Practiss - Welcome

ØRECLESS: Postpartum Hemorrhage in a Rural Family Practice.

You just started as the new locum in the community and spent the past few days hiking and backcountry camping. The hospital is a rural 1A maternity site (no local cesarean section capabilities), and the nearest urban centre is 530 km away. Your colleagues are great, the area is beautiful, and it feels like home. You may even consider staying here a little longer.

You were the only physician on-call when a 32 y/o woman presented to the ED today at 2345 in labour. The neonate was delivered five minutes ago with Apgar scores of nine at one minute and five minutes. There was no notable maternal or fetal trauma.

The woman is from a neighbouring community, has had no prenatal care, and stated that she had no issues throughout the pregnancy. She has no allergies and only takes “natural supplements.” She doesn’t smoke or drink alcohol. The delivery went well, and you are now tasked with delivering the placenta.

The learner will manage the delivery of the placenta followed by postpartum hemorrhage. The learner will demonstrate active management of the third stage of labour, navigate a resource shortage (e.g., blood products), and administer appropriate medications for postpartum hemorrhage management.

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: July 14, 2023
Most Recent Modification: October 14, 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

You just started as the new locum in the community and spent the past few days hiking and backcountry camping. The hospital is a rural 1A maternity site (no local cesarean section capabilities), and the nearest urban centre is 530 km away. Your colleagues are great, the area is beautiful, and it feels like home. You may even consider staying here a little longer.

You were the only physician on-call when a 32 y/o woman presented to the ED today at 2345 in labour. The neonate was delivered five minutes ago with Apgar scores of nine at one minute and five minutes. There was no notable maternal or fetal trauma.

The woman is from a neighbouring community, has had no prenatal care, and stated that she had no issues throughout the pregnancy. She has no allergies and only takes “natural supplements”. She doesn’t smoke or drink alcohol. The delivery went well, and you are now tasked with delivering the placenta.

Patient Chart
Name: Luna Petrov	Age: 32	Gender: F	Weight: 66.4 kg	Height: 176 cm	Rh Status: Positive
Temp: 36.2	HR: 110 bpm	BP: 115/73	RR: 25/min	O₂Sat: 93%	GCS: 15

1. Delivery of Placenta

The woman successfully delivered the neonate. Oxytocin (10 U IM) was given during the delivery of the anterior shoulder. Deliver the placenta, assess the uterine tone, and make note of any complications.

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: 115/73	HR (Rhythm): 110 bpm (Sinus Tachycardia)	RR: 25/min.
O₂SAT: 93%	Temperature: 36.2 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 Don relevant PPE Cord Clamping Delayed cord clamping (60-120 seconds) Umbilical Clamp #1: 3-5cm from neonate Instrument Clamp #2: 10cm away from Clamp #1 Clamp #3: Between Clamp #1 and Clamp #2, close to Clamp #1 Cut cord between Umbilical Clamp #1 and Clamp #3 Collect cord blood for gasses and Rh status (using segment between Clamp #2 and Clamp #3) Cord clamped ⇒ Facilitator: "There has been no umbilical cord lengthening and the uterus is not becoming firm." Controlled cord traction (Brandt-Andrews Maneuver) and counter traction (secure uterine fundus to prevent uterine inversion) Cord traction applied ⇒ Facilitator: "The placenta has delivered but the woman is still bleeding." Inspect the placenta (regular surface with complete cotyledons, umbilical cord, complete amniotic membranes, x3 blood vessels (2 aa. and 1 v.), and placental integrity) Call nursing/staff to increase available team numbers Prepare obstetric hemorrhage equipment tray (full list in equipment recommendations) Assess uterine tone by palpating the fundus (uterus is boggy) Recognize uterine atony Uterine tone assessed ⇒ Nurse: "The uterus is boggy and hasn't contracted. Did the whole placenta come out? She's still bleeding. Is there a way we can compress the uterus to reduce blood flow?" Transabdominal uterine massage Administer Oxytocin, 5 IU IV over 1-2 min or 10 IU IM or 20-40U in 1L normal saline IV (150mL/hr) Examine the uterus Rule out retained tissue (placental fragments, membranes, and clots) Rule out uterine inversion or uterine rupture Inform the woman of the current situation and management plan Woman not informed (in 5 min.) ⇒ Woman: "What's going on? Is something wrong?"
10 min. OR Actions Complete ⇒ 2. PPH Management

