The case:
33 year old primip with shoulder dystocia and subsequent PPH, neonate requiring resuscitation initially by attending pediatrician.
Sim report 2/3/23
Interdepartmental simulation training ED
Hi everyone,
A bit late this time but I got around to think about and sum up our excellent get together from two weeks ago.
Firstly, thank you very much for participating in our simulation and giving us great ideas where to improve the work between ED, Anaesthetics, Neonates and Paediatrics. I also apologize again for putting pressure on theatre and not informing them about our simulated patient.
The case:
A 33 year old G1P0 was rushed to ED during a failed home delivery. The midwife was unable to deliver the babies shoulder, in other words she was worried about a shoulder dystocia. Before the obstruction she had a prolonged labour and now was very distressed with pain. Babies head was cyanotic as per midwife.
The pregnancy was otherwise uncomplicated so a midwife guided home delivery was attempted.
An ambulance got called to scene, they scooped and ran with the patient to escalate quickest care.
Once ED received the phone call a Onet was called appropriately very early on as help was expected to be required from specialist teams.
It quickly became very very busy which is to be anticipated and realistic.
The baby was delivered quickly by the OG team in a stepwise escalation approach (McRoberts, episiotomy, rotational manoeuvres and early plan for section if required)
Once delivered the neonate was flat with bradycardia and no resp effort but was resuscitated by the neonatal/paediatric team and stabilized once intubated and insertion of an ambi line.
Mum developed a PPH due to prolonged and obstructed labour and was escalated to theatre after compression and pharmacological management in ED.
Learning points:
Role distribution:
ED as team leader and communicator/assist specialist teams in unfamiliar environment
Manage noise level and amount of bystanders
OG: deliver the baby
Anaesthetics: assist distressed mum, analgesia and manage complications
Neonates/Paediatrics: expected a flat neonate, preparation for neonatal resus
For ED medical staff
Management of shoulder dystocia is part of our curriculum,
be familiar with steps up to performance of an episiotomy,
we are lucky to have specialist support, if this happens in the country, we should have plan in our minds how to help
General staffing
Presence/availability of at least four runners (two for each team) who are very familiar with drugs equipment and locations of these
however, keep area free of unnecessary bystanders (yes, it is a learning opportunity but people can get into the way in an extremely busy resus
Area
Space for neonatal resuscitation
if available free up two bays as two patients expected more room for neonatal team/ equipment issues such as availability of wall oxygen solved
Equipment
Episiotomy scissors are in delivery kit even though not stated on front (named Metzenbaum scissors as on pack)
availability of doppler for foetal heart beat assessment (doppler in resus, to be checked and not moved elsewhere)
extension for wall oxygen for neonatal resucitair. Risk of running out with lengthy resuscitation and cylinder use
Drugs
Early administration of nitrous oxide to patient
Neonatal team brings there onet pack to delivery
PPH pack to be adjusted to theatre pack to facilitate independence of anaesthetic team and free up staff
Disposition
Early communication with NETs to facilitate infant transfer to tertiary hospital
I think these were the points that were highlighted during this simulation.
If anyone has other points to add please contact me and I will add them on to my report.
Here is a link for the stepwise approach to shoulder dystocia:
https://www.ncbi.nlm.nih.gov/books/NBK470427/
Once again thank you very much for all the input and we will probably see you for further scenarios soon.
Irene Pelletier
FACEM