Outcomes: A team is only as strong as its weakest link and so its important that all staff providing care to mothers and babies are trained. Teamwork: teamwork training applies the paradigm that people make fewer errors when they work in effective teams. - Communication. Communication is the transfer of information and the sharing of meaning! Team roles and responsibilities : their primary concern should be the success of the team not the leader! Situational awareness: Notice (awareness of the patient status, the team members and available resources) – understand (share information with the team, re- evaluate/ stand back at regular intervals) - think ahead ( anticipate, plan and prioritise) People sometimes enter „fast time“. Characteristics signs for it: poor communication, inability to plan ahead, tunnel vision and fixation on irrelevant issues
The aim of obstetric emergency training is two-fold: Firstly it aims to provide the theoretical knowledge required for the effective treatment of maternal emergencies. In addition, it aims to teach the practical skills employed in these emergency situations and, specifically, maternal collapse.
The most recent British Confidential Enquiry into maternal and child health and the Confidential Enquiry into stillbirths and deaths in infancy has estimated that about half of maternal deaths and 75% of all intrapartal caused deaths could be prevented with better. However, the report acknowledges that there has been no increase in the overall percentage of maternal deaths considered to have avoidable factors. Both enquiries have repeatedly recommended multiprofessional obstetric emergencies training
Annual drill training of all obstetric and midwifery staff is now mandated by the Clinical Negligence Scheme for Trusts – a UK insurance scheme where maternity hospitals with a high standard of training, guidelines and audit rewarded with reduced insurance premiums. Similar recommendations have also been made in the USA.
South West Obstetric Network ran a Department of Health Funded Study, the SaFE Study, looking at where best to train multi-professional teams ie ‘in house’ or at a ‘high tech’ Simulation Centre. Also evaluated the effect of including teamwork training
Training was undertaken in six hospitals and a medical simulation center in the United Kingdom All staff randomly allocated into teams of six comprising: 1 junior and 1 senior obstetrician, and 2 junior and 2 senior midwives. Each team videoed in their own unit managing 3 simulated obstetric emergencies (eclampsia, PPH and shoulder dystocia) before training intervention. They then undertook training either in their own unit or at a simulation centre, with or without additional teamwork training (training intervention randomly allocated). Then videoed again, post training, back in their own units, managing the same 3 simulated obstetric emergencies 3 weeks post training, 6 months post training and 12 months post training. They also completed a multiple-choice questionnaire pre and post training to assess gain in knowledge
Objectives were to determine whether the introduction of Obstetrics Emergency Training in line with the recommendations of the Clinical Negligence Scheme for Trusts (CNST) was associated with a reduction in perinatal asphyxia . The study was a retrospective cohort design. 19,460 infants were included
To determine whether the introduction of multi-professional simulation training was associated with improvements in the management of cord prolapse, in particular, the diagnosis-delivery interval. Large tertiary maternity unit within a University Hospital in the United Kingdom. Sample: All cases of cord prolapse with informative case record: 34 pre-training, 28 post-training
Teamwork is about people from different backgrounds and disciplines working together to achieve the same goals in a cooperative and mutually respectful manner. Groups of people who only consider their own individual output are not working as a team. A TEAM has focus on overall performance and shared goals . So why is teamwork important?
Teamwork was introduced into aviation because air crashes were caused by failure in teamworking. The aviation industry trains cockpit and cabin crews in specific teamwork principles that are thought to be important to performance and safety. For example: preflight briefings, using set phrases to alert other team members of a problem and identifying ways to overcome. Many of these issues are also common to health care. A team is only as strong as its weakest link and so its important that all staff providing care to mothers and babies are trained.
Example: Sara Smith has an eclamptic fit Liz and Susan, please can Mrs Smith into McRoberts position Susan is having a postpartum haemorrhage and has lost approximately one litre of blood. you want me to give 10 Units of oxytocin intramuscularly Okay, thats 10 Units of Oxytocin given intramuscularly.
