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Twin Vaginal Delivery Date Time Program Length 10:10 Appendix 1. Twin Delivery STRATUS Curriculum Program Agenda: Twin Vaginal Delivery Date Time Program length 10:10 - 11:55 AM 105 minutes Duration Session Title Content Parallel Number Faculty Room requirements / Format Description session of Learners 10 Introduction: Taking of pretest, No 16 6 Classroom minutes Twin Vaginal review of didactic Delivery format, and basic review of eligibility criteria for twin vaginal delivery 30 Twin Patient Simulated Yes 6 2 Classroom, Setup with Minutes Counseling: conversation of table and two chairs at standardized front, otherwise no patient supplies needed. (attending) with resident counseling about laboring with vertex/vertex and vertex/nonvertex twins 30 Vertex Simulated Yes 5 2 OR Minutes Second Twin delivery of vertex second twin reviewing general twin management principles 30 Nonvertex Skill station for Yes 5 2 MicroSim Minutes Second Twin delivery of nonvertex second twin 5 Wrap up / Taking or post- No 16 6 Minutes Evaluations test survey Easter SR, Gardner R, Barrett J, Robinson JN, Carusi D. Simulation to improve trainee knowledge and comfort about twin vaginal birth. Obstet Gynecol 2016; 128. The authors provided this information as a supplement to their article. ©2016 American College of Obstetricians and Gynecologists. Page 1 of 16 Easter SR, Gardner R, Barrett J, Robinson JN, Carusi D. Simulation to improve trainee knowledge and comfort about twin vaginal birth. Obstet Gynecol 2016; 128. The authors provided this information as a supplement to their article. ©2016 American College of Obstetricians and Gynecologists. Page 2 of 16 Twin Vaginal Delivery Simulation: Case Title: Twin Vaginal Delivery Simulation Lead Faculty/ Course Name: Nicole A. Smith MD, MPH Director: Title/Position: Division of Maternal-Fetal Medicine Additional Faculty: Name: Roxane Gardner MD, MPH (Please include names where available) Title/Position: Department of Obstetrics, Gynecology, and Reproductive Biology Case Summary 31 yo G1P0 with 36 week vertex-vertex Di-Di twins presenting in spontaneous labor. Estimated weights 2500 gms for each and concordantly grown, no maternal issues this pregnancy. Scenario begins after uncomplicated delivery of first twin with one physician scanning, one physician assisting, and one acting as delivering physician. Clinical Diagnosis Bradycardia of second twin Educational Objectives Following this session, the participants should be able to: of this case: 1. Describe general principles of team management in twin delivery including communication to nursing and anesthesia staff. 2. Display appropriate use of ultrasound for twin delivery. 3. Display options for expedited delivery of second twin including operative vaginal delivery, internal podalic version and breech extraction, and cesarean delivery. Venue OR Total Time 30 mins: Case=10 min + Debriefing=5 min + Repeat Case=10 min + Debriefing=5 min Number/role of Patient: Delivering MD Confederate: Nurse / Participants: Noelle Assistant MD Noelle loader US MD Patient Information Name: Noelle DOB: 9/10/1983 Meds: Prenatal vitamin Age: 31 Allergies: NKDA Gender: F Easter SR, Gardner R, Barrett J, Robinson JN, Carusi D. Simulation to improve trainee knowledge and comfort about twin vaginal birth. Obstet Gynecol 2016; 128. The authors provided this information as a supplement to their article. ©2016 American College of Obstetricians and Gynecologists. Page 3 of 16 PMH: None PSH: IVF Procedures Case ‘Narrative’ ‘Flow’: Prior to Start You are beginning your shift on Labor and Delivery and prior to completing signout are paged to the operating room for a delivery. You are accompanied by two obstetric colleagues for assistance in management of the patient. Anesthesia and nursing staff are already in the operating room with the patient. Patient is hooked up to maternal and fetal monitors with routine vaginal delivery kit open and bed broken with patient in lithotomy position. Trigger: Vitals / Status: Learner actions/ Comments: Phase 1: Assessment Physician enters the room and begins Fetal heart When learner asks for more of Clinical to assess the clinical situation by tracing category clinical information, nurse Situation asking for more information. assess 1 for both twins, shares the following clinical clinical situation and asks Noelle with scenario: Assistant MD delivers first twin and stable vital passes off to pediatricians. signs. “Noelle is a 31 yo G1P0 who presented in labor at 36 weeks with IVF Di-Di twins. This pregnancy has been uncomplicated with concordant growth of approximately 2500 grams of each twin. She has had a normal labor curve, reassuring tracings for each babies, and was just transferred to OR for delivery of her vertex/vertex twins.” Phase 2: Delivery of After receiving