Practiss - Welcome

ØRECLESS: Shoulder Dystocia in a Rural Family Practice.

It’s Canada Day weekend and you’re the physician on-call for obstetrics at a rural 1A maternity site (no local cesarean section capabilities). The hospital is staffed by one other physician who is on-call to the ER, two registered nurses (RNs), and a registered practical nurse (RPN). All the other doctors and nurses are out of the community enjoying the wild. The other physician, an RN, and the RPN are currently in the ER dealing with an acute trauma when the remaining RN calls the obstetrics provider into the delivery room.

You’re rounding on patients at the hospital when a 34 y/o woman presents to the ED at 40 weeks gestation with approximately four hours of labour pain. On examination, the fetus will be in a cephalic presentation and will develop shoulder dystocia. The learner must deliver the fetus from shoulder dystocia using various maneuvers with the assistance of one novice RN and the woman’s support person. The learner will practice auscultation and manual maneuvers for the management of shoulder dystocia.

This simulation is part of ØRECLESS (Rural Emergencies and Complications in Labour Events Simulations Suite).

Goals and Learning Objectives

Technical/Equipment Recommendations

Supporting Roles and Scripts

Moulage and Scenario Set-Up

Printable Supporting Documents (Will also be accessible at relevant Scenario Stage)

Note: While prepping for your simulation, don't forget to prep for the debrief. Become comfortable with your chosen framework, review your objectives. For additional debriefing resources, see our Resources page.

Original Author: Tiana Bressan
Originally published on: October 26, 2023
Most Recent Modification: November 3, 2023

Prebriefing

A good prebriefing is an essential component of running effective simulations, as it sets the stage for everything that comes after it^1-3. An effective prebrief will create a safe container for learning, and in doing so, help participants feel more comfortable pushing their limits, sharing their thoughts and feelings, and buying into the experience. In turn, this will enhance engagement, participation, and learning. To that end, the prebriefing process needs to cover a lot of information^1-5, which can make it daunting to novice or non-expert facilitators. To help, we have consulted the relevant literature and put together a prebrief guide to ensure that you have the tools you need to run an effective pre-briefing session.

Throughout the pre-brief, it is important that you convey your commitment to respecting learners and their perspective^2-4, and establish and maintain the simulation as a safe space for learning^1,4,5.

Prebrief Guide (Sample Phrases in Italics)

Welcome and Introduction

Orient to Basic Logistics

Clarify Objectives

Review the Evaluation Structure for the Day

Clarify Expectations

This could be a good place to pause and ask learners if they have any additional expectations, fears, comments, or questions about the topic for the day.

Establish Confidentiality

Establish the Fiction Contract

Explain and Assign Roles

Go over Logistical Details

Orient to the Environment

Ask for questions!

References

1. Rudolph JW, Raemer DB, Simon R. Establishing a safe container for learning in simulation: the role of the presimulation briefing. Simul Healthc. 2014 Dec;9(6):339-49. doi: 10.1097/SIH.0000000000000047. PMID: 25188485.

2. Leigh G, Steuben F. Setting Learners up for Success: Presimulation and Prebriefing Strategies. Teaching and Learning in Nursing. 2018; 13(3):185-189. https://doi.org/10.1016/j.teln.2018.03.004

3. Lecomte F, Jaffrelot M. Chapter 33 - Prebriefing and Briefing. Clinical Simulation. 2019; 2nd ed.; 471-482. https://doi.org/10.1016/B978-0-12-815657-5.00034-6.

4. INACSL Standards Committee (2016, December). INACSL standards of best practice: Simulation^SMFacilitation. Clinical Simulation in Nursing, 12(S), S16-S20. http://dx.doi.org/10.1016/j.ecns.2016.09.007.

5. Simon R, Raemer D, Rudolph J. Rater's handbook for the Debriefing Assessment for Simulation in Healthcare (DASH) Rater Version. 2009. http://www.harvardmedsim.org/debriefing-assesment-simulation-healthcare.php.

Case Briefing

It’s Canada Day weekend and the hospital is staffed by you (on-call for obstetrics), one other physician (on-call to ER), two RNs, and an RPN. The hospital is a rural 1A maternity site (no local cesarean section capabilities). The other physician, an RN, and the RPN are currently in the ER dealing with a serious acute trauma.

You get called into the delivery room where you find a young woman entering in visible distress accompanied by her wife. She appears to be full-term and offers that they are not from here and came in off the highway. She’s been having abdominal pain for the past four hours. She has no known allergies, her family history and past medical history are insignificant, and her general physical exam is otherwise normal.

Patient Chart
Name: Julie Esposito	Age: 34	Gender: F	Weight: 95 kg	Height: 165 cm	GA: 40 Weeks
Temp: 37.2	HR: 110 bpm	BP: 115/65	RR: 23/min	O₂Sat: 99%	GCS: 15
Presenting complaint: Abdominal pain.

1. Assessment

34 y/o woman presents to the ED in labour with her wife. You've called for assistance but the other physician, a RN, and the RPN are currently in the ER dealing with a serous acute trauma. It is only yourself, a novice RN, and the support person (wife).

Modifiers (in red): Actions by the learner (which will have a consequence) OR actions to prompt learner. Extra information, audio clips, etc. are provided below.

