Scenario in a Nutshell
Patient develops a non-reassuring CTG that deteriorates to a fetal bradycardia requiring a category 1 caesarean section.
Stage 1: Recognition of non-reassuring CTG and request for review.
Stage 2: Onset of fetal bradycardia.
Stage 3: Review by obstetrician, decision to deliver, communicate decision and consent.
Stage 4: Prepare patient and move to theatre.
Target Learner Groups
All members of the multidisciplinary obstetric team: midwives, anaesthetists and obstetricians.
| Specific learning opportunities |
|---|
| Recognition and classification of CTG – persistent fetal bradycardia |
| Knowledge and implementation of intrauterine resuscitation and escalation measures |
| Clear decision-making for category 1 caesarean section and communication of that decision |
Timely transfer to theatre – ideally exiting the delivery room within 9 minutes of onset of bradycardia |
| Suggested learners (to represent their normal roles) | In the room from the start | Available when requested |
|---|---|---|
| Anaesthetic CT2/ST | √ | |
| Midwifery healthcare assistant | √ | |
| Obstetric ST3+ | √ | |
| Midwife Coordinator | √ | |
| Midwife in room | √ | |
| Operating Department Practitioner (ODP)/anaesthetic nurse | √ | |
| Suggested facilitators | ||
| Faculty to play role of patient (alternatively, manikin can be used) | √ | |
| Faculty to play role of patient’s partner, Richard | √ | |
Details for Facilitators
Patient Demographics
Name: Hayley Age: 33 Gestation: 39+1 Booking weight: 68 kg Parity: P0 |
Scenario Summary For Facilitators
Patient is a 33-year-old, 39-week pregnant primip. Transferred to delivery suite from midwifery-led birth centre due to suspected fetal bradycardia on auscultation. CTG monitoring commenced and reassuring since transfer. Commenced on oxytocin for failure to progress, just re-examined: cervix 4 cm dilated.
Fetal bradycardia on CTG – persists.
Intrauterine resuscitation commenced; escalation to senior midwife/obstetrician.
Decision for category 1 caesarean section.
Explanation and consent by obstetric and anaesthetic teams.
Safe and timely transfer to theatre.
Set-up Overview for Facilitators
| Clinical setting | In delivery unit, on a delivery bed |
| Patient position | Sitting |
| Initial monitoring in place | CTG |
| Other equipment | 16G cannula dorsum of hand. 10 IU syntocinon in 500 ml normal saline running at 48 ml/h (or as per local guidelines). Hartmann’s running at 80 mls/h. Entonox |
| Useful manikin functions | This scenario is best suited to a simulated patient actor (SPA) (see discussion) |
Medical Equipment
For core equipment checklist, see Chapter 9.
| Additional equipment specific to scenario | |
|---|---|
| Simulated pregnant abdomen | Patient property to simulate the environment of normal labour: clothing, books, music, etc. |
| Drug chart showing ranitidine PO 150 mg given 2 h ago | Entonox mask/mouthpiece |
| Tocolytic drugs e.g. terbutaline 250 μg | |
Information Given to the Learners
Time: 08:00.
This handover is given by a facilitator playing the role of the night shift midwife, who is now going home, to the midwife taking over the care of the woman.
The SBAR handover is as follows:
Situation: This is Hayley, she is in spontaneous labour and was transferred to us earlier in the night from the midwifery-led unit.
Background: Hayley is primiparous with an uncomplicated pregnancy. She was transferred to the consultant-led delivery suite from the midwifery-led birth centre 6 hours ago, as her midwife was concerned about the fetal heart rate on auscultation. However, her CTG has been reassuring since then.
She has been in active labour for 8 hours now. However, she has failed to progress and was commenced on an oxytocin infusion four hours ago. She is using entonox for pain relief.
Assessment: She is contracting 4 in 10. I have just examined her and she is 4 cm dilated.
Recommendation: Are you happy to take over Hayley’s care?
Scenario Schedule
Suggested Topics for Debrief Discussion
Was CTG abnormality recognised in a timely way and appropriate help sought?
How was communication between the team and the patient/partner? Use the Patient Perception Score for patient/partner (see Discussion).
How was the consent procedure (both obstetrician and anaesthetist)? How was the balance between amount of information given and time efficiency of the process?
How could the process be streamlined while maintaining safety and good communication? Get the team to list each process required from decision made to deliver to leaving the room. On which of the processes was most time spent?
Discussion
Classification of Urgency of Caesarean Section
Caesarean sections are graded by urgency according to the classification developed by Lucas et al. (2000). Category 1 caesarean sections are described as ‘emergency’ caesarean sections, and are undertaken when there is an immediate threat to the life of the woman or the fetus. The Royal Colleges of Anaesthetists and Obstetricians and Gynaecologists (RCOG) have adopted Lucas’ classification, and issued guidance that the decision to delivery interval (DDI) for category 1 caesarean sections should be under 30 minutes; in practice, this often means ‘as quickly as possible’. This auditable standard can be used as a target and may be used to assess performance. This culture introduces additional pressure to a situation where the stakes are already high, potentially affecting decision-making and performance.
In an Australian study of over 14,000 women, the commonest indication for immediate delivery was prolonged fetal bradycardia (53%) (Warren et al., 2018).
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