COVID 19 Maternity Simulation Scenarios

Urgent Caesarean Section Fetal Bradycardia

Simulation Scenario Design and Development

Dr Belinda Lowe Obstetrician and Gynaecologist Gold Coast University Hospital (FRANZCOG)Simulation Teaching Fellow Bond University Faculty of Health Sciences and Medicine @Belinda_J_Lowe

Dr Victoria Brazil Professor of Emergency Medicine Gold Coast University Hospital (FACEM) Director of Simulation Bond University Faculty of Health Sciences and Medicine @SocraticEM

Dr Rebecca Szabo FRANZCOG MClinEDObstetrician/Gynaecologist & Medical Educator the Women’sLead Gandel Simulation Service & Women’s Health Education Senior Lecturer The University of Melbourne MDHS@inquisitiveGyn

COVID-19 in Pregnancy  COVID-19 is a new strain of virus in the coronavirus family which causes a respiratory illness with symptoms including fever, a cough, sore throat, fatigue, shortness of breath. In some patients an acute respiratory distress syndrome and pneumonia can occur. What do we know about COVID-19 and pregnancy?There are only limited case reports of COVID-19 infections in pregnancy. COVID-19 does not appear to be associated with increased severity of illness in pregnant women. There is currently no evidence of vertical transmission.  Practical considerations for COVID-19 in Labour and Delivery  1.     Entonox may increase aerosolization and spread of the virus. If used then the breathing system must contain a filter to prevent contamination with the virus (< 0.05μm pore size). 2.     Continuous electronic fetal monitoring using cardiotocograph (CTG) is recommended There appears to be a higher proportion of fetal compromise reported in COVID-19 affected pregnancies in labour.   3.     There is currently no evidence to favour one mode of birth over another Mode of birth should not be influenced by the presence of COVID-19, unless the woman’s respiratory condition demands urgent delivery. 4.     Early epidural Should be recommended to women with suspected or confirmed COVID-19 to minimise the need for general anaesthesia if urgent delivery is needed 5.     PPE Donning is time consuming This has potential to significantly impact management of obstetric emergencies and time to delivery internals. Women and their families should be told about his possible delay. Practical considerations should be made for location of emergency drugs and equipment (ie terbutaline and PPH drugs). Removal of PPE DOFF is a high risk period for health care worker contamination - education around DON and DOFF techniques is encouraged.  6.     Minimise the number of staff where possible The number of staff in the delivery room or operating theatre should be kept to a minimum. This may result in differences to standard team organisation and structure for management of obstetric emergencies   7.     Neonatal considerations There is currently limited data to guide the postnatal management of babies of mothers who tested positive for COVID-19. There is no current evidence of vertical transmission but there has been cases of neonatal infection. Early involvement of the neonatal team is essential. Babies born to infected mothers should be tested for COVID-19.           

Resources and Further Reading Coronavirus (COVID-19) Infection in Pregnancyhttps://www.rcog.org.uk/globalassets/documents/guidelines/coronavirus-covid-19-infection-in-pregnancy-v2-20-03-13.pdf Practice Advisory: Novel Coronavirus 2019 (COVID-19)https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Advisories/Practice-Advisory-Novel-Coronavirus2019?IsMobileSet=false From the font lines of COVID-19 - How prepared are we as obstetricians: a commentary https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1111/1471-0528.16192 COVID-19: The Novel Coronavirus 2019 https://rebelem.com/covid-19-the-novel-coronavirus-2019/

Simulation Participant InformationWe’re running a simulation focused on the care of a patient with an obstetric patient with COVID-19.   The aims of this exercise are to 1. Review the systems and process around care delivery for a COVID-19 patient 2. Specifically reflect on the team communication and department interfaces3. Have a chance to discuss this patient’s obstetric and neonatal care with the various providers involved  Teams involved may include anaesthesia, midwifery, obstetrics, preoperative and others FAQsDo I need to come down for the prebriefing?The briefing will re-iterate the practicalities of the simulation, introduce the team, and answer any queries you have. What are we allowed to ‘do’ to the patient?We’ll be working with a manikin specifically prepared for this sim. You will be able to do most of the things we usually do in birthsuite and theatre eg give drugs through IV lines, vaginal and obstetric examination, roll, move and position the patient (no cables), airway management including intubation, prep/ drape etc.   What about ‘fake’ medications etc. ?We encourage staff to use real drugs and equipment, to minimise the risk of fake equipment being left in any patient areas. Please document as you would normally and prep/ drape/ monitor the patient as you would normal. Don’t open any significantly expensive equipment or drugs. Bloods products will be ‘fake’ but will have labels and sheets that require checking. Please don’t remove any medications from the birthsute or theatre used.  Do we actually call people like Anaesthetics/ OT/ Neonates?Yes. We should have prepared those you might call in advance. In addition we ask that you start each conversation with “This is a simulation…”  What about real patients?Safety of actual patients outside the simulation is the highest priority. Sim team staff will maintain awareness of those potential needs around the sim. We also ask that each of your areas think ahead to possible issues. If you are in any doubt during the sim – err on the side of your attention going to a real patient. If a major incident occurs requiring ED care we may modify the sim or stop if necessary. What about bloods/ Xrays etc?These will be provided in either paper or electronic form as per usual care. Do we all need to come to the debrief?This is a critical part of learning from the exercise, so we’d like you to prioritise it if you can. What if I do the wrong thing?The sim is complex and multifaceted. Individual performance is not the focus and its unlikely we’ll be discussing that in the debrief  Can others (eg students/ other staff) watch?Yes. However we ask that those not directly involved in the patient care come to the OT education room and stay there. Cameras will be following the patient and sending the AV to this room, and team leader will be miked up. So we’ll be filmed?Some of the simulation filming may be recorded. You will be asked to sign an attendance/ AV consent form. We use the video and still pictures for our own sim QA, and sometimes for teaching purposes. If you don’t consent that is fine – we can either blur faces or not use the footage. Most of the video is simply streamed in real time and not recorded.