Patient Vitals
BP: 115/65	HR (Rhythm): 110 bpm (Sinus Tachycardia)	RR: 23/min.
O₂SAT: 99%	Temperature: 37.2 degrees Celsius	GCS: 15

Expected Learner Actions
Introduction (name and role) and confirmation of patient name and pronouns Patient consent to provide care and for physical touch Assess maternal vitals Brief patient history Brief Patient History ⇒ Provide history (below). Auscultation Contraction pattern Differentiate MHR from FHR Place device (handheld Doppler, Pinard, or Fetoscope) over area of maximum intensity of the fetal heart sounds (usually fetal back or shoulder) Establish baseline FHR (bpm for 1 min. between contractions) Rhythm (Regular or Irregular) Auscultate following contractions (30-60 sec.) for accelerations and decelerations (abrupt or gradual increases or decreases from baseline) Auscultation ⇒ Provide audio files. Don relevant PPE Abdominal Exam General Abdominal Exam Leopold Maneuvers (x4) Uterine Activity Characteristics (Frequency, Duration, Intensity, Resting Tone) Vaginal Exam Cervical Dilation (size of a donut) Cervical Effacement Fetal Station Feel for fontanelles/ suture lines No Vaginal Exam (in 6 min.) ⇒ Woman screams "I think the baby is coming out!" Prepare for delivery Consider preparation for neonatal resuscitation - NOT required Inform the woman and partner of the current situation and management plan Woman not informed (in 3 min.) ⇒ Wife: "Is she having the baby? What's going on?"
10 min. OR Actions Complete ⇒ 2. Delivery

Expected Learner Actions

Introduction (name and role) and confirmation of patient name and pronouns
Patient consent to provide care and for physical touch
Assess maternal vitals
Brief patient history
Brief Patient History ⇒ Provide history (below).

Auscultation
     Contraction pattern
     Differentiate MHR from FHR
     Place device (handheld Doppler, Pinard, or Fetoscope) over area of maximum intensity of the fetal heart sounds (usually fetal back or shoulder)
     Establish baseline FHR (bpm for 1 min. between contractions)
     Rhythm (Regular or Irregular)
     Auscultate following contractions (30-60 sec.) for accelerations and decelerations (abrupt or gradual increases or decreases from baseline)
Auscultation ⇒ Provide audio files.

Don relevant PPE
Abdominal Exam
     General Abdominal Exam
     Leopold Maneuvers (x4)
     Uterine Activity Characteristics (Frequency, Duration, Intensity, Resting Tone)
Vaginal Exam
     Cervical Dilation (size of a donut)
     Cervical Effacement
     Fetal Station
     Feel for fontanelles/ suture lines
No Vaginal Exam (in 6 min.) ⇒ Woman screams "I think the baby is coming out!"

Prepare for delivery
Consider preparation for neonatal resuscitation - NOT required
Inform the woman and partner of the current situation and management plan
Woman not informed (in 3 min.) ⇒ Wife: "Is she having the baby? What's going on?"

10 min. OR Actions Complete ⇒ 2. Delivery

Brief Patient History

Auscultation (Audio Files)

Abdominal Exam and Uterine Activity Characteristics

Vaginal Exam

2. Delivery

The woman is now in screaming pain, "I need to push!" The full fetal head becomes visible and then retracts on the perineum (Turtle Sign Explained: https://youtu.be/XA0Vn8zGbt0?t=41).

Modifiers (in red): Actions by the learner (which will have a consequence) OR actions to prompt learner. Extra information, audio clips, etc. are provided below.

Retrieved July 5, 2023 from https://www.amboss.com/us/knowledge/abnormal-labor-and-delivery/

Expected Learner Actions
Start 2. Delivery ⇒ Provide supporting document (2. Delivery - Turtle Sign). Consider analgesic administration (Fentanyl, 25-50mcg IV, Onset: 1-3 min, Duration: 30-60 min) Assess shoulder location Recognize shoulder dystocia Avoid the 4 Ps: Push, Pull, Panic, Pivot Maneuvers: Coach woman to push after each maneuver (not during) Life/hyperflex legs (McRoberts Maneuver) Instruct Wife and Nurse: Flatten the head of the bed Assist with hyperflexion of the legs No instruction to nurse or support person (in 1 min.) ⇒ Novice Nurse: "Uh, what should I be doing right now?" Anterior Shoulder Disimpaction (suprapubic pressure and/or Rubin Maneuver) Instruct Nurse: Apply suprapubic pressure Assist with ongoing hyperflexion of the legs Attempt rotation of the posterior shoulder (Woods Maneuver) Attempt manual removal of the posterior arm Consider axillary traction Roll over onto "all fours" (Gaskin Maneuver) 30-60 seconds of attempting each maneuver ⇒ Facilitator: "The fetus has not delivered." Nurse: "This isn't working! What should we do now?" Facilitator selects Option 1 or proceeds to 3. Case Complete: Option 1: None of the above maneuvers were successful. Six minutes have passed of attempted maneuvers and/or neither shoulder is in the pelvic concavity. Break fetal clavicle
10 min. OR Actions Complete ⇒ 3. Case Complete

Expected Learner Actions

Start 2. Delivery ⇒ Provide supporting document (2. Delivery - Turtle Sign).
Consider analgesic administration (Fentanyl, 25-50mcg IV, Onset: 1-3 min, Duration: 30-60 min)
Assess shoulder location
Recognize shoulder dystocia
Avoid the 4 Ps: Push, Pull, Panic, Pivot

Maneuvers:
Coach woman to push after each maneuver (not during)
Life/hyperflex legs (McRoberts Maneuver)
Instruct Wife and Nurse:
Flatten the head of the bed
Assist with hyperflexion of the legs
No instruction to nurse or support person (in 1 min.) ⇒ Novice Nurse: "Uh, what should I be doing right now?"