Expected Learner Actions

Introduction (name and role) and confirmation of patient name and pronouns
Patient consent to provide care and for physical touch
Don relevant PPE
Cord Clamping
Delayed cord clamping (60-120 seconds)
     Umbilical Clamp #1: 3-5cm from neonate
     Instrument Clamp #2: 10cm away from Clamp #1
     Clamp #3: Between Clamp #1 and Clamp #2, close to Clamp #1
     Cut cord between Umbilical Clamp #1 and Clamp #3
     Collect cord blood for gasses and Rh status (using segment between Clamp #2 and Clamp #3)

Cord clamped ⇒ Facilitator: "There has been no umbilical cord lengthening and the uterus is not becoming firm."

Controlled cord traction (Brandt-Andrews Maneuver) and counter traction (secure uterine fundus to prevent uterine inversion)
Cord traction applied ⇒ Facilitator: "The placenta has delivered but the woman is still bleeding."

Inspect the placenta (regular surface with complete cotyledons, umbilical cord, complete amniotic membranes, x3 blood vessels (2 aa. and 1 v.), and placental integrity)
Call nursing/staff to increase available team numbers
Prepare obstetric hemorrhage equipment tray (full list in equipment recommendations)
Assess uterine tone by palpating the fundus (uterus is boggy)
     Recognize uterine atony
Uterine tone assessed ⇒ Nurse: "The uterus is boggy and hasn't contracted. Did the whole placenta come out? She's still bleeding. Is there a way we can compress the uterus to reduce blood flow?"

Transabdominal uterine massage
Administer Oxytocin, 5 IU IV over 1-2 min or 10 IU IM or 20-40U in 1L normal saline IV (150mL/hr)
Examine the uterus
     Rule out retained tissue (placental fragments, membranes, and clots)
     Rule out uterine inversion or uterine rupture
Inform the woman of the current situation and management plan
Woman not informed (in 5 min.) ⇒ Woman: "What's going on? Is something wrong?"

10 min. OR Actions Complete ⇒ 2. PPH Management

2. PPH Management

Bimanual external/internal uterine massage and oxytocin have been implemented to manage PPH. The hospital is stocked with 2U pRBC. The woman is still bleeding. Continue managment.

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.

Expected Learner Actions
Estimate blood loss Assess signs of excessive bleeding (blood on floor, dripping off the bed, continuous suction, etc.) Estimate blood loss ⇒ Facilitator: Provide soaked towels or have a 1000mL bottle of red-dyed water pour out of the OB mannequin. Ask the learner to estimate the blood loss. Place two wide-bore IV lines Insert Foley catheter and drain maternal bladder Bladder not drained (in 2 min.) ⇒ Nurse: "Is there another way to assist the uterus in contracting and to monitor the effectiveness of fluid resuscitation?" Administer crystalloid fluids (up to 2L) Call for and transfuse 2U pRBC IV (consider pressure bag) Note: Woman is Rh positive Continous assessment of ABCs and vital monitoring Re-assess uterine tone by palpating the fundus Recognize boggy uterus Uterine tone not re-assessed (in 4 min.) ⇒ Nurse: "She's still bleeding. Have you re-assessed her uterine tone? What other medications can we use?" Consider Ergot Alkaloid/Ergonovine, 0.2-0.25mg IM repeated at 2hr-intervals - contraindicated in hypertensive pregnancy disorders Selects Ergot Alkaloid/Ergonovine ⇒ Nurse: "Ergonovine is contraindicated in hypertensive pregnancy disorders." Consider Carboprost/Hemabate, 250mcg IM or IMM q15min (max. 8 doses) - extreme caution if asthma or major cardiovascular/renal/hepatic dysfunction Selects Carboprost/Hemabate ⇒ Nurse: "Carboprost/Hemabate should be used with extreme caution in women with asthma." Administer Misoprostol, 400mcg SL or 800mcg rectally - Note: 30min onset delay Administer Tranexamic Acid, 1g IV (100mg/mL at a rate of 1mL/min = 10mL over 10min); repeat if bleeding persists after 30min or restarts after 24 hours Consider External Aortic Compression
8 min. OR Actions Complete ⇒ 3. Organize Transportation