1.  Demonstrate a systematic team based approach to a COVID 19 positive patient with an obstetric emergency2.  Familiarity to COVID19 PPE protocol and safely perform PPE DON and PPE DOFF3. Theatre preparation and transfer of a COVID positive patient requiring an emergency caesarean section delivery4. RSI and LSCS  in a pregnant COVID19 patient   

Target Audience 

Name: Pamela Little Age: 36 G2P0 Confirmed COVID 19 with mild respiratory symptoms only at K 38+5/40 in spontaneous labour. At 4cm dilated she has a prolonged bradycardia requiring an emergency Caesarean section.

Learning Objectives 

10-15 Participants MDT Team 

Patient Details 

Pm Hx : Nil Medications: Nil Allergies: NKA Non-smoker, no ETOH in pregnancy

Staff Required

Participants: Midwifery team, Obstetrics team, Anaesthetics Team, Perioperative TeamSimulation Educator/Tech: 1 Confederate: 1 Midwifery confederate Facilitator: Nurse/doctor 

Equipment: Mannikin/SiMoMisimulate/monitoringIVC with fluids running CTG PPECrash Cart Advanced Airway Equipment Caesarean section theatre packOxygen mask

Equipment and Props Required 

Setup 

Documentation:Observation chart Medication Chart Bloods - FBC, U&E, LFTCTG ECG Clothes:

Hospital gown on mannikin

Medications:RSI drugs TerbutalineIVF

The mannikin is lying on the birthsuite bed with CTG attached and running Confederate midwife presses the staff assist " Pamela is having a prolonged deceleration"

Confederate Midwife Script

I  Hi I’m .................... S Pamela is having a prolonged fetal deceleration (by the time the team DON it will be a 5 minute bradycardia)   B She presented in spontaneous labour about an hour ago. Pamela was tested and confirmed positive for COVID-19 2 days ago but she has only had mild respiratory symptoms. She’s 38+5/40 with an otherwise uncomplicated pregnancy. She doesn’t have an epidural and she’s not on oxytocinon. Uterus feels soft and not tonic. A Observations have all been normal. I’ve just done a vaginal examination and she’s 4cm dilated. I applied a FSE and there was fresh meconium liquor.  R I think we need to prepare for emergency caesarean section    

Scenario Management

Scenario Resources - Facilitator Results Summary

FBC  - Marginally elevated WCC - normal for pregnancy U&E  - Normal LFT's- Normal (ALP elevated due to pregnancy)

Bloods

CTG

Fetal bradycardia 6 minutes

ECG

Sinus Tachycardia

Antenatal Record

Unremarkable antenatal course

COVID-19 in Pregnancy 

Coronavirus (COVID-19) Infection in Pregnancyhttps://www.rcog.org.uk/globalassets/documents/guidelines/coronavirus-covid-19-infection-in-pregnancy-v2-20-03-13.pdf  COVID-19: The Novel Coronavirus 2019 https://rebelem.com/covid-19-the-novel-coronavirus-2019/

There are only limited case reports of COVID-19 infections in pregnancy. COVID-19 does not appear to be associated with increased severity of illness in pregnant women. There is currently no

evidence of vertical transmission. 

Resources 

Entonox may increase aerosolization and spread of

the virus  

Continuous electronic fetal

monitoring using cardiotocograph (CTG) is recommended 

   

There is currently no evidence to favour one mode of birth

over another  

 Consider early epidural in all suspected or confirmed

COVID-19 patients in labour

Minimise the number of staff where possible and consider

neonatal management  

PPE donning is time consuming and will impact the management

of obstetric emergencies