Anterior Shoulder Disimpaction (suprapubic pressure and/or Rubin Maneuver)
Instruct Nurse:
Apply suprapubic pressure
Assist with ongoing hyperflexion of the legs

Attempt rotation of the posterior shoulder (Woods Maneuver)
Attempt manual removal of the posterior arm
Consider axillary traction
Roll over onto "all fours" (Gaskin Maneuver)
30-60 seconds of attempting each maneuver ⇒ Facilitator: "The fetus has not delivered." Nurse: "This isn't working! What should we do now?"

Facilitator selects Option 1 or proceeds to 3. Case Complete:
Option 1: None of the above maneuvers were successful. Six minutes have passed of attempted maneuvers and/or neither shoulder is in the pelvic concavity.
Break fetal clavicle

10 min. OR Actions Complete ⇒ 3. Case Complete

3. Case Complete

After Gaskin maneuver (rolling over onto "all fours") the neonate is successfully delivered. Apgar scores at one and five minute(s) are normal, the neonate is handed to the mother for skin-to-skin contact, and the case is complete.

Option 1 selected:
Breaking the clavicle was successful and the neonate was safely delivered without further complications. Apgar scores at one and five minute(s) are normal, the neonate is handed to the mother for skin-to-skin contact, and the case is complete.

Go to Debrief

Cervical Dilation Diagams

Retrieved July 2, 2023 from: https://www.parents.com/pregnancy/giving-birth/labor-and-delivery/cervix-dilation-chart-pictures-that-explain-the-stages-of-labor/

Retrieved July 27, 2023 from: https://www.instagram.com/p/CHJCbAhgdIu/?utm_source=ig_web_button_share_sheet

Retrieved July 27, 2023 from: https://www.youtube.com/watch?v=x17vY7_3M2M

Cervical Effacement Diagram

Adapted September 12, 2023 from https://www.medicalnewstoday.com/articles/326380

Intermittent Auscultation During Labour

Shoulder Dystocia: ALARMER Mnemonic

Do Not 1. Pull, on the head 2. Push, on the fundus 3. Pivot or rotate the head 4. Panic
ALARMER Mneumonic for Shoulder Dystocia Management Note: Ask the woman to push after each maneuver. Avoid pushing between contractions while maneuvers are carried out to maximize cerebral perfusion.
A: Ask for help	Appropriate equipment and personnel Cooperate with support person Recognize initial presentation of turtle sign (fetal head delivers and retracts onto the perineum)
L: Lift/Hyperflex legs	McRoberts Maneuver 1. Flatten the head of the bed. 2. Bring the woman to the end of the bed. 3. Hyperflex both legs at the hip (knees bent to woman's shoulders to increase the AP pelvic diameter).
A: Anterior Shoulder Disimpaction	Abdominal Approach 1. Assistant applies steady or rocking suprapubic pressure with heel of clasped hands from the posterior aspect of the anterior shoulder to dislodge it. 2. Attempt with McRoberts maneuver. Vaginal Approach (Rubin Maneuver) 1. Advance your index finger, middle finger, or whole hand laterally and apply pressure to the posterior aspect of the anterior shoulder (push the shoulder towards the chest or apply pressure to the scapula of the anterior shoulder). 2. Adduct the anterior shoulder.
R: Rotation of the posterior shoulder	Woods Maneuver (Screw-like Maneuver) 1. Apply pressure with whole hand in vagina to the anterior aspect of the posterior shoulder. 2. Attempt to rotate the posterior shoulder to an anterior position. Alternative: Rotate posterior shoulder in the opposite direction with pressure on the posterior aspect to collapse the biacromial diameter. Note: No fundal pressure or pulling. May combine maneuvers with anterior disimpaction maneuvers.
M: Manual removal of the posterior arm	The arm is usually flexed at the elbow. If the arm is NOT flexed, 1. Apply pressure to the antecubital fossa and splint the humerus. 2. Grasp the hand and sweep the arm over the fetal chest. 3. Grasp the wrist/forearm and deliver the arm. Note: If the fetal abdomen faces the maternal right, the left hand is grasped (and vice versa). Alternate maneuver or if the posterior hand cannot be reached, deliver the posterior shoulder using axillary traction: 1. Assistant gently flexes the fetal head toward the anterior shoulder. 2. Place your middle finger into the fetus' posterior axillary fold and apply downward traction. Alternative: Place your middle fingers from both hands (one from anterior and the other from posterior) in the posterior axilla and apply downward traction. Note: Once the shoulder has been brought down sufficiently, the posterior arm can be grasped and delivered. These maneuvers may release the anterior shoulder or allow a rotation maneuver to release the anterior shoulder. Fractures of the humerus can heal, however, brachial plexus palsies may be permanent.
E: Episiotomy	Note: An episiotomy may facilitate the Woods maneuver or manual removal of the posterior arm by creating more space. However, shoulder dystocia is NOT caused by obstructing soft tissue, therefore, performing an episiotomy on its own will not relieve a shoulder dystocia.
R: Roll over onto "all fours"	Gaskin's Maneuver 1. Move the woman onto "all fours" with her back arched. Objective: Increase pelvic dimensions and shift fetal position. This creates easier access to the posterior shoulder for rotational maneuvers and removal of the posterior arm. 2. Apply gentle downward pressure on the posterior shoulder of the fetus. Note: Can do with epidural analgesia (unless the degree of motor block makes turning and maintaining the position impossible).
Last Resort: 1. Zavanelli Maneuver (Cephalic Replacement): Reversing the cardinal movements of labour. - Rotate the head to the occiput anterior position - Rotate, flex the head, and push it up - Rotate the head to the transverse, disengage the head, and perform a cesarean delivery 2. Symphysiotomy: Surgically remove the cartilage of the symphysis pubis to increase the size of the pelvic outlet. 3. Break Clavicle: Apply direct upward pressure on the mid-portion of the fetal clavicle. Figure retrieved July 2, 2023 from https://www.glowm.com/pdf/aip%20chap13%20shoulder%20dystocia.pdf