Expected Learner Actions

Estimate blood loss
Assess signs of excessive bleeding (blood on floor, dripping off the bed, continuous suction, etc.)
Estimate blood loss ⇒ Facilitator: Provide soaked towels or have a 1000mL bottle of red-dyed water pour out of the OB mannequin. Ask the learner to estimate the blood loss.

Place two wide-bore IV lines
Insert Foley catheter and drain maternal bladder
Bladder not drained (in 2 min.) ⇒ Nurse: "Is there another way to assist the uterus in contracting and to monitor the effectiveness of fluid resuscitation?"

Administer crystalloid fluids (up to 2L)
Call for and transfuse 2U pRBC IV (consider pressure bag) Note: Woman is Rh positive
Continous assessment of ABCs and vital monitoring
Re-assess uterine tone by palpating the fundus
Recognize boggy uterus
Uterine tone not re-assessed (in 4 min.) ⇒ Nurse: "She's still bleeding. Have you re-assessed her uterine tone? What other medications can we use?"

Consider Ergot Alkaloid/Ergonovine, 0.2-0.25mg IM repeated at 2hr-intervals - contraindicated in hypertensive pregnancy disorders
Selects Ergot Alkaloid/Ergonovine ⇒ Nurse: "Ergonovine is contraindicated in hypertensive pregnancy disorders."

Consider Carboprost/Hemabate, 250mcg IM or IMM q15min (max. 8 doses) - extreme caution if asthma or major cardiovascular/renal/hepatic dysfunction
Selects Carboprost/Hemabate ⇒ Nurse: "Carboprost/Hemabate should be used with extreme caution in women with asthma."

Administer Misoprostol, 400mcg SL or 800mcg rectally - Note: 30min onset delay
Administer Tranexamic Acid, 1g IV (100mg/mL at a rate of 1mL/min = 10mL over 10min); repeat if bleeding persists after 30min or restarts after 24 hours
Consider External Aortic Compression

8 min. OR Actions Complete ⇒ 3. Organize Transportation

3. Organize Transportation

Misoprostol and Tranexamic Acid have been administered. Nurse: "What should we do if the medications don't work?"

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.

Expected Learner Actions
Initiate contact with referral centre specialist (e.g., Ontario - Criticall) Referral centre is contacted ⇒ Response: Agrees to accept the woman. Initiate contact with Air Ambulance Service (e.g., Ontario - Ornge) Air Ambulance Service contacted ⇒ Response: "It'll be an hour before we can get to you. Try to keep her stable until then." Initiate contact with nearby hospitals for pRBC (O-Negative) and note the potential for massive transfusion support Contact for pRBC ⇒ Response: "We can send over four units of pRBC. It'll be about 40 minutes."
2 min. OR Actions Complete ⇒ 4. Case Complete

Expected Learner Actions

Initiate contact with referral centre specialist (e.g., Ontario - Criticall)
Referral centre is contacted ⇒ Response: Agrees to accept the woman.

Initiate contact with Air Ambulance Service (e.g., Ontario - Ornge)
Air Ambulance Service contacted ⇒ Response: "It'll be an hour before we can get to you. Try to keep her stable until then."

Initiate contact with nearby hospitals for pRBC (O-Negative) and note the potential for massive transfusion support
Contact for pRBC ⇒ Response: "We can send over four units of pRBC. It'll be about 40 minutes."

2 min. OR Actions Complete ⇒ 4. Case Complete

4. Case Complete

30 minutes have passed, and administration of appropriate medications was successful. The woman is no longer bleeding and her vitals are stable. The neonate was returned to the woman for skin-to-skin contact and transportation has been cancelled. The case is complete.

