2 C L I N I C A L F O C U S : T OWA R D S S A F E R C H I L D B I RT H

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Scenario training: how we do it and the lessons we have learned

Ceris Burke
The Royal Oldham Hospital, Oldham, UK

INTRODUCTION
Obstetric emergencies may be infrequent but when they happen the consequences for mother and baby could be life threatening. Sadly, many of the deaths associated with obstetric emergencies are considered avoidable: deficiencies in the care of mothers and babies have been identified in the Confidential Enquiries into Maternal Deaths,1 the Confidential Enquiries into Stillbirths and Deaths in Infancy,2 and in the document Towards Safer Childbirth.3 Often these deficiencies arise because health professionals, and the organizations in which they work, are not geared to handle dire emergencies. For this reason, it was recommended that practice runs (fire drills) should be conducted periodically on labour wards,4 and such training is now mandatory for level 2 accreditation by the Clinical Negligence Scheme for Trusts (CNST).5 However, whilst units are obliged to conduct fire drills there are, to the authors knowledge, no guidelines or manuals on how to organize, monitor and evaluate such training.

Clinical governance holds us responsible for the quality of care we provide, and should be a stimulus for the development of a multidisciplinary, coordinated, well-prepared and structured approach to obstetric emergencies which in turn should reduce substandard care and improve outcomes for mothers and babies. At the Royal Oldham Hospital we have tried to adopt this approach, and this article describes our experience.

FIRE DRILLS
At the Royal Oldham Hospital maternity unit monthly fire drills are carried out on the labour ward. The drills vary and have included cord prolapse, shoulder dystocia, eclampsia and neonatal resuscitation. Every 6 months, and on a much bigger scale, we hold a major haemorrhage drill where the delivery unit works closely with the pathology laboratory to evaluate not only the performance of clinical staff but also that of the haemotology and blood transfusion services. In cases of major haemorrhage the Confidential Enquiries into Maternal Deaths1 recommend that all members of staff, including those in the blood bank, must be involved and must know exactly what to do to ensure that large quantities of cross-matched blood are available without delay. Prior to running fire drills all staff were notified that we would be starting to carry out fire drills on a regular basis. It was made clear that we would not be targeting individuals but rather testing the system for managing a variety of obstetric emergencies in a controlled setting. The drill objectives were:
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Clinical governance holds us responsible for the quality of care we provide, and should be a stimulus for the development of a multidisciplinary, coordinated, wellprepared and structured approach to obstetric emergencies ...

Ceris Burke, Labour Ward Practitioner/Practice Development Midwife, Supervisor of Midwives, The Royal Oldham Hospital, Rochdale Road, Oldham, OL1 2JH, UK.

To assess the response of the multidisciplinary team to an obstetric emergency; To identify any dysfunction in emergency reaction and communication.