Videos:
Shoulder Dystocia & ALARMER Mnemonic (8.5 min.): https://youtu.be/BvkKMwDaryg
ALARMER Mnemonic (8.5 min.): https://youtu.be/jNmSJDbTARw

Reference(s):
Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

Systemic Analgesics: Labor and Vaginal Delivery

Important Notes Regarding Pharmacological use in Labour:

Sedative and hypnotic drugs do not provide pain relief and may increase respiratory depression when given with opioids.
No pharmacological method is devoid of maternal or fetal side effects - with almost all pharmaceutical therapies, some amount of the drug gets access to the fetus.
Anticholinergic side effects may occur with opioids and care should be directed at recognizing and addressing these discomforts.
A pregnant person can receive opioids just before birth without significant respiratory depression in the newborn.
When any opioid is used, opioid antagonists (e.g., naloxone) and resuscitation capabilities should be available. Before a pregnant person is sent home following opioid administration, she needs to be assessed to determine the effects and side effects of the medication.
Action should be taken to prevent toxicity with all local anesthetics.
Epidural analgesia provides the most efficacious pharmacological analgesia, with limited side effects to the mother and fetus.

Options for Pharmacological Pain Management in Labour (see dosing information below):

Opioids
- Fentanyl preferred as it has a shorter half-life (use of meperidine, which has a longer half-life, is discouraged)
- Remifentanil patient controlled analgesia (PCA) may offer some benefits over traditional intramuscular (IM) opioids for labour analgesia
  - Limitation: remifentanil requires constant nursing presence and oxygen saturation monitoring due to the narrow therapeutic window, as well as the increased risk of respiratory complications
- Opioids may be combined with an antiemetic as side effects of opioids include nausea and vomiting

Suggested Opioid use in labour:

Stage of Labour	Nulliparous	Parous
Latent Stage:	IM/SC Morphine	IM/SC Morphine
Early Active Stage:	IM/SC or IV Morphine	IV Morphine or Fentanyl
Late Active Stage:	IV Morphine or Fentanyl	IV Fentanyl
Second Stage:	IV Fentanyl	IV Fentanyl

Nitrous Oxide
- Has been shown to provide mild analgesia, but high patient satisfaction.
  - Often useful for the pregnant person who has coped well until transition and then requires pain relief for a short time.
- Deep inhalation should begin as soon as the pregnant person is aware of the onset of a contraction to allow for maximal benefit.
- Non-analgesic benefits include relaxation, distraction from pain, anxiolysis, and an improved sense of being able to cope with the pain.
- Common side-effects: dizziness, nausea, altered cognition, dysphoria, and a feeling of claustrophobia.
- It must be self-administered for safety reasons via a demand-valve.
- Should be used in a well-ventilated room for workplace safety.
  - Nitrous oxide is destructive to the ozone layer - shorter use decreases environmental exposure.
- May also be used as an adjunct during other procedures such as the placement of a pudendal block or perineal repair.
Peripheral Nerve Blocks
- A pudendal block can be used for analgesia of the perineum in the second stage of labour.
- Useful for the sacral nerves and should be considered when other regional analgesia is not available or provides insufficient sacral spread.
- Important to recognize that local anaesthetic toxicity is additive. Toxic limits of each local anaesthetic should be known to ensure maximum cumulative dosing is not exceeded.
Neuraxial Anesthesia
- Catheter in the epidural space (i.e., labour epidural analgesia (LEA))
- Quite common in Canada and remains the most effective form of labour analgesia
- Epidural analgesia can provide effective pain relief throughout all stages of labour and delivery, with limited side effects to the mother and fetus
- This option is often not available in rural 1A labour and delivery units, therefore will not be discussed in detail in this resource.

Reference(s):

Grant G. (2022). Pharmacologic management of pain during labor and delivery. In Crowley M (Ed.), UpToDate. Retrieved Jul 2, 2023, from https://www.uptodate.com/contents/pharmacologic-management-of-pain-during-labor-and-delivery

Society of Obstetricians and Gynecologists of Canada. ALARM Manual, 28th Ed. 2022.

Maternal Triage Assessment

Date and Time

ID

Age
GxPx - see below.
Gestational Age (GA)
Estimated Date of Delivery (EDD)
EDC
Group B Strep (GBS)
Rh status

CC

Contractions
Per Vag (PV) blood loss: amount, pain, Rh Status
Ruptured membranes
Fetal movement
Infection: fever, pain, GBS status
Other complications: U/S abnormalities, GDM, HTN

HPI: 4 Key Questions

Contractions

Since when
How close together (q x min)
How long (x sec)
How painful

Bleeding

Since when
How much (pads)
Colour (pinky vs. brownish vs. bright red)
Pain
Last ultrasound
Trauma/intercourse

Fluid (Rupture of Membranes - ROM)

Since when
Large gush vs. trickle
Soaked pants
Clear vs. green vs. red
Continuous

Fetal Movement (FM)

As much as usual?
Time since last movement
Kick counts (lie still for 1-2h, cold juice, feel FM) → Should have 6 movements in 2h

Hx of Pregnancy

Antenatal screening (genetic screening, Rh status, serology)
Previous U/S
Biophysical profile (BPP) score
Growth
Estimated Fetal Weight (EFW)
Presentation
Last Vaginal Exam
Complications
Gestational Diabetes (GDM)
Group B Strep (GBS) result
HTN
Infection
Twins