At this time, you may quantify the blood loss and compare it to the learner's estimate. Subtract the dry weight of the towels from the "blood" soaked towels provided earlier (1g weight = 1mL blood loss).

Go to Debrief

PPH Case Approaches

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

PPH Decision Tree

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

Uterotonics for Prevention & Treatment of PPH

Signs of Placental Separation
1. Gush of blood 2. Cord lengthening 3. Uterine fundus rising in the abdomen 4. Uterus becoming firmer
Active Management
Oxytocin (10 IU IM or 5 IU by slow IV push over 1-2min or 20-40 IU in 100mL normal saline at 150mL/hour) - after delivery of the anterior shoulder to prevent PPH Oxytocin not available, use Misoprostol (400mcg SL) Medications not available, encourage breastfeeding Controlled cord traction: Traction applied in the axis of the pelvis (45 degrees from horizontal) during a contraction. Apply external counter traction (one hand supporting the uterus above the uterus above the pubic bone). - see Cord Traction Education, Note: Excessive traction may tear the umbilical cord or placenta Ensure all membranes are delivered Assess amount of bleeding and fundus (ensure it is well contracted) If the uterus is not contracted, perform uterine massage Inspect the placenta

Drug Name	Characteristics	Side Effects	PPH Usage
Medication Class: Oxytocics
Oxytocin	Preferred first line uterotonic Stimulates muscle of upper uterine segment causing contraction to compress blood vessels IV: acts immediately IM: 3-5 minutes	Rare: nausea, vomiting, headache, flushing Never give as IV bolus → hypotension, tachycardia & potential cardiovascular collapse possible Water intoxication with high doses, prolonged infusion, or hypotonic IV solution → Use normal saline or Ringers Lactate	Prevention Vaginal Delivery: 10 IU IM or 5 IU IV over 1-2min or 20-40 IU in 1000 mL, 150 mL/hour Cesarean (elective): Bolus 1 IU Start infusion at 2.5-7.5 IU/hour (0.04-0.125 IU/min) Cesarean (intrapartum): 3 IU over ≥ 30 seconds Start infusion at 7.5-15 IU/h (0.125-0.25 IU/ min) Treatment: 20-40 IU in 1000 mL normal saline, initially wide open
Carbetocin	Long-acting oxytocin analogue Alternative agent if oxytocin is not available or consider if pt. is at high risk of PPH	Nausea, vomiting, flushing, headache	Prevention Vaginal Delivery: 100 mcg IM Cesarean: 100 mcg over ≥ 30 seconds Treatment: Limited data available
Medication Class: Ergot Alkaloids
Ergot Alkaloids	Stimulates myometrium of upper AND lower uterine segments IM: 2-5 minutes IV: acts <1 minute (however, IV not recommended)	Nausea, vomiting, hypertension Contraindicated in all hypertensive disorders of pregnancy	Prevention: 0.2-0.25 mg IM Treatment: 0.2-0.25 mg IM (may repeat at 2h intervals)
Medication Class: Prostaglandins
Misoprostol	Prostaglandin E1 Causes vasoconstriction & enhanced contractility of the myometrium	Fever (most common with >600 mcg)	Prevention: 400 mcg SL (SL achieves highest serum peak level) Treatment Fastest Acting: 400 mcg SL Alternate: 800 mcg REC
Carboprost	Prostaglandin F2α Causes vasoconstriction & enhanced contractility of myometrium	Vomiting, diarrhea, fever, bronchospasm Use with extreme caution if asthma or major cardiovascular, renal, or hepatic dysfunction)	Treatment 250 mcg IM or intramyometrial q15min (maximum 8 doses, aka 2mg)
Medication Class: Tranexamic Acid
Tranexamic Acid	Not a uterotonic Inhibits fibrinolysis Consider in pt. at very high risk of PPH	N/A	Prevention Vaginal Delivery: 1 g IV over 10 minutes within 10 minutes after vaginal delivery Cesarean: 1 g IV over 10 minutes before skin incision Treatment 1 g IV over 10 minutes within 3h of PPH diagnosis

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

Bimanual Massage/Compression Technique

Compress the uterus against the anterior part of the cervix with a hand in the vagina and a hand on the fundus.

