COVID 19 Maternity Simulation Scenarios

Uncomplicated Vaginal Birth Spontaneous Vaginal Delivery

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. Recognise need for CTG and close maternal and fetal monitoring in labour in COVID-19 patients4. Preparation and planning for neonatal resuscitation in an infant from a COVID-19 positive mother    

Target Audience 

Name: Pamela Little Age: 36 G2P1 Confirmed COVID 19 with mild respiratory symptoms only at 38+5/40. SROM ? Meconium. Contracting 3-4:10

Learning Objectives 

5-6 Participants  

Patient Details 

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

Staff Required

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

Equipment: Simulated Patient/MannikinPregnancy belly Simulated baby and placenta isimulate/monitoringIVC with no fluids runningCTG PPEOxygen mask Delivery pack Cord Clamps Meconium on a pad

Equipment and Props Required 

Setup 

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

Clothes: Hospital gown on mannikin/ simulated patient

Medications:Oxytocinon IM

Nothing in the birthsuite room Confederate midwife tells the team " I've just had a call from the ambulance - they're bringing in a COVID-19 positive patient at 38 weeks in labour"

Simulated Patient Role Play Case Narrative

You are 38 weeks and 5 days in your second pregnancy. You were found to be COVID-19 positive 2 days ago after having some mild fevers, dry cough and a runny noise. Your family had a gathering for a wedding 7 days ago and there were multiple family members who had recently travelled from overseas. Several of your family have been found to be COVID-19 positive also but thankfully no one has been very unwell and you have all been self- isolating at home. Your pregnancy has been uncomplicated and you previously had a very quick vaginal delivery with your first baby. Today you started having contractions about 2 hours ago and ruptured your membranes about an hour ago. You decided to call an ambulance as you could really feel your contractions getting more uncomfortable. You’re worried about what is going to happen with your baby and if your baby is at risk of contracting the COVID infection from you. 

Confederate Midwife Script

I  Hi I’m .................... I've just had a call from the paramedics.  S They're bringing in Pamela Little who is a G2P1 36y/o COVID-19 positive patient at 38 weeks in labour B Pamela was tested and confirmed positive for COVID-19 2 days ago but apparently only has fairly mild respiratory symptoms. She's 38+4/40 with an otherwise uncomplicated pregnancy. She had a quick vaginal birth with her first baby. She ruptured her membranes at home about an hour ago and it sounds like she could have meconium liquor.  A The paramedics have said she doesn't appear to have severe respiratory distress and has had normal observations with them. They think she's in well established labour.  R I think we need to get our birthsuite room ready for a COVID-19 positive patient who sounds like she's likely to have a vaginal delivery  

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

Normal

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