the clinical information, Fetal heart Nurse assists Noelle with Presenting Noelle complains of pelvic pressure tracing category uncomplicated delivery of Twin and the urge to push. Physician 1 for both twins, presenting twin, takes baby and checks patient and fetus is crowning. Noelle with reloads in a vertex presentation stable vital with high station as baby B. signs. Phase 3: Assessment Easter SR, Gardner R, Barrett J, Robinson JN, Carusi D. Simulation to improve trainee knowledge and comfort about twin vaginal birth. Obstet Gynecol 2016; 128. The authors provided this information as a supplement to their article. ©2016 American College of Obstetricians and Gynecologists. Page 4 of 16 of Second Physician returns attention to second Noelle with When learner performs exam Twin fetus and performs exam to assess stable vital he/she announces findings to second twin. signs. No the room of full dilation, intact tracing available membranes, vertex for second fetus. presentation, and 0 station. If no findings are announced nurse prompts learner to describe findings. Physician then assesses fetal status If learner requests fetal heart by requesting fetal heart rate check check from nurse, states she is preferably by ultrasound. unable to find the fetal heart. If requests sonographic assessment of fetal heart rate, colleague performs ultrasound and image of fetal bradycardia to 60s on screen. Phase 4: Physician announces fetal Noelle with If learner calls for emergent Delivery of bradycardia and need for expedited stable vital cesarean delivery anesthesia Second Twin delivery. Articulates plan for signs, FHT responds she does not have a expedited delivery. remains in 60s surgical level and will need on projected general anesthesia. Plan may include cesarean delivery, ultrasound Anesthesiologist asks if there operative vaginal delivery with high image as long as are any other options for vacuum preferred over forceps for this ultrasound still expedited delivery. scenario, and internal podalic version being used. and breech extraction. If learner calls for forceps or vacuum for delivery that is readily provided by assistant. If learner makes plan for operative vaginal delivery or internal podalic version and breech extraction without addressing patient, Noelle or nurse ask “What’s going on, is my baby okay?”. Scenario End Scenario ends with liveborn female infant, apgars 6 and 9, and first twin stable doing skin to skin with a stable Noelle. Easter SR, Gardner R, Barrett J, Robinson JN, Carusi D. Simulation to improve trainee knowledge and comfort about twin vaginal birth. Obstet Gynecol 2016; 128. The authors provided this information as a supplement to their article. ©2016 American College of Obstetricians and Gynecologists. Page 5 of 16 Desired Learning Objectives: Learner Actions 1. Identify and quickly acquire necessary clinical information for safe management of vaginal delivery. 2. Quickly and accurately assess fetal presentation, station, and status using a combination of physical exam and ultrasound. 3. Articulate options for expedited delivery of a second twin with goal of avoid cesarean delivery if possible. 4. Appropriately counsel patient about delivery options within a time-constrained situation and execute simulated delivery of choice. 5. Utilize supporting staff for management of twin delivery and demonstrate appropriate communication techniques to maximize patient safety in a high acuity setting. Cues for Patient asks “what is happening, is everything okay” if updates on exam, fetal status, or plan patient and for delivery are not provided. /or confederates Patient consents to “whatever is safest for baby” if asked about mode of delivery. If CS called, anesthesia expresses concern about room setup and analgesia. Setup Equipment (examples): Quantity STRATUS to Faculty to required provide provide Noelle 1 1 Pelvic Trainer Babies 2 2 Delivery Kit (with Boots for PPE) 1 1 Forceps 1 1 Vacuum 1 1 Video of US Findings to Display on Screen 1 1 Sonosite Ultrasound 1 1 Easter SR, Gardner R, Barrett J, Robinson JN, Carusi D. Simulation to improve trainee knowledge and comfort about twin vaginal birth. Obstet Gynecol 2016; 128. The authors provided this information as a supplement to their article. ©2016 American College of Obstetricians and Gynecologists. Page 6 of 16 Nonvertex Second Twin Skills Session: Program / Session Title: Nonvertex Second Twin Delivery Lead Faculty/ Course Name: Julian Robinson MD Director: Title/Position: Chief of Obstetrics, Division of Maternal-Fetal Medicine Additional Faculty: Name: Katherine Economy MD, MPH (Please include names where available) Title/Position: Division of Maternal-Fetal Medicine Goal of the session: Successfully perform simulated breech extraction of second twin Educational Objectives: Following
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