OBHx: Outcomes of previous pregnancies

Year
Term/premature
Miscarriages/abortions
Vaginal or C-section delivery
Use of vacuum or forceps
Size of babies
Length of labours
Complications

PMHx

Medications (dose & route of admin)
Allergies (include reactions)
Surgical history
Routine problem list (HTN, DM, asthma…)

On Examination (O/E)

Maternal Vitals
Fetal Heart Tracing (baseline fetal heart rate, variability, accels/decels)
Uterine Activity Characteristics (frequency, duration, intensity, resting tone)
Position of Baby - Leopold’s Maneuvers
Vaginal Exam: membrane status, cervix (effacement, dilation, position, presentation)
Sterile Speculum Exam: pooling of amniotic fluid, ferning, fetal fibronectin, nitrazine test
Ultrasound
Other relevant features depending upon chief complaint

GxPx/GTPAL: Both are ways of describing overall obstetrical history. GTPAL includes more detail.

GxPx

GTPAL

G = Gravidity → total # of pregnancies
P = Parity → # births carried to viability (20 weeks) - whether or not the fetus was born alive

G = Gravidity → total # of pregnancies
TPAL → Parity (in detail)
T = # of term deliveries (>37 weeks)
P = # of preterm deliveries (20+0 → 36+6)
A = # of abortions & ectopic pregnancies (ending <20 week gestational age)

Induced (therapeutic) & spontaneous (misscarriage)

L = number of living children

E.g., Patient has been pregnant 4 times. The first one ended in a miscarriage at 10 weeks, the second child was born healthy at 38 weeks, the third was carried to 23 weeks but was born stillborn and she is currently 35 weeks gestation with the fourth pregnancy.
This can be described as: G4P2 in GxPx format or G4T1P1A1L1 in the GTPAL format.

Assessing Contraction Pattern

Assessing Contraction Pattern
Methods of Assessment
Palpation by Hand Can assess frequency & duration of contractions Estimate intensity & resting tone		Tocodynamometer (external) Assesses relative frequency & duration Cannot measure intensity or resting tone		Internal Intrauterine Pressure Catheter (IUPC) Most accurate Invasive - use if uterus not easily palpated or external provide inadequate info
Characteristics of Contractions
Frequency	Duration		Intensity		Resting Tone
# of contractions in 10 minutes, averaged over 30 minutes Normal: ≤ 5 in 10 mins	# of seconds from beginning to end of contraction Normal: <90 s		Strength of contraction By palpation if using tocodynamometer: mild, moderate, or strong (strong = uterus cannot be indented) Normal (IUPC): 25-75 mmHg above baseline		Firmness between contractions Palpation: soft or firm IUPC: in mmHg Normal (palpation): soft between contractions for at least 30s to allow for placental perfusion Normal (IUPC): 7-25 mmHg
Abnormal Contraction Pattern
Tachysystole - excessive uterine activity (commonly d/t exogenous augmentation by oxytocin or other uterotonic agent) Characteristics: >5 contractions per 10-min period averaged over 30 mins and/or Inadequate resting tone (resting period <30s OR uterus doesn’t return to resting tone) and/or Prolonged contraction lasting >90s Impact: Can reduce placental perfusion & result in fetal hypoxemia Management: consider tocolytic drugs (e.g., nitroglycerin IV, terbutaline SubQ)

Leopold Maneuvers & Fetal Orientation

Leopold Maneuvers: Systematic abdominal palpation maneuvers performed after 30-32 weeks gestation. They are used to determine the presentation, position, and engagement of the fetus in utero.

First: to determine which fetal part is lying furthest away from pelvic inlet
Second: to determine the location of the fetal back
Third: to determine which fetal part is lying above the pelvic inlet
Fourth: to locate the fetal brow

from Toronto Notes 2022

Fetal Orientation:

Fetal Lie
Fetal Presentation
Fetal Position
Fetal Attitude
Station
Synclitism

1. Fetal Lie: Relation of fetal long axis to long maternal uterus
Longitudinal (0 degrees) - most common Transverse (45 degrees) Oblique (90 degrees)
2. Presentation: The part of the fetus that overlies pelvic inlet (separation between abdominal & pelvic organs - borders include sacral promontory & pubic symphysis)
Cephalic (head down in pelvic inlet) - most common Breech (bum of feet) - Frank breech - bum presenting, knees extended (pike position) - Complete - cannon ball position - Single footling breech - Double footling breech Compound (more than one part presenting - e.g., cephalic or breech + extremity Shoulder: Shoulder is presenting combined with a transverse or oblique lie
3. Fetal Position: Relationship to maternal pelvis
Occiput Anterior (OA) - fetal occiput (posterior head) towards pubic symphysis (face down) - Left OA - fetal back faces left, anterior fontanelle faces right (most common position) - Right OA - fetal back faces right, anterior fontanelle faces left Occiput Posterior (OP) - fetal occiput towards sacral promontory Sacrum - direction of fetal sacrum in breech presentation Mentum - (chin) in extended cephalic (aka face) presentation
4. Fetal Attitude: How much the fetal head flexes/extends during cephalic presentation
Vertex - maximum flexion (most common) Forehead/Military - partial flexion Brow - partial extension Face - maximum extension - Mentum anterior - chin to pubic symphysis - Mentum posterior - chin to coccyx *spontaneous vaginal delivery possible in all attitudes
5. Fetal Station: Measurement (in cm) of where the presenting part of the fetus is located in the pelvis, in relation to ischial spine
Negative (-) = above ischial spine Positive (+) = below ischial spine 0 = at level of ischial spine Rule of fifths: when ⅖ or less of the fetal head are felt above the pubic symphysis through the maternal abdomen, the head is engaged
6. Synclitism: Parallelism between pelvic plane and plane of fetal head
Synclitism - posture in which the 2 parietal bones are at the same level Asynclitism - posture in which one parietal bone is at a lower level than the other due to lateral inclination of the head - Anterior / Naegele obliquity - sagittal suture towards sacral promontory → spontaneous vaginal delivery possible - Posterior / Litxmann obliquity - sagittal suture towards pubic symphysis, vaginal delivery NOT possible - indication for C-section

