clinical situation simulated in this scenario is a mandatory element of the O+G curriculum, and participating in a drill simulating this scenario is also mandatory. Team simulation training has been shown to improve both staff confidence and performance in the live situation, and also patient safety and outcomes.

Simulation focuses on facilitation of emergency scenarios to enable staff to gain knowledge using their own learning styles, while being supported and encouraged by senior experienced in-house staff.

The simulation scenario works best when participants take on their own roles, and hence is most valuable when all members of the MDT train together (midwives, doctors, ODPs and anaesthetists)

Learning Objectives for the shoulder dystocia station

To provide a safe environment for staff to explore their role within the scenario of managing shoulder dystocia.

To encourage and promote MDT working.

To promote and facilitate interpersonal and communication skills during the emergency.

To expose staff to the shoulder dystocia emergency scenario in order for them to gain experience and competency in working within their role. Expected level of competence (level 1/2/3) depends on the stage of training of the trainee.

To provide practice-based learning environments

This document remains the property of Western Sussex Hospitals Trust PGMC Simulation Centre 5 Created by Julie Turner, Clinical Skills and Simulation lead. www.cmec.info Demographics

Case Title: Shoulder dystocia

Patient Name: Claire

Simulation Team: Lead faculty member: normally an obstetric consultant or senior registrar Role: Manage clinical picture, take notes for debrief, lead debrief.

Supporting faculty: could be any senior doctor or midwife Role: Midwife giving handover, extra support in scenario if needed, help facilitate debrief.

Supporting faculty no 2: could be any senior doctor or midwife Role: patient actor controlling delivery of the baby doll through the pelvis mannequin

Simulation Plan

Time Line:

1-2 minutes: Handover/scenario brief 2-15 minutes: simulation 15-30 minutes: Debrief and discussion

Patient Details

Patient Age: 25

Patient Allergies: NIL

Past medical History: NIL

Current Obstetric History:

 P0 40+4w, uncomplicated pregnancy.  spontaneous labour  appropriate progress to full dilatation

Current Medication: nil

This document remains the property of Western Sussex Hospitals Trust PGMC Simulation Centre 6 Created by Julie Turner, Clinical Skills and Simulation lead. www.cmec.info Preparation

The following props and kit should be available for this station:

Equipment Alternatives if no specialised sim kit available Equipment for participants to use Laminated picture of wall call bell Call bell drawn on a piece of paper stuck to the wall Delivery pack instruments as on labour ward Laminated photograph of phone to allow Disconnected old phone which is not in 2222 call to be put out use in any clinical areas Shoulder dystocia scribe proforma (laminated) Dry wipe pen for participants’ use Maternity notes for the ‘patient’ including partogram Laminated photocopy of normal CTG stuck onto a shoebox to represent CTG machine

Equipment for facilitators to use Pelvis mannequin which is not tied down Unfortunately this scenario is difficult to run without a pelvis mannequin Bed with removable end and which can be lowered from sitting position to flat Lubricating spray Baby doll which fits through pelvis

This document remains the property of Western Sussex Hospitals Trust PGMC Simulation Centre 7 Created by Julie Turner, Clinical Skills and Simulation lead. www.cmec.info Handover

The pelvis will be on the bed with the back of the bed at 45 degrees and the end of the bed still attached. The patient actor is sitting in a gown above the pelvis and the gown is draped over the pelvis so that the patient actor can control the delivery of the baby with their hands under the gown.

“This is Claire. Her partner is on his way in but it looks as though he won’t be here in time. It is her first baby and she is 40 weeks and 4 days pregnant. She had an uncomplicated pregnancy so far. She arrived on the labour ward about 6 hours ago in spontaneous labour (all the low risk birth facilities are full), having ruptured her membranes spontaneously this morning before she came in. She has made appropriate progress in labour and had an epidural at 8cm which is working well. She is contracting strongly 4 in 10 and was fully dilated 1 hour ago, with the PP in OA position at the spines, with one plus of caput but no moulding. She started pushing spontaneously at this stage and the vertex has been advancing slowly. 30 minutes ago the vertex was visible on parting the labia and the vertex was on the perineum 5 minutes ago, advancing very slowly. Maternal observations have all been normal and so has the CTG, all of which I’ve documented on the maternity notes over there.

Claire, this is [team member’s name], who will be looking after you now. Hope things go well, see you later” and exit.

Team member 1 (a midwife) takes over the delivery and with the next push the head is born with chin retraction.

Second contraction quickly after first – gentle downward traction fails to effect delivery.

The candidates will need to call for help using the call bell which will summon another person (another midwife): this person should be told to call the local hospital emergency number eg 2222 and state ‘obstetric emergency’ and ‘neonatal emergency’.

This will summon the team.

The drill will continue through the use of the HELPERR mnemonic until the team roll the patient and repeat suprapubic pressure for a second time, which will effect delivery.

This document remains the property of Western Sussex Hospitals Trust PGMC Simulation Centre 8 Created by Julie Turner, Clinical Skills and Simulation lead. www.cmec.info Scenario route card Below is the running program of the scenario. Maternal observations are constant throughout: HR 100, bp 120/65, RR 18, SpO2 100% room air, t 37.0. FH remains reassuring at 120bpm. You will notice that the plan is broken into 3 with the start, middle, end. This is used to guide the controller during the scenario.

