For the ED in situ simulations this month we ran through a case of a woman arriving in labour with EMS, imminently delivering.

Learning Point 1: This patient should come to the ER, NOT be sent upstairs in an elevator.

Call for OB nurses to come down to US with FHR monitor, PANDA warmer, delivery kit etc.

After delivery, she beings bleeding. How do we approach a post-partum hemorrhage in the ER? 

• Address the 4 T’s (and start with Tone!)

Learning Point 2: Oxytocin – Always give Oxytocin 10units IM or 3units IV with delivery of the anterior shoulder for prevention of PPH. Once PPH identified, can put 40units in 1L NS and run at 250cc/hr (10units/hr)

Learning Point 3: Physical maneuvers first – bimanual compression of the uterus, place a Foley Catheter to empty the bladder.

Learning Point 4: Secondary medications – 

• TXA 1g IV
• Misoprostol 200mcg (New SOGC guidelines recommend SL/PO – NOT PR)
• Ergotamine 0.25mg IM
• Carboprost (Hemabate) 0.25mg IM or IMM

*These are all available in the ADU but must be drawn out individually

OR can be found in the PPH kit on the floor

• Resuscitate the patient – all our usual principles apply. 
• Consider DIC screen/empiric fibrinogen (RiaSTAP)
• Call for Help (Remember CODE OB gets you OR staff/surgery mobilized)

Learning Point 5: Bakri Balloon – 

If required for packing the uterus, this is found in the PPH kit on the floor, or in the OR 

In Dr. Branigan’s eloquent words: 

The goals of this simulation involve the principles of patient safety – the right care (skill sets, equipment and drugs) in the right place (in this case the ED due to imminent delivery).  It is a process to look at clinical knowledge (imminent delivery, PPH 4 Ts and treatment strategies) and organizational knowledge (who is your team and how do you call them, where is your equipment and your drugs)

I will attach the case we used in a group reply to this email, along with the new SOGC guideline if you are motivated to review it.  If you have a quiet shift and want to verbally review this case with the nurses on shift to make sure everyone knows where to find the medications and equipment etc feel free to refer to this! Hopefully little tidbits of education like this can help with group morale 🙂