Debriefing

Choosing a Debrief Framework:

A good debrief has been identified in the literature as the most important part of a successful simulation experience. If you're a novice or inexperienced facilitator, use this table to help you choose which debrief framework you want to use, just tap the button on their name and you will be directed to the appropriate aids or scripts. While we recommend the PEARLS framework, take a look to see if there may be another that is a better fit for your situation.


	Time	Facilitator Level	Prep Time	Scenario Type	Flexibility
PEARLS (Our Favourite)	Moderate	Novice	Moderate	Any	High
GAS	Short-Moderate	Novice	Low	Short w/ Clear Objectives	Low
Team Dynamics	Moderate	Novice	Moderate	Any, esp. Team-focused	Moderate
SHARP	Very Short	No experience	None	Any	Low
Diamond	Short	Novice	Low	Low number of non-technical skills	Low
Plus-Delta	Very Short	No experience	None	Any	Moderate
Debriefing w/ Good Judgement	Moderate-Long	Novice	Moderate	Any	Moderate

PEARLS Debrief Framework

(To learn more about this debriefing framework, visit our page on Debriefing resources)

If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic

Phase	Objective		Task		Sample Phrases
1. Setting the Scene	Create a safe context for learning		State the goal of debriefing; articulate the basic assumption		“Let’s spend X minutes debriefing. Our goal is to improve how we work together and care for our patients.” “Everyone here is intelligent and wants to improve”
2. Reactions	Explore feelings		Solicit initial reactions and emotions		“Any initial reactions?” “How are you feeling?”
3. Description	Clarify Facts		Develop a shared understanding of the case		“Can you please share a short summary of the case?” “What was the working diagnosis? Does everyone agree?”
4. Analysis	Explore a variety of performance domains: Decision making Technical skills Communication Resource utilization Leadership Situational Awareness Teamwork		See bottom of guide for details on the analysis phase		For each item to be debriefed: 1. Preview Statement: (to introduce topic) “At this point, I’d like to spend some time talking about [insert topic] because [insert rationale]" 2. Pick Analysis method + Analyze: (see below for more info on each method) a. Learner Self-Assessment b. Focused Facilitation c. Provide information 3. Mini Summary: (to summarize discussion of topic) *“That was a great discussion. Are there any additional comments related to [insert here]”* Phase Wrap-up: "Any outstanding issues or concerns before we start to close?"
5. Application or Summary	Identify take-aways		Can be learner- or instructor-centered		Learner-centered: “What are some takeaways from this discussion for our clinical practice?” Instructor-centered: “The key learning points for the case were [insert learning points]”
Analysis Phase Details
Choose an analysis approach (Different approaches can be used for different topics within the same analysis stage):
Approach		Objective		Sample Phrases
Learner Self-Assessment Time: Short/Moderate Performance Domain: Cognitive/Technical Rationale Evident: Yes/No Facilitator Experience: Low		Promote reflection by asking learners to assess their own performance		“What aspects were managed well and why?” “What aspects do you want to change and why?”
Focused Facilitation Time: Moderate/Long Performance Domain: Cognitive/Behavioural Rationale Evident: No Facilitator Experience: More experience required, can be difficult		Probe deeper on key aspects of performance, uncover mental frames guiding performance		Use Advocacy-Inquiry Method Advocacy: "I saw [observation], I think [your point-of-view]” *"I noticed [observation]* I liked that/I was concerned..." Inquiry: “How do you see it? What were your thoughts at the time?”**
Provide Information Time: Short Performance Domain: Cognitive/Technical Rationale Evident: Yes Facilitator Experience: Low		Teach to close clear knowledge gaps as they emerge and provide directive feedback as needed		“I noticed[behaviour]. Next time you may want to consider [suggested behaviour], because [rationale]”

PDF from debrief2learn.org: Here
Visual Guide: debrief2learn.org
Alternative Script: Here
Originally Created by: Bajaj K, Meguerdichian M, Thoma B, Huang S, Eppich W, Cheng A. The PEARLS Healthcare Debriefing Tool. Acad Med. 2018, 93(2), 336.

GAS Debrief Framework

(To learn more about this debriefing framework, visit our page on Debriefing resources)

If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic

Phase	Goal	Actions	Possible Scripts
Gather (Listen) 25%	Actively listen to participants to understand what they think and how they feel Identify what occurred during scenario	Elicit emotional state	*How do you feel?*
		Request narrative(s)	*How do you think it went?* *Can you tell me what happened?*
		Request clarifying or supplemental information	*Can anyone add anything to that account?*
Analyze (Guide Reflection) 50%	Provide feedback on performance Facilitate participant’s reflection on and analysis of their actions and systems issues Investigate basis for performance gaps	Review accurate record of events	*I noticed…*
		Report observations (correct and incorrect steps) Ask questions to reveal participant thinking	*I noticed…. What was the thought process behind….* *When….happened, I saw….What do you think…..* *I saw…I think….How do you see it?*
		Stimulate reflection and provide redirection	*Tell me more about…* *How did you feel about….* *I understand, but tell me about X aspect of the scenario*
Summarize (Help gather Conclusions) 25%	Facilitate identification and review of lessons learned	Identify positive aspects of session (participants)	*What are two things that you thought were effective or went well?*
		Discuss behaviours that require change	*What do you think are some areas you/your team need to work on?*
		Summarize session	*In today’s session, we….* *Going forward, we should….*

