Scenario in a Nutshell
Respiratory arrest in a woman using remifentanil patient- controlled analgesia (PCA) for labour with a fetal death in utero (FDIU).
Stage 1: Assessment and immediate management of collapsed patient in labour.
Stage 2: Management of respiratory arrest and consideration of differential diagnosis.
Target Learner Groups
Midwives and anaesthetists. For remifentanil to be used safely on a delivery unit, staff must have a robust training programme and be confident in recognising and managing serious complications such as severe respiratory depression or arrest. This scenario would fit well with a midwifery staff training programme for remifentanil PCA.
| Specific learning opportunities |
|---|
| Demonstrate rapid assessment and resuscitation of respiratory arrest in labour |
| Identify the key safety concerns surrounding the use of remifentanil on the labour ward and steps that should be taken to minimise this risk |
| Demonstrate effective communication, appropriate leadership and team-working |
| Suggested learners (to represent their normal roles) | In the room from the start | Available when requested |
|---|---|---|
| Anaesthetic CT2/ST3 | √ | |
| Midwife Coordinator | √ | |
| Midwife in room | √ | |
| Operating Department Practitioner (ODP)/anaesthetic nurse | √ | |
| Obstetric ST3+ | √ | |
| Suggested facilitators | ||
| Faculty to play role of patient’s partner | √ |
Details for Facilitators
Patient Demographics
Name: Cheryl Age: 24 Gestation: 31+4 Booking weight: 51 kg Parity: P0 |
Scenario Summary for Facilitators
A 24-year-old, primiparous woman is admitted to the labour ward at 31 weeks gestation for induction of labour after an unexplained fetal intrauterine death.
Otherwise uneventful pregnancy to date.
No significant medical history. No regular medications or known drug allergies.
Given oral mifepristone one day previously.
A dose of IM diamorphine was administered at 11:00 a.m. She became increasingly distressed and was requesting further analgesia by 3 p.m. She did not want an epidural.
Anaesthetist set up a remifentanil PCA 30 minutes ago. The PCA pump was programmed as per local protocol to deliver a bolus of 40 μg with a 2-min lockout and no background infusion (can be adapted to adhere to local protocol).
Supplemental oxygen was given via nasal cannula at 2 l/min (or as per local protocol). Patient was observed by anaesthetist for six boluses with no evidence of desaturation or apnoea.
Midwife left room briefly approximately 30 minutes later. Partner noted patient to be unresponsive and shouted for help in the corridor. Midwife assesses the collapsed patient, calls for help and initiates basic life support.
Emergency team attends immediately. On arrival, patient unresponsive and deeply cyanosed.
Respiratory arrest with low blood pressure.
With adequate and prompt resuscitatory efforts, the patient’s oxygen saturations improve along with the return of spontaneous respiratory effort.
If the respiratory arrest is not effectively managed the scenario will end with maternal cardiorespiratory arrest.
Set-up Overview for Facilitators
| Clinical setting | In a delivery room, on a delivery bed |
| Patient position | Semi-recumbent |
| Initial monitoring in place | Pulse oximeter |
| Other equipment | 16G cannula dorsum left hand attached to 10 IU syntocinon in 500 ml normal saline running at 12 ml/h |
| 20G cannula dorsum right hand attached to remifentanil PCA pumpO2 at 2 l/min via nasal cannulae (if this is local policy) | |
| Useful manikin functions | Pupillary accommodationIntubation |
Medical Equipment
For core equipment checklist, see Chapter 9, including advanced airway equipment.
| Additional equipment required for this scenario | ||
|---|---|---|
| Remifentanil pump with syringe/bag of remifentanil and giving set | Syntocinon infusion with infusion pump and giving set | Naloxone (keep naloxone in usual place on delivery unit) |
| Perimortem caesarean section pack | External defibrillator pads | Pen torch |
| Cardiovascular drugs: e.g. metaraminol, phenylephrine, atropine, adrenaline | Sedative drugs: benzodiazapines, propofol | |
Information Given to the Learners
| Information given to midwife who is taking over care at start of their shift |
|---|
| Time: 19.50 |
| This handover is given by a facilitator: |
| Situation: This is Cheryl. She is having an IOL for FDIU. |
| Background: She has been admitted for induction of labour at 31 weeks gestation with a confirmed fetal intrauterine death. She is on an oxytocin infusion. A remifentanil PCA was started 30 min ago and has been working very well for her. |
| Assessment: She is currently 3–4 cm dilated. HR and BP are fine. She is so much more comfortable with the remifentanil. SpO2 drop a little when she dozes but come straight back up again when she wakes. |
| Recommendation: Are you OK to take over her care? |
| To anaesthetist: You received the same information at your handover. |
| To midwife: You have had to briefly leave the room to get some ranitidine that the anaesthetist had prescribed. As you return to the room, the woman’s partner rushes into the corridor, looking very worried and shouting for help. |
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