Patient/manikin Interactions expected Other info (actions) Start: after General introduction to patient This phase only lasts during 1st and 2nd handover to Patient sitting up on bed Encouragement to push contractions. candidate 1 End of bed in place No concerns First contraction – head is born, turtle (a midwife) necking seen Second contraction – gentle downward traction fails to effect delivery After head Patient should be laid flat Wall call bell pulled born and End of bed should be removed Another team member arrives gentle First team member states ‘This is a shoulder downward dystocia, can you call 2222’ traction fails 2222 call put out on phone in scenario – call is to effect ‘obstetric emergency’ and ‘neonatal emergency’ delivery Once 2222 Legs into McRoberts – 2 people hold legs Once patient has been rolled and is back has been Patient should be flat by now Consider episiotomy into McRoberts there will be some put out until Other team members arrive to help Nominate scribe movement of the head and delivery will end of Suprapubic pressure from correct side – follow. scenario constant then rocking Internal manoeuvres Remove posterior arm Roll over and repeat Back onto back – McRoberts again

This document remains the property of Western Sussex Hospitals Trust PGMC Simulation Centre 9 Created by Julie Turner, Clinical Skills and Simulation lead. www.cmec.info Potential problems for each staff group

Staff group Potential problem Anaesthetists  If the delivering person is getting into difficulties, when to offer help OPDs  How can they help with what is essentially an obstetric emergency Obstetricians  Leadership/ communication with MDT  Willingness to discuss with other senior people present when usual manoeuvres fail to effect delivery  Organisation of rolling the woman over Midwife  Gentle traction at all times  Communication with the woman  Escalation but also remaining vigilant to help if the obstetrician is getting into difficulties

This document remains the property of Western Sussex Hospitals Trust PGMC Simulation Centre 10 Created by Julie Turner, Clinical Skills and Simulation lead. www.cmec.info Debrief – generic advice

This is a generic pathway we suggest you use as a template when facilitating any debrief.

Debriefing is a vital part of simulation training.

1. Make opening gambit (phrases)

2. Jointly explore any issues that emerge

3. Include impressions / suggestions from the rest of the group (we have candidate debrief cards which can be used to assist)

4. Share your thoughts using advocacy with inquiry

5. Check whether anyone has any other issues that they want to discuss

6. Summarize

Underlying principles Credibility Authenticity Empathy Mutual dialogue

Techniques Advocacy with inquiry Listening and responding Using the group to solve puzzle Highlighting genuine strengths Being precise rather then general about what you have observed Making / sharing concrete suggestions for improvement

Impediments Easing in and the use of leading questions or tag question Relentless optimism Repetition (can be avoided by dealing with issues as they emerge rather then shelving them) Listing (“You did this, then this, then this…”) Mechanistic approaches to feedback More detail to go with the structure

1. Make opening gambit (phrases). You are looking to start the conversation here. The opening gambit is something of a hurdle you have to get over in order to get the discussion started. Below are some suggestions; their strength however is in being individualized so see them as examples waiting to be tailored.

 What did you feel were your specific challenges there?

This document remains the property of Western Sussex Hospitals Trust PGMC Simulation Centre 11 Created by Julie Turner, Clinical Skills and Simulation lead. www.cmec.info  Can you tell me what your plan was and to what extent that went according to plan?  Can you describe to me what was going on in the group during your discussion?  Let’s talk  That looked pretty tough. Shall we see if we can work out together what was going on there so that you can avoid that situation in the future?  That seemed to me to go smoothly, what was your impression?  Can you describe to me what was happening to the patient during that scenario?

2. Jointly explore issues that emerge.

This will require listening to what the candidate says and picking up on what appears to be the key issue for them. You will probably need to ask additional questions to deepen their thinking and may need to give your own opinion. Where solutions are to be sought your immediate resources include yourself, the practice candidate, the group and other instructors. Here your role as the facilitator is to deepen and widen the conversation (see the bigger picture); introduce new concepts; challenge perceptions; listen and build on what has been said.

3. Include impressions / suggestions from the rest of the group e.g.  Let’s check with the rest of the group how they reacted to you saying that.  What did you [members of the group] want from [the facilitator] at that point?  What ideas suggestions has anyone else got for how to deal with that situation?

4. Share your thoughts using advocacy with inquiry  These can be both strengths and areas for change  Consider the whole group’s learning without overloading the practice candidate: Some points can be left until later  Use advocacy with inquiry to share your observations and explore perception

5. Check whether anyone has any other issues they want to discuss  Avoid asking the practice candidate what they would have done differently given another chance. This will already have been covered  See whether any other group members or instructors have additional points to discuss. 5. Summarise  Keep this brief

This document remains the property of Western Sussex Hospitals Trust PGMC Simulation Centre 12 Created by Julie Turner, Clinical Skills and Simulation lead. www.cmec.info Checklist to guide debrief for shoulder dystocia

This checklist can be used during the scenario to keep track of what candidates should be doing, and can be used to inform the debrief afterwards

Performed Recognise emergency Gentle traction throughout H Call for help

Call bell pulled Emergency call (eg 2222) put out correctly Bed flat End of bed removed E Episiotomy consider episiotomy L Legs into McRoberts S Suprapubic pressure

Correct side Constant for 30s with routine traction Rocking for 30s with routine traction E Enter

Attempt rotation in either direction Hands used appropriately Suprapubic pressure used only when attempting rotation the appropriate way, and stopped when attempting to rotate the other way R Remove posterior arm

Attempt to remove posterior arm R Roll patient

Try all fours Roll back Suprapubic pressure again Complete delivery

Teamworking checklist Instructions clearly worded Goals clearly identified Specific instructions given to team members Situational awareness – problems identified Team members were updated regularly Each team member had appropriate task Tasks delegated appropriately There was a clearly defined team leader

This document remains the property of Western Sussex Hospitals Trust PGMC Simulation Centre 13 Created by Julie Turner, Clinical Skills and Simulation lead. www.cmec.info