Scenario	Normal Delivery with PPH
Estimated Simulation Time (Includes pre/post quizzes, coaching, activity performance, etc)	3 hr Q1 20 min Q2 20 min Orientation/Roles/Report 20 min Labor 1 hr PPH 1 hr
Estimated Debriefing Time	1 hr
Estimated Learner Prep Time (case study)	1 hr
Prerequisite Knowledge The student shall have the prior knowledge of
the labor and delivery process the risk factors for PPH the potential complications of PPH the application of the nursing process for labor and delivery followed by PPH when to notify the phcp transcription of orders execution of orders providing hand-off communications

Cognitive Skills	Psychomotor Skills
Understands the labor and delivery process Identifies the patient’s risk factors for PPH Compares the patient’s current status to the baseline status received in report Identifies s/sx of labor stages Identifies s/sx of PPH Identifies nursing interventions for labor, delivery, and PPH Identifies appropriate and/or inappropriate orders from phcp Identifies appropriate documentation Identifies appropriate reporting components	Performs physical and psychosocial assessment Reviews patient chart for H&P, VS, labs, test results, prior orders Measures VS Provides physiologic monitoring (pulse ox, ECG, FHR monitoring) Facilitates vaginal delivery Performs fundal massage Completes assessment components, documentation, and medication administration using available technology resources properly

Learning Objectives Upon completion of the scenario, in regards to labor, delivery, and subsequent postpartum hemorrhage, the student shall
Function within the scope of practice of a registered nurse Apply the nursing process while caring for the laboring client who develops a postpartum hemorrhage Utilize EBP while providing culturally competent, safe nursing care for the laboring client Demonstrate proficient medication dosage calculation and administration Participate as a member of the interprofessional team Communicate with team members, the client, and the client’s family member(s) professionally Provide client and family education that is pertinent for the laboring client who develops a postpartum hemorrhage

Patient Information
Demographics	Name: June Peters Age: 31 Gender: Female Height: 5’ 7” Weight: 156 lb Marital Status: Married Advance Directives: Full code
Setting	L & D unit setup for labor, delivery and subsequent PPH
Hand-off communication to participants:	June Peters, 31 y/o female G5P4, 39 weeks, patient of Dr. Andrews, presented to ER with contractions and cervical dilation of 3 cm with SROM shortly after. No significant medical, surgical, or obstetrical history. NKA. Admitted to L&D. Physical exam is WNL. Screenings: GBS neg, STI neg, Hep B neg, HIV neg, Rubella immune. Rh positive, FHR 140s. Monitors applied once patient was admitted to L & D unit 4 hours ago. Pain management achieved with Stadol. Contractions every 6 minutes/lasting 30 seconds/mild pain rated 4/10 in abdomen and lower back. Cervical dilation 3 to 4 cm. Significant other is present, excited for a baby boy, but is worried about the birthing process. T 98.6, HR 78, R 14, BP 130/82, urinary output 200 mL

Group Assignments
Group A completes labor process, client coaching and education, delivers a healthy male neonate, and completes APGAR scores and initial skin-to-skin contact.	Group B identifies s/sx of PPH, notifies PHCP, initiates IV oxytocin and methylergonovine, fundal massage, and assesses for the bleeding to decrease and VS to stabilize.

Role Assignments
Role	Responsibilities
Primary Nurse	Initial assessment, review of previous assessment findings including VS, labs, diagnostics, etc. Provide and assign the provision of direct client care and communication with team members to facilitate the scenario.
Medication Nurse	Proper administration of medications, review of previous assessment, VS, labs, and diagnostics as related to medication administration, evaluation of the provided medications, and communication with team members to facilitate the scenario.
Documentation Nurse	Correct documentation of assessment findings as reported by the primary nurse, correct documentation of communications, review of previous assessment, VS, labs, diagnostics, and communication with team members to facilitate the scenario.
Family member	Question team members about results of previous assessments, labs, diagnostics, request clarification and explanation throughout the scenario, and communicate with team members to facilitate the scenario.
Observer	Observers participants and critiques performance of psychomotor skills and application of cognitive skills of the participants and communicate with team members to facilitate the scenario.