2008, we started in Basel doing internal simulation courses. Since 2012 we offer courses for external doctors and midwives or even entire clinic teams. Beside the fast dealing with a problem in a scenario, which is as close to reality as possible, algorithm and communication in the team and with the patient will be trained. 8.30 – 9.00 Registration of around 20- 30 participants. Senior and junior doctors and midwives from different hospitals in Switzerland. 9.00 – 10.00 Welcome and introduction (theory) 10.00 – 10.30 Coffee Break and Division of the groups Rotation in teams to the different scenarios. Each scenario is supervised by a obstetrician or a midwife, supported from assistants (as “actors”, midwife students). 10.30- 12.45: Praeklampsie, Post partum haemorrhage, shoulder dystocia 12.45 – 14.00 Lunch 14.00 – 16.15 maternal collapse and basic life support, basic newborn resuscitation, intrapartum fetal monitoring (pathological CTG- vacuum) 16.15 – 17.00 End of the course, certificates
The six scenarios are build up the day before in different rooms. It takes always a few hours to install all the mannequins and to prepare the material needed.
For each scenario we use a prepared box, with a content list on the top. Trolleys with all material needed (syringes, needles, medication, infusions) are installed in each scenario to work with.
Common difficulties observed in training drills are: Not calling the neonatologist Not clearly stating the problem Inability to gain appropriate internal vaginal access Confusion over internal rotation manoeuvres Resorting to traction to effect delivery Use of Fundal pressure instead of suprapupic pressure
Prevention: shoulder dystocia can only be prevented by caesarean section
The post training video will be shown and for example team working factors will be discussed. For example; the increased noise levels. The Debriefing directly after the scenario demonstrates strengths and weaknesses of the team. Using video sequences can illustrate critical moments during the procedures. Beside the quality of teamwork, valid algorithms for the scenario will be evaluated.
Common difficulties observed in training drills are: Delay in recognition of the problem, such as significant tachycardia but not initially hypotensive. Not stating the problem clearly to all who attend emergency. Delay in commencing resuscitation fluids. Underestimation of blood loss and delay in recognising need for transfer in theatre. Unsure location of 0- negative blood.
A technician modulate the vital parameters and the bleeding from a room beside ( behind a window)
The management of major PPH requires the rapid initiation of multiple overlapping actions Call for help : activate the emergency buzzer to summon assistance: Senior midwife, obstetrician, additional support staff, anaesthetist – later alert haematologist. PPH emergency box : many units have an emergency box containing emergency equipment, treatment, algorithms and mediation required for the immediate management of PPH. Assessment- rapid evaluation : blood pressure, pulse, oxygen saturation, abdominal palpation, catheterise and monitor urine output, estimate blood loos, blood samples (coagulation, crossmatch... Check whether uterus is contracted, check that the placenta has been expelled and is complete. Examine cervix, vagina and wounds Observe signs of clotting disorder Employ initial measures to treat schock Stop the bleeding: massage the uterus, bimanual compression of uterus, first- line drug therapy, catheterise the bladder, repair the tear Fluid replacement : establish two intravenous infusions, choice of intravenous fluids – give blood and blood products.
The debriefing is very important. No one has to be blamed. Everyone can learn from mistakes Algorithms will be discussed and video sequences are watched. Questions: what would you do different? What could you have done earlier?
However, there are a lot of people needed to organise and conduct such courses. We normally need around 20 people to handle a course of 36 participants. Questions
Practical obstetric simulation training
MULTIPROFESSIONAL OBSTETRICEMERGENCIES 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 FOROBSTETRIC EMERGENCIES- EVIDENCE
CONFIDENTIAL ENQUIRIES- 1Potentially preventable: o 50% of all maternal deaths o 75% of all intrapartal caused deaths
CONFIDENTIAL ENQUIRIES- 2Recurrent 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 trainingCEMACH 2007, Clinical Negligence Scheme for Trusts 2007, CESDI 1996
SAFE STUDYSimulation and Fire drill EvaluationDepartment 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 STUDYMain study 6 hospitals 141 staff 96 midwives 45 doctorsOwn unit Simulation centre
SAFE STUDY - BEFORE TRAININGo 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 minuteso 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 TRAININGThe introduction of obstetric emergencies trainingcourses was associated with a significant reduction inlow 5-minute Apgar scoresDraycott 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 anaesthesiaThe introduction of annual training, in accordance with national recommendations, was associated with improved management of cord prolapse.Siassakos et al. 2009
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
EXAMPLE: SCENARIO SHOULDER DYSTOCIAKey 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 DYSTOCIAHandover 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− DocumentationTo avoid: traction and fundal pressure
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- 1Handover , 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.
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)
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