Introduction
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An Obstetric Hemorrhage is an Emergency!
Obstetric Hemorrhage is the most preventable cause of maternal mortality in the United States. The United States ranks 47th amongst other nations for maternal mortality. The New York State Department of Health reports that 97% of all hemorrhage deaths occurred while the mothers were hospitalized. In this WebQuest you will learn that obstetric hemorrhage is preventable and occurs mostly in the hospital setting. New York State and New York City Health Departments have teamed up with American College of Obstetricians and Gynecologist (ACOG), and the District II Safe Mother Hood Initiative (SMI), which is sponsored by MERCK for Mothers, and created bundles that are aimed to help reduce the rates of maternal obstetric hemorrhage and maternal mortality.
This WebQuest is for the annual mandatory continuing education for the Obstetrical Team at Local Community Hospital. Although this WebQuest can be used for all and any medical professional who may encounter such emergencies in their practice.
At the end of this WebQuest, as an obstetric nurse, you will be able to:
- Measurable Objective #1: Student demonstrates proper use of Bakri
- Measurable Objective #2: Student explains the 4T’s that cause obstetrical hemorrhage.
- Measurable Objective #3: Student demonstrates clear communication with interdisciplinary team by collaborating with team members during a mock Code H (Code Hemorrhage).
It is imperative as an obstetric nurse you know what your role is to prevent maternal death.
Technology Support: Please note we offer a plethora of support services offered. Everyone has been enrolled in TURNITIN, an anti-plagerism cite. It is important to log into your account and become familiar with the process of submitting papers to this cite. Also, you can call 1800-get-help; available 24/7, this is a direct line to the IT team and they can assist in and technical issues you may encounter during the course. There is also a link on the left side of the websites home page for further assistance.
Please check out the college library, for there is information available to you for your research and studies here. The library is available 24/7 and is free for enrolled students.
Please note images on this page have been obtained by SnagIt.
Task
Here is your Task for this WebQuest
The importance of team based training is essential for positive patient outcomes and clear communication within the team.
You're assigned the task of being able to run a mock "Code H" (Code Hemorrhage), with your team in front of the class at the end of the WebQuest. The object of this WebQuest is to familiarize you with the process of readiness, escalation, recognition and response to an obstetric hemorrhage. Your evaluation will also consist of a submitting the answers you discussed with your team on the specified questions, your qualitative blood loss assessment, a mock Code H, and debrief on what you did not do well, what you did do well and how you can change or build off of this experience.
Here you will review the given literature on what an obstetric hemorrhage is and what the Maternal Early Warning Signs are. Let's begin the review of the material. Please note, if the links do not open when you click, simply copy and paste in to your URL.
Begin by listening to this Power Point Presentation: https://youtu.be/KhXqzfBv1-g
Check out this Animoto! https://animoto.com/play/ivU1GBxZiBMLNNqjQFM0QA
Read this article on Team Training in Obstetrics. Familiarize yourself on the importance of training as a team: http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Patient-Safety-and-Quality-Improvement/Preparing-for-Clinical-Emergencies-in-Obstetrics-and-Gynecology
Please watch this video on Post Partum Hemorrhage:
Review this picture of Post Partum Hemorrhage: UTERUS
Please watch this video on Quantification of Blood Loss:
Now that you have watched the above video, this picture below summarizes the rates of and the causes of Post Partum Hemorrhage:
*Review the Maternal Safety Bundle for Obstetric Hemorrhage by clicking the link below.
*Review the Maternal Early Warning Signs listed from ACOG:
*Review and become familiar with the AWOHNN poster for Readiness, Recognition and Response:
https://c.ymcdn.com/sites/www.awhonn.org/resource/resmgr/PDFs/PPH/PPHPoster.pdf
Please watch this video on the Bakri Balloon:
Read this article on debriefing for Obstetric emergencies:
https://www.awhonn.org/news/news.asp?id=261745&hhSearchTerms=%22debriefing%22
Once you have read and familiarized yourself with Post Partum Hemorrhage, please proceed to the next section Process.
Process
Let's begin building the fundamentals needed to run a Mock Code H. You will need paper and pencil for this next section of your WebQuest, for you submission of the answers to the questions is part of your evaluation. Label your paper with your group number.
Now, let's begin.
PART 1: discuss and answer as a group the following questions:
- What is a Post Partum Hemorrhage?
- What are the 4 T's are and how do they play a role in maternal morbidity and death?
- BLOOD LOSS ASSESSMENT: As a group, go to the Blood Loss Station. Each student is to write down on a separate piece of paper (provided at station) how much blood loss you think is on the pad. You may pick up the pad, but do not weigh it. First, try to do a visual assessment and give the amount of blood you think is on the pad. Once you all have your individual amounts, as a group, weigh the pad on the given scale. Discuss your findings with each other. Review and answer questions such as:
- How many of you were close to guessing the actual amount?
- How many were not close to guessing the amount?
- Which is the best method for more accurate quantification of blood loss?
- How do you quantify blood loss?