Unfolding Scenario
Scene (times are max allowed including coaching)	Setup	Outcome
4 hrs post admit to L & D unit (20 min)	Maternal VS stable, FHR stable in 140s, labor progresses to natural vaginal delivery	Complete focused maternal assessment and head to toe assessment
Labor Progression (20 min)	Labor progression to 10 cm dilation	Coach client through labor process, educate on pain management options available, employ nonpharmacological methods as well, notify OB/Gyn of impending delivery
Delivery of neonate (20 min)	Head crowns, delivery completes	Facilitates passage of neonate through the birth canal as OB/Gyn “enters” the patient room, APGAR scores are completed, skin-to-skin contact initiated, maternal client is cleaned and positioned for comfort
Hand-off communication (10 min)	Change of shift at nurse’s station – instructor to insert Victoria’s PPH belly and perineum at this time	Group A gives hand-off report to group B using SBAR format
1 hour post delivery (20 min)	Maternal VS begin to decline indicating hypovolemia	Recognize change in VS, complete assessment, identify PPH
Determine severity of PPH (20 min)	Approximately 900 mL of dark red blood with clots between manikin legs, saturated peri pad	Attempt to estimate blood loss by weighing pad and determining if pad is saturated within 1 hr, reassess VS, urinary output, and CO status, notifies OB/Gyn
Interventions (20 min)	Approximately 900 mL of dark red blood with clots between manikin legs, saturated peri pad	Begin fundal massage, call OB/Gyn for med orders to include IV oxytocin and methylergonovine
Evaluation (10 min)	Approximately 900 mL of dark red blood with clots between manikin legs, saturated peri pad	Clean up maternal client, reassess for blood loss, VS, and fundal firmness

Event List Group A (Group B to observe and check-ff)
S	NI	US	Notes
Assessed patient upon initial meeting
Measured vital signs
Analyzed maternal VS
Reviewed current admission orders
Analyzed FHR
Assessed pain level and intervened appropriately
Notifies phcp when at 7 cm
Set up delivery bed
Facilitates vaginal delivery
Communicates with patient/family during labor/delivery
Provided hand-off communication (SBAR)

Event List Group B (Group A to observe and check-off)
S	NI	US	Notes
Assessed patient upon initial meeting
Measured vital signs
Analyzed maternal VS
Identified PPH (determining # pads/hr and/or weighing pad for estimated blood loss)
Performed fundal massage appropriately
Obtains order for postpartum oxytocin and rectal misoprostol
Reassessed vital signs
Reassessed PPH blood amount
Reassessed /continued fundal massage until firm
Communicates with patient/family during PPH
Provided hand-off communication (SBAR)

Equipment Checklist
☐Patient monitor with ECG, NIBP, RESP	☐O2 flowmeter
☐FHR/TOCO monitor	☐ O2 delivery (NC, mask)
☐BP Cuff	☐Peri pads
☐SpO2 probe	☐Chux
☐PPE	☐Telephone
☐IV pump w/pole	☐Pt medical record
☐IV fluids (LR, NS)	☐Documentation system
☐Medication Cart
☐ IV medications and admin supplies

Debriefing
Reactive Phase	How do you feel about that scenario? Did that scenario feel any different when you switched roles? How confident are you about the work you did? How did you feel about the process? How did you feel about the deadlines for your team activity? How did you feel when responding to objections? How do you feel about the number of options available? How do you feel about your potential for success? What was your reaction as the scenario was negotiated? Did you get more or less comfortable?
Analysis/Understanding Phase	What was happening in each situation presented? What assessment findings guided your thinking and decision-making for each situation? When you come into the situation, did you have a strategy for prioritizing? What are the nurse’s immediate priorities for a client experiencing labor? Experiencing PPH? What would you do clinically with a patient like this? How can understanding this process help you on the job?
Summary/Take home Phase	What did you learn from the feedback from your group? What did you learn? What do you still need to learn? What insights did you have in that activity? Which personal objectives have been addressed? What are you going to take away from this learning experience?