References/Adapted From:

Phrampus P.E., O’Donnell J.M. (2013) Debriefing Using a Structured and Supported Approach. In: Levine A.I., DeMaria S., Schwartz A.D., Sim A.J. (eds) The Comprehensive Textbook of Healthcare Simulation. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-5993-4_6
Baily K (2019) Gather – Analyze – Summarize: The Simple GAS Method for Healthcare Simulation Debriefing (w/ Quick Template). www.healthysimulation.com/18874/gas-debriefing/

Team Dynamics Debrief Framework

(To learn more about this debriefing framework, visit our page on Debriefing resources)

If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic

Instructions:

Use the table below to guide your debriefing (Example phrases provided in plain text)
Observe and record elements of team dynamics
Identify 2 or 3 elements of team dynamics to discuss per debriefing section

Actions

Gather

Analyze

Summarize

Closed-loop communication

Orders acknowledged and confirmed when given
Orders announced when executed

Clear Messages

Team members speak clearly
Orders are questioned when doubt exists

Clear Roles

All team members have appropriate roles
Roles are reallocated when appropriate

Knowing one’s limitations

Calls for assistance
Seeks advice when appropriate

Knowledge Sharing

Sharing information between team members
Asks for ideas and suggestions

Constructive Intervention

Identifies priorities
Questions colleagues who make mistakes

Reevaluation and Summarizing

Reevaluates patient
Summarizes patient condition and treatment plan

Mutual Respect

Speaks in a professional, friendly tone of voice
Provides positive feedback

Student Observations

Can you describe the events from your perspective?
How did you think your treatments went?
Can you review the events of the scenario?
What could you have improved?
What did the team do well?

Instructor Observations

I noticed that [insert action here]
I observed that [insert action here]
I saw that [insert action here]

Done Well

How were you able to [insert action here]?
Why do you think you were able to [insert action here]?
Tell me a little bit more about how you [insert action here]?

Needs Improvement

Why do you think [insert action here] occurred?
How do you think [insert action here] could have been improved?
What was your thinking while [insert action here]?
What prevented you from [insert action here]?

Student-led Summary

What are the main things you learned?
Can someone summarize the key points made?
What are the main take-home messages?

Instructor-led Summary

Let’s summarize what we learned….
Here is what I think we learned….
The main take-home messages are….

References/Adapted from:

Cheng, A MD, FRCPC; Rodgers, DL. EdD; van der Jagt, É MD, MPH; Eppich, W MD, MEd; O’Donnell, J CRNA, MSN, DrPH (2012) Evolution of the Pediatric Advanced Life Support course, Pediatric Critical Care Medicine. 13(5). 589-595 doi: 10.1097/PCC.0b013e3182417709
American Heart Association Team Dynamics Debriefing Tool. 2011. https://ahainstructornetwork.americanheart.org/idc/groups/ahaecc-public/@wcm/@ecc/documents/downloadable/ucm_488325.pdf

SHARP Debrief Framework

(To learn more about this debriefing framework, visit our page on Debriefing resources)

If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic

Before Case

Set learning objectives
What would you like to get out of this case?

After Case

How did it go?
What went well? Why?

Address Concerns
What did not go so well? Why?

Review learning points
Were your learning objectives met for this case?
What did you learn about your clinical/technical skills?
What did you learn about your teamwork skills?

Plan ahead
What actions can you take to improve your future practice?

Framework from:

Imperial College London (ND). The London Handbook for Debriefing: Enhancing Performance Debriefing in Clinical and Simulated Settings. www.imperial.ac.uk/media/imperial-college/medicine/surgery-cancer/pstrc/lw2222ic_debrief_book_a5.pdf

Diamond Debrief Framework

(To learn more about this debriefing framework, visit our page on Debriefing resources)

If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic

Diamond Debrief: Sample Phrases

Description

“So what happened?...and then what happened next?”

Continue asking until confident that the details of the scenario have been raised by the learners

“Let’s not judge our performance now, let’s just focus on what happened”

Transition

“This scenario was designed to show…”

“Let’s address technical and clinical questions. What is the protocol for…?”

“How do we normally deal with this clinical situation?”

“Everyone ok with that?”

Analysis

“How did that make you feel?” To participants, then group

“Why?” Then use silence

“How did you/they do that exactly?”

“Why did you respond in that way? “ or “Why did you take that action?”

“It feels like…was an issue. Did it feel like that to you?”

What I’m hearing from you is…is that correct?”

“This is part of…” (identify the non-technical skill/human factor)

“We refer to that as a human factor or non-technical skill, which means…”

Transition

“So, what we’ve talked about in this scenario is…”

“What have we agreed we could do?”

Application

“What other kinds of situations might you face that might be similar? How are they similar?”

“How might these skills we discussed play out in those situations?”

“What are you going to do differently in your practice going forward?”

Underlying Principles

Description

Reinforce a safe learning environment.

Situate the debrief in the shared and meaningful activity that occurred.

Keep the focus dispassionate—discuss what happened but avoid focus on emotions.

Listen for emotional responses but resist the temptation to discuss emotions.

Make sure everyone shares the same understanding of what happened.

Transition

Transition into analysis by clarifying any technical and clinical issues

Analysis

Spend most of your time in Analysis.

Deconstruct behaviours into specific actions, and explore what happened in detail.

Ask about affective responses and validate them.