Retrieved July 20, 2023 from Bromberek, Elaine & Smereck, Janet. (2017). Evaluation and Treatment of Postpartum Hemorrhage. 10.1007/978-3-319-54410-6_8.

External Aortic Compression

Perform external aortic compression with the non-pneumatic anti-shock garment (NASG).

Manual compression of the aorta by standing on the woman's left and using one's right fist to compress the aorta and using one's left hand to feel for the loss of the femoral pulse.

Reference(s):
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.

Controlled Cord Traction

Brandt-Andrews Maneuver (preferred): an abdominal hand secures the uterine fundus to hold it in a fixed position and prevent uterine inversion while the other hand exerts sustained downward traction on the clamped umbilical cord.

Reference(s):
Anderson, Janice M, and Duncan Etches. 2007. Prevention and Management of Postpartum Hemorrhage. www.aafp.org/afp. (October 12, 2023).

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)

Provincial Massive Hemorrhage Protocol

Provincial Massive Hemorrhage Protocol: https://transfusionontario.org/wp-content/uploads/2021/10/Recommendation-Statements_April-2021-1.pdf
Ontario Regional Blood Coordinating Network. Ontario MHP: Guidance for small/remote hospitals. https://youtu.be/ofvNsScQ58M?feature=shared

Refractory Hemorrhage Caution:

Dilution of clotting factors (including platelets and fibrinogen)

E.g., for hemorrhagic shock with ongoing bleeding, crystalloid administration may dilute the coagulation factors and RBC concentration. Beginning resuscitation with crystalloid early may promote volume overload.

Hypothermia from transfusion of cold products
Hypocalcemia-induced coagulopathy (due to citrate in blood products)
Acidosis

Minimum Laboratory Protocol Resuscitation Targets for Transfusion:

Hemoglobin >80 g/L (RBC)
INR <1.8 (plasma or prothrombin complex concentrates)
Fibrinogen >1.5 g/L (cryoprecipitate or fibrinogen concentrates)
Platelets > 50x10^(9)/L
Ionized calcium >1.15 mmol/L

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

Third Stage of Labour:

Delivery of the Placenta (2 min): https://youtu.be/I4Lb6W5HXxA?t=201
Examining the Placenta (4.5 min): https://youtu.be/l1V8hi_1aoc
Manual Removal of the Placenta (1.5 min): https://youtu.be/4iHSXADzc98
Bimanual Uterine Compression: https://youtu.be/eiTslknDtcY
Uterine Compression (3.5 min): https://youtu.be/DmNkxCpMlo4
Aortic Compression (3.5 min): https://youtu.be/M8QZ4GXfx0k

Shock and Massive Hemorrhage Protocol:

MD Calc Shock Index: https://www.mdcalc.com/calc/1316/shock-index
Ontario Regional Blood Coordinating Network Physician Resources: https://transfusionontario.org/tag/physicians/
Ontario Regional Blood Coordinating Network. Ontario MHP: Guidance for small/remote hospitals: https://youtu.be/ofvNsScQ58M?feature=shared
Provincial Massive Hemorrhage Protocol: https://transfusionontario.org/wp-content/uploads/2021/10/Recommendation-Statements_April-2021-1.pdf
ABCDE Acute Seizure Management: https://geekymedics.com/acute-management-of-seizures/
UpToDate: Overview of Postpartum Hemorrhage

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: Postpartum Hemorrhage in a Rural Family Practice.

Scenario Overview

Scenario Info:

Prebriefing:

Scenario Stages: (Toggle) Educational

Debriefing:

Clinical Pearls:

ØRECLESS: Postpartum Hemorrhage in a Rural Family Practice.

Prebriefing

Case Briefing

1. Delivery of Placenta

2. PPH Management

3. Organize Transportation

4. Case Complete

PPH Case Approaches

PPH Decision Tree

Uterotonics for Prevention & Treatment of PPH

Bimanual Massage/Compression Technique

External Aortic Compression

Maternal Triage Assessment

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

Controlled Cord Traction

Assessing Contraction Pattern

Provincial Massive Hemorrhage Protocol

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