CLINICAL RISK (2003) 9, 103106

The Royal Society of Medicine Press Ltd 2003

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At the end of each drill a debriefing session was held in a friendly, relaxed atmosphere. Light refreshment was provided. Assessment The overall obstetric management was good. When the labour ward emergency call bell was set off, it was not heard by staff on the other maternity floors. The estates department was invited to test and upgrade the bell. The ward clerk on duty for labour ward was overwhelmed with requests to various departments from various people and at one time, three people gave her several similar requests. At one stage in the drill she was asked every minute to contact different departments. A midwife should manage the majority of these requests and coordinate contact with other departments. Although she was asked to call him, the overwhelmed ward clerk did not bleep the consultant obstetrician on-call, as there was no midwife or other staff to support her. It is essential that an obstetric consultant is involved in the early stages of a major obstetric haemorrhage. In total, the simulated blood loss totalled 3000ml, but participants in the drill did not formally estimate blood loss. One of the benefits of this exercise is that weighing scales are now available in the labour ward theatre, for weighing swabs and pads. This will facilitate quantification of blood loss in real and simulated blood loss. The haematologist was contacted, but it was initially the ward clerk who spoke to her until another midwife, not involved with the drill, took over. A member of the clinical staff should make contact with the haematologist when a mothers condition deteriorates during a major haemorrhage. This has now been made clear on the obstetric haemorrhage checklist. The turnaround time for blood of group type specific to reach the unit, from the initial cross match request to the arrival of the blood, was 17 minutes. This was a good time, facilitated by the designation of a porter to transfer blood from the pathology laboratory in an emergency situation. However, while four units of blood were asked for in the labour room, this became three units from the pathology laboratory. Recommended allocation of staff The midwife in charge needs to allocate staff, noting that:
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CASE STUDY
In December 2002 an emergency major obstetric haemorrhage drill was carried out on the labour ward. Early that morning a labour room was designated for the drill and a manikin set up to simulate a recently delivered mother who was haemorrhaging. The labour ward staff were not warned of the drill. In advance of the drill, maternity hand-held records had been compiled, with made-up identity details including name, address, unit number and obstetric history. A consultant anaesthetist, a labour ward manager, a labour ward practice development midwife, an antenatal ward manager, a core team midwife and a member of the medical illustration team were involved in the drill set-up and were aware of its start time. At an early stage, the cooperation of the pathology laboratory manager and a haematologist was sought to assist with blood sample investigation and the supply of units of blood when requested by staff during the drill. These were the only staff outside the maternity unit who were aware of the drill start time. The hospitals resuscitation officer provided a manikin and a midwife involved in the drill made up a safe red solution to simulate blood loss. The consultant anaesthetist and the labour ward practice development midwife were present throughout the drill and called the different stages of the scenario. The antenatal ward manager and a core team midwife umpired the drill and chronologically recorded events. The labour ward manager monitored communication with other departments from the midwives station. In addition, a member of the medical illustration department video-recorded all events, to assist later analysis. The scenario involved a mother who had delivered a healthy baby and the placenta and membranes had been delivered by active management of the third stage of labour. The mother was now found to be trickling blood per vaginum. She was gravida 2, para 1. Her only significant antenatal history was an admission the previous day with antepartum haemorrhage. On admission a blood specimen had been taken for group and save. As planned, the drill was stopped when the units of blood arrived on the labour ward from the pathology laboratory. All staff involved with the drill were debriefed after the event to reduce their anxiety levels and allow them to express their views of the exercise. Communication and team working were also discussed with pathology laboratory staff.

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One midwife needs to remain present at the midwives station during an emergency, to call for medical aid, including the obstetric consultant and to coordinate all departments; One midwife or healthcare assistant is to be responsible for record keeping in an emergency; Two healthcare assistants to be available outside the emergency room to convey messages and fetch essential equipment.

LESSONS FROM OTHER DRILLS

In general, the standard of management as assessed in other emergency drills was good. When we first

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started running fire drills, record keeping was identified as an area of weakness, but this has since improved. In recent drills it has been noted that a member of staff is always allocated to record all events taking place.
H Call for Help E Evaluate for Episiotomy L Legs. Place in Lithotomy position with full flexion and abduction of the hips P Pressure. Apply suprapubic pressure E Enter manoeuvres R Remove posterior arm R Roll on to hands and knees Box HELPERR7 mnemonic for shoulder dystocia.

When we first started running fire drills, record keeping was identified as an area of weakness, but this has since improved. In recent drills it has been noted that a member of staff is always allocated to record all events taking place.
As a result of a previous major haemorrhage fire drill there is now a dedicated major haemorrhage trolley in use on the labour ward, which has significantly reduced the staff having to fetch and carry the necessary equipment to control the haemorrhage. The staff are now able to stay in the labour room and provide care more effectively. The trolley is checked periodically to ensure that it is complete and whether the drugs have expired. A major haemorrhage checklist, which was drafted and approved by the maternity staff, is now in place at the midwives station and on the major haemorrhage trolley and this includes:
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A list of staff to contact; Early notification for the pathology laboratory staff, the distribution staff and the bleep holder; Double-checking blood specimens and the blood request card; Contacting the on-call haematologist, if the mothers condition continues to deteriorate.

Another major haemorrhage drill led to the designation of a porter who carries a bleep at all times, to speed up the transfer of blood from the pathology laboratory to an area requiring the blood. This has proven to be an invaluable service. The midwives have stated that while they feel competent scrubbing up in theatre for routine obstetric surgery, they did not feel competent scrubbing for emergency hysterectomies. They felt unfamiliar with the different surgical instruments used and there was clearly a further training issue in this area which has since been addressed with an educational programme.

