COVID 19 Maternity Simulation Scenarios

Respiratory DistressAntenatal Patient

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

Dr Leanne Ryan Anaesthetist Gold Coast University Hospital (FANZCA)Medical educator with special interest in simulation @L_R_yan

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.  How should we manage antenatal admissions with COVID-19? A multidisciplinary team should be involved in the woman's care. Investigation and management should not be withheld due to pregnancy status - in particular radiological imaging should not be withheld due to pregnancy. Fetal wellbeing monitoring is suggested depending on gestation. There is no evidence to suggest that steroid for fetal lung maturity are harmful - they should be given if clinically indicated by fetal gestation. How should we manage respiratory distress in pregnancy?  Regular maternal observations should be as per routine practice with the addition of oxygen saturation monitoring. Aim for oxygen saturation is >94% titrating oxygen therapy as required. Aerosol generating procedures are high risk for exposure and include nasal cannula, bag-mask ventilation, nebulisers. Intubation is a high risk procedure for both patient and clinician. If intubation is required this should be with PPE, by the most experienced practitioner available.           

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. RSI and LSCS  in a pregnant COVID19 patient4. Theatre preparation and transfer of a COVID positive patient requiring an emergency caesarean section delivery   

Target Audience 

Name: Pamela Little Age: 36 G2P0 Diagnosed COVID-19 positive 2 days ago with worsening respiratory symptoms. Presented with PPROM and TPTL at K 34+5/40 and admitted to the maternity ward.

Learning Objectives 

15-20 Participants MDT Team 

Patient Details 

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

Staff RequiredParticipants: Midwifery team, Obstetrics team, Anaesthetics Team, Perioperative Team, Code team, ICU team, Neonatal team Simulation Educator/Tech: 1 Confederate: 1 Midwifery confederate Facilitator: Nurse/doctor

Equipment: Mannikin/SiMoM with ability to perform LSCSisimulate/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 OxytocinonIVF

The mannikin is lying on a bed on the antenatal ward with oxygen mask on and CTG attached and running. Confederate midwife presses the staff assist " I'm really worried about Pamela"

Confederate Midwife Script

I  Hi I’m .................... S I'm really worried about Pamela - she has COVID-19 appears to have worsening respiratory distress.  B Pamela was tested and confirmed positive for COVID-19 2 days ago and has a worsening cough, fevers and shortness of breath. She was admitted 24hrs ago with PPROM and TPTL. She's had ongoing clear fluid loss but no further contractions. Her pregnancy has otherwise been uncomplicated. Her SOB just seems to be getting worse and worse despite putting her on 15L O2 non-rebreather. A She's actually SOB with a RR 26, Sats of only 91% on 15L Non-Rebreather, BP 105/60, HR 110 and febrile to 38. I'm also concerned about her CTG.  R I think we need to call a MET call and get anaesthetics and obstetrics to see her. I'm worried she might need advanced airway support and an emergency caesarean.  

Scenario Management

Scenario Resources - Facilitator Results Summary

FBC  - Normal WCC with Lymphopenia (described feature of COVID-19) U&E  - Normal LFT's- Mildly deranged LFT's have been associated with COVID-19 especially with worsening respiratory function. ALP elevated due to pregnancy

Bloods

CTG

Abnormal CTG

ECG Sinus Tachycardia

Antenatal RecordUnremarkable antenatal course

ABGABG 1 : Acute Type 1 Respiratory Failure ABG 2 : Mixed Response Respiratory Failure

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/

Management of Maternal Respiratory Distress

Resources 

A multidisciplinary team should be involved in the woman's care.

   

Radiological imaging should not be with-held in pregnancy if otherwise

clinically indicated.     

Aim for oxygen saturation is >94% - titrating oxygen therapy

as required to achieve this.

Aerosol generating procedures are high risk for exposure and include

nasal cannula, bag-mask ventilation, and nebulisers.

If intubation is required this should be with PPE, by the most experienced

practitioner available.  

Intubation is a high risk procedure for both patient and clinician in

COVID-19.