Analyze and interpret the activity by applying appropriate frameworks or lenses (such as non-technical skills, or the clinical context surrounding the scenario).

Keep discussion positive, and avoid the temptation to focus on “strengths and weaknesses”.

Reflect responses back, allowing participants to amend or augment.

Transition

Transition into Application by reinforcing learning.

Application

Focus on moving from the specifics of the scenario to the more general world of practice.

Break behaviours down into specific actions.

Explore the other kinds of situations that these might apply to.

Ask what participants will do differently in their practice.

Adapted From: Jaye P, Thomas L, Reedy G (2015). 'The Diamond': a structure for simulation debrief. The Clinical Teacher 12(1). 171-175. onlinelibrary.wiley.com/doi/full/10.1111/tct.12300

Plus-Delta Debrief Framework

If you need help with debriefing Crisis Resource Management skills, check out this infographic from Isaak & Stiegler: View Infographic

Pluses:

Things that are working first
Items that the individual or team wants to build on
Ex: What went well?

Deltas:

Opportunities for improvement things that can be changed so that the individual team might become more effective
Should be specific, within the realm of possibility
To be reviewed and acted upon
Ex: What would you do differently next time?

Plus (+)	Delta (∆)

References:

Klair MB (2000). The Mediated Debrief of Problem Flights. in Facilitation and Debriefing in Aviation Training and Operations (1st ed). Routledge. www.taylorfrancis.com/chapters/mono/10.4324/9781315255576-12/mediated-debrief-problem-flights-key-dismukes-guy-smith
ACPS Quality Tools: Plus/Delta (ND). fhop.ucsf.edu/sites/fhop.ucsf.edu/files/custom_download/ACPS_Plus_Delta_Template.pdf

Assessment:

Leopold Maneuvers (1.5 min): https://youtu.be/KQ3L1n5XiLw
Obstetric Examination (8 min): https://youtu.be/rx_yn_cN8gg?t=156
Vaginal Exam (8 min): https://youtu.be/x17vY7_3M2M
Guide to creating cost-effective materials to practice measuring dilation: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8730796/
Fetal Station (22 sec): https://youtu.be/ieTRPRKFI9g
Fetal Station (4.5 min): https://youtu.be/3jlMT95Zs9U
Fetal Positions (Link): https://www.verywellfamily.com/fetal-positions-for-labor-and-birth-2759020
Fetal Positioning from Sutures and Fontanelles (5 min): https://youtu.be/TASoMrvIuPE
Fetal Positions from Fontanelles (Link): https://oacapps.med.jhmi.edu/OBGYN-101/Text/Abnormal%20L&D/fetal_position.htm
Caput and Moulding (4 min): https://youtu.be/ohruykQSVgk
Caput and Moulding Explained (Link): https://www.open.edu/openlearncreate/mod/oucontent/view.php?id=272&section=20.8

Fetal Heart Rate Monitoring:

Fetal Heart Rate Auscultation (3.5 min): https://youtu.be/uuX0YtSAUpA
Intermittent Auscultation (steps from 2:22-4:50): https://www.youtube.com/watch?v=dSdWAq_W2vU

Shoulder Dystocia Maneuvers:

Shoulder Dystocia & ALARMER Mnemonic (8.5 min): https://youtu.be/BvkKMwDaryg
ALARMER Mnemonic (8.5 min): https://youtu.be/jNmSJDbTARw

Phase	Purpose	Process	Sample Phrases
Reactions	Allow learners to express emotional reactions to simulation Provide facts underlying simulation	Ask for emotional reactions	*How are you feeling?* *What are some initial reactions to what just happened?* *So, in that scenario…*
Analysis	Uncover the ideas, thought processes, and other factors that lead to a learner behaviour (uncovering “frames”) Help learners find ways to improve	1. Observe an event or result. Comment on the observation. 2. Advocate for your position	*I saw that… I think…* *I noticed that…To me…* *I saw…I’m concerned that…*
		3. Investigate basis for learner’s thinking that led to the observed event or result	*What do you think?* *Why do you think that happened?* *How do you see it?* *What was the thought process behind….?*
		4. Close the gap through discussion and didactics	*I hear…. What would it take for you to do this next time?* *How could we do this differently next time?* *I think a few good ideas that came up were…* *I’d like to say a little bit about…from my experience/literature*
Summary	Distill lessons learned from debriefing Invite reflection on the experiences as a whole	Ask learners to summarize their takeaways, what went well/what could be done differently Summarize session and learning	*What are some takeaways from today?* *What went well today? What would you do differently next time?* *In today’s session, we….* *Going forward, we should…*

ØRECLESS: Shoulder Dystocia in a Rural Family Practice.

Scenario Overview

Scenario Info:

Prebriefing:

Scenario Stages: (Toggle) Educational

Debriefing:

Clinical Pearls:

ØRECLESS: Shoulder Dystocia in a Rural Family Practice.

Prebriefing

Case Briefing

1. Assessment

2. Delivery

3. Case Complete

Cervical Dilation Diagams

Cervical Effacement Diagram

Intermittent Auscultation During Labour

Shoulder Dystocia: ALARMER Mnemonic

Systemic Analgesics: Labor and Vaginal Delivery

Maternal Triage Assessment

GxPx/GTPAL: Both are ways of describing overall obstetrical history. GTPAL includes more detail.

Assessing Contraction Pattern

Leopold Maneuvers & Fetal Orientation

Debriefing

PEARLS Debrief Framework

GAS Debrief Framework

Team Dynamics Debrief Framework

SHARP Debrief Framework

Diamond Debrief Framework

Plus-Delta Debrief Framework

Debriefing with Good Judgment Framework