PART 2:
Now, we can begin the Mock Code. With your group, determine who will go first as primary nurse and go to the Labor Room Simulation setup with the instructor. Everyone will have the opportunity to run the mock code, we will rotate turns with each scenario. Please pick a scenario from the hat and with your group, begin the mock code. Please refer to the Hemorrhage Bundle from SMI for the Hemorrhage Checklist. This will be useful to use during your code to help guide and determine your next action during the code.
PART 3:
Debriefing is a learning tool to help us as individuals and as a team learn from our experiences. For this part, reflect with your group on how the mock code went. Ask yourselves the following questions:
What did we do well?
What did we not do well?
How can we improve?
What did we learn from this experience?
These answers will be collected. Please mark your group number on the top of the page before submitting.
Evaluation
Your Quiz grade and Rubric Grade will be averaged together for your final Grade.
Please obtain an answer sheet from me prior to beginning the Quiz. Once complete, submit your answers to me for grading.
Obstetrical Hemorrhage Quiz:
Quiz: Please complete the attached quiz and return to instructor for grading. Quiz is worth 50points, each question is 5 points each. Must achieve a 45 or better to pass this Quiz. You may re-take it one time.
Let's Begin the Quiz:
1. The following complications during pregnancy increase the risk of postpartum hemorrhage (PPH) except:
A. Hypertension
B. Macrosomia
C. Twin pregnancy
D. Hydramnios
2. Causes of postpartum hemorrhage. Select all that Apply
A. Atony
B. Trauma
C. Coagulopathy
D. Retained placenta and placental fragments
E. Morbidly adherent placenta
F. Uterine inversion
- To be considered a PPH, what would the estimated blood loss have to be for a C-section?
A. < 550 ML
B. > 600 ML
C. > 1000 ML
D. < 900 ML
- What types of trauma during labor and birth would lead to PPH risk?
A. Instrumental assisted birth (vacuum or forceps)
B. C-Section
C. Lacerations of the cervix or vaginal wall
D. All of the above
- In which of these cases could you diagnose PPH following vaginal delivery:
1. > 500 blood loss over 24 hrs
2. hypotension
3. tachycardia
A. 1 & 3
B. 2
C. 3
D. 1
6. The 4T’s of PPH are:
- Trauma,
- Toxins
- Travel
- Tissue
- Time
- Thrombin
- Tongue
- Tone
Select the correct answer:
A. 1, 4, 6 & 8
B. 1, 5 7 & 8
C. 1, 2, 3 & 6
D. 3, 4, 5 & 6
- If continued bleeding occurs during the third stage with a contracted uterus, the cause is most likely to be:
A. Cervical and perineal Lacerations
B. Placental abruption
C. Uterine atony
D. Cervical Polyp
- Which answer best describes four known risk factors for Post Partum Hemorrhage?
A. Previous PPH; polyhydramnios; multiple pregnancy; anemia conditions
B. Placental Abruption; polyhydramnios, grand multi; iron deficiency
C. intrauterine death; placental abruption, previous PPH,, iron deficiency
D. Placenta previa; polyhydramnios, fetal demise
E. A & C
- Fill in the blanks from word bank, select 2:
Tissue, Tone, Trauma, Thrombin
_________________ and ________________ are the two most common causes of primary
- Did you find this WebQuest helpful?
- Not at all helpful
- Somewhat helpful
- Very helpful
Once you have completed the quiz, please submit your answer sheets to me.
Grading Rubric for Obstetrical Hemorrhage Review course:
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Concerns Areas that Need Work |
Criteria Standards for This Performance |
Advanced Evidence of Exceeding Standards |
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Criteria #1: Student demonstrates proper set up of and removal of the Bakri and can explain indications for use at a mastery level. |
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Criteria #2: Student can recognize the 4Ts that cause obstetrical hemorrhage and verbally explain the physiological changes occurring with each. |
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Criteria #3: Student participates in a mock CODE H in the role of team leader; demonstrates proper escalation of, readiness, recognition of and response to hemorrhage with clear communication and collaborates with interdisciplinary team for management of hemorrhage. |
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Criteria #4: Student explains the importance of debriefing after Code H and can identify new knowledge gained from program. |
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Criteria #5 Student can explain measures taken by healthcare professionals to reduce obstetrical hemorrhages in New York State |
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0-80points |
80-95 points |
95-100 points |
Conclusion
Click this IMAGE
At the end of this WebQuest, you, a member of the inter-disciplinary team, should be able to recognize high risk low volume patients at risk for a post partum hemorrhage. This WebQuest was geared to give you basic fundamentals that will have you prepared and ready for such emergencies. Also, this WebQuest had taught you the process of and the importance of escalation and communication.
*Early detection is the best policy for patients at risk for a post partum hemorrhage.
*Coordination and collaboration with the multi-disciplinary team is essential in the in order to provide the best possible outcome.
*A standardize approach with a checklist provides the best guidance in steps to take when working an emergency "Code H", or otherwise known as a post partum hemorrhage.
*Debriefing after plays an important role to allow each member of the team discuss the "good" and the "bad" on what occurred during the emergency.
*Preparing for an emergency with the use of simulation drills and team based training allows team members to practice effective communication.
*Most importantly, remember that ANYONE can call the code or escalate the situation. As the nurse, you do not need to wait for the doctors permission. For every minute you wait in the delaying escalation, can be the life of the patient.
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