The midwife scribe was seen as particularly effective as she fully noted all events taking place in the delivery room, whilst also calling out each passing minute. This freed the lead midwife to assess and then progress to the next manoeuvre in trying to free the shoulders. This made it easier to follow the ALSO mnemonic, where it is recommended that an attempt at each manoeuvre should take up to 1 minute. The record keeping of events was excellent. During this drill, when the initial emergency bleep call was made, it only took 2 minutes for all the team to reach the unit and assist with the delivery. The units midwifery bleep holder was informed of the emergency on the labour ward, but unfortunately did not attend the labour ward. This may have implications for other emergencies, such as a major haemorrhage where extra staff may be needed to assist. The recommendations from this drill were that if the unit bleep holder is not on the labour ward when an emergency occurs, then the bleep holder should attend the labour ward and, where necessary, deal with any issues including staff redeployment. As a result of this drill, staff are encouraged to use the new labour ward recommended documentation guide for shoulder dystocia, to assist in risk management.

CORD PROLAPSE
A recent cord prolapse drill on the antenatal ward demonstrated good management: there was a time interval of only 14 minutes between diagnosing cord prolapse and commencing Caesarean section a commendable achievement, considering the antenatal ward is two floors away from the labour ward. Good leadership and teamwork were instrumental to this achievement. In a recent case of medical litigation arising from the management of cord prolapse in another hospital, an award of 2 550 000 was granted.6 In that case there was a lapse of 43 minutes from diagnosing the cord prolapse to an emergency Caesarean section. This highlights the value of testing our maternity systems to reduce litigation and to improve outcomes for our mothers and babies. On the other hand, the drill revealed that the clocks on the antenatal ward were not synchronous with the radio-controlled clocks on the labour ward.

SHOULDER DYSTOCIA
In a recent shoulder dystocia drill leadership and teamwork were found to be good. When the staff were debriefed they felt positive about the drill and they agreed the positive outcomes. The ALSO mnemonic HELPERR was used during the drill (see box).

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The admission room clock had a 5-minute difference to the labour ward clocks and the midwives station clock on the antenatal ward had a 2-minute difference. This is a serious risk management issue and funding is being sought for the provision of synchronized clocks. The antenatal ward staff also struggled to transfer the mother off the static bed in the antenatal admission room onto a ward bed for transfer up to labour ward. The admission bed had to be dragged to one side of the room to allow access for the ward bed and this is not in line with the Trusts moving and handling guidelines. This bed is now under review. detrimental to normal activity on the maternity unit. The running of regular fire drills is proactive risk management, and allows all maternity staff to maintain and develop their clinical skills and gives them the confidence to deal with infrequent critical incidents. Clearly, a coordinated multidisciplinary approach is essential.

The running of regular fire drills is proactive risk management ...

References
1 Department of Health. Why Mothers Die Report on the Confidential Enquiry into Maternal Deaths in the United Kingdom 19971999. London: Department of Health 2 Confidential Enquiry into Stillbirths and Deaths in Infancy. Fifth Annual Report. London: Maternal and Child Health Research Consortium, 1997 3 Royal College of Obstetricians and Gynaecologists/Royal College of Midwives. Towards Safer Childbirth: Minimum Standards for the Organisation of Labour Wards. Report of the Joint Working Party. London: RCOG Press, 1999 4 Confidential Enquiry into Stillbirths and Deaths in Infancy. Sixth Annual Report. London: Maternal and Child Health Research Consortium, 1999 5 NHS Litigation Authority. Clinical Negligence Scheme for Trusts: clinical risk management standards for maternity Services. London, June 2002 6 W v Cambridge & Huntington Health Authority. Clinical Risk 2003; 9(1): 38 7 American Academy of Family Physicians. Advanced Life Support in Obstetrics (ALSO) Course Syllabus. Fourth edition, 2000

The drills have improved our clinical practice and clinical effectiveness by giving our staff an improved knowledge of local guidelines.
CONCLUSION
These examples are just some of the lessons we have learnt at the maternity unit of The Royal Oldham Hospital. The drills have improved our clinical practice and clinical effectiveness by giving our staff an improved knowledge of local guidelines. Patient safety considerations were taken into account, and the drills were scheduled for a time when disruption of clinical work was likely to be minimal. For example, the cord prolapse drill was not commenced until the mornings elective Caesarean sections had been performed. So far there has been no indication that mobilizing staff for a drill has been