The midwifery students' response to the unfolding emergency in the scenario started with them:
Pain assessment
Eighteen (51%) students assessed the mothers' pain, and of these, the majority noted pain in response to palpation/rubbing of the uterus. Only one of these students ordered pain relief for the mother (alongside fluids and oxytocics).
Algorithms have been developed to help students cope with emergency situations, however, where more than one procedure is recommended to be implemented simultaneously or within a very short space of time, the students struggled to prioritise their action. There were a number of significant issues that emerged from these data. They include the students:
1) remained calm throughout an extremely stressful experience (the use of actresses added to the sense of emergency and distress)
2) engaged with the woman and made an effort to explain what was happening
3) identified the problem although on occasions an accurate diagnosis was arrived at by default rather than through deliberation
4) drew upon a repertoire of behaviours that were relevant to that diagnosis, but not necessarily in a timely, logical order or related to emergent findings
5) appeared to only process one thing at a time. Some students focused on the woman's deterioration and implemented treatment for this, and once this was dealt with they moved onto the cause of the bleeding by giving oxytocics
6) The level of training (diploma, degree, masters), prior nursing experience seemed to have no significant effect on performance, although prior experience of emergency care and supportive clinical mentorship did.
The students had built a preliminary set of expectations before they entered the scenario. First, they had consented to participate in research examining deterioration. Secondly, the use of the simulation environment suggested an emergency scenario. The students were taught to be aware of four types of obstetric emergency. On entering the scenario they could immediately eliminate antenatal emergencies when they saw the baby in the cot and knew 'Lisa's' history (28 year old + primigravida + full term delivery). Therefore, before the students were conscious of honing in on the events of the scenario and what they meant, they had filtered out an enormous array of possibilities. Shortcutting to the cause of the emergency came from limited information that was assimilated from the initial experience of walking in the room:
'I thought she was going to have a PPH on the first one (scenario) because she had the baby' (Std 29, reflective interview).
'The lady was lying on the bed touching her baby - she seemed quite fine, talking - but with (the researchers) in the room .... I knew something was going to happen! This wasn't just a lady in the labour room - you know you had to be on the look out! (Student 15, reflective interview).
Whilst other students used these cues to hone in on possible emergencies that might unfold during the simulation.
'I thought - instantly .... because the baby was born it wasn't to do with birth-it could only be haemorrhage as the other obstetric emergency - so that was what I was thinking straight up - I was going through those scenarios thinking through those protocols'. (Std 1, reflective interview).
Here the students demonstrarte how they generate a hypothetical cause and then use clinical cues to confirm or refute their intial hunch of what was happening:
'the first thing was when she said she felt tired and her pulse was 110 my reaction was to look down below and feel her fundus and see how that felt' (Std 3, reflective interview).
'when I did the BP & realised it was low & felt the uterus & it was boggy that pretty much grounded my thoughts. OK, we are going down the PPH line' (Std 4, Reflective interview).
'It's always in the back of my mind a postpartum haemorrhage. I'm aware that can happen anytime ... so that is what I watching out for. ... I always go through, blood pressure, pulse and fundus. She said she felt cold so I went to check her fundus and check her loss and that's when I noticed a trickling that didn't stop.' (Std 25, reflective interview).
However, student 18 demonstrated an unsystematic assessment process that led to her discovering the PPH. Although she had made an initial decision about the emergency, she retrospectively gave importance to more subtle cues:
'When I walked in (Lisa) looked tired, but she had just had a baby, so there wasn't anything out of the ordinary. Perhaps she was guarding her stomach a little bit too much but not so sure. Attached to her baby. I only did some of her obs. I thought I might check her fundus and that's when I found it. She was bleeding.... I was expecting a PPH and then I went blank' (Std 18, reflective interview).
Student 7 articulated how the algorithm directed her cue seeking behaviour to build a clinical picture and account for the deterioration.
[Video footage - IV access requested and Std 7 feels Lisa's uterus] (she explains at reflective interview) - 'to see if it is contracting down. I am thinking tone, tissue, and thrombin. (laughs) it's in my head. We have complete placenta - so therefore I am thinking it can't be retention of products it has to be something else - it could be a clotting disorder - but I did tell the Dr what bloods to take (in the video footage the student did not make this request). That is a poor attempt at me trying to contract the uterus down by that manoevre .... [Video restarts - The student says: call a code] .... she is losing consciousness and the BP is really low - I didn't feel as though I needed to do any more observations as she was deteriorating and massaging the fundus to get some contraction going was the best I could do in that situation. Get the Dr to get the IV access and start giving some drugs and fluids'. (Std 7, reflective account on the video footage).
A cycle of deductive (working from the general possibility of a postnatal emergency and therefore what specific observations should be undertaken "top down") and inductive (building and collating specific observations and measures to assess patterns and trajectories to generate the clinical condition - "bottom - up") and back to deductive reasoning (testing the hypothesis of the diagnosis against specific cues) the students were able to capture what was happening in the scenario and decide how they should respond. Student 33 explains:
'I saw the baby in the cot .... You said about the BP, so I was already thinking about PPH ... she was feeling dizzy and light headed which is a definite sign of low BP and I was thinking bleeding. I went to feel the fundus and it was boggy so I wanted to rub that up so I could feel a contraction and I was thinking we might need some syntometrine. ....'
Of note the students tended to build single layers of information to inductively build diagnostic conclusions i.e. excessive postpartum PV blood loss = possible postpartum haemorrhage, the presence of a boggy uterus, indicative of retained products. The volume of PV blood loss stimulated them to ask for blood pressure and pulse readings - against a baseline they were able to detect the deterioration trajectory and thereby deduce hypovolaemic shock. The shock state was further reinforced when the mother lost consciousness along with abnormal oximetry recordings. Student 33 reflected on this
'I should've done CPR. I needed to bring her back. She was in trouble. That's when I wasn't sure what to do'. (The student had not assessed AVPU, nor assessed airway or circulation).
She did not call a CODE or the MET team.
Initially the student used the inductive-deductive cycle to test her hypothesis of PPH and hypovolaemic shock. However, when Lisa went unconscious Student 33 failed to inductively build a picture to support her hypothesis of cardiac arrest (or no volume output). She reflectively constructs the loss of consciousness to be due to no volume output, the trajectory of hypovolameic shock, without checking the mother's rousability, carotid pulse or respiratory pattern. In the reflective interview she fixates on this faulty diagnosis, but in the video she did not make a cardiac arrest call. This leaves one to suspect that she possibly added this hypothesis into the reflective review of the video to right herself perceived error rather than account for her decision-making in the scenario. This example demonstrates how the iteration between inductive and deductive reasoning helps to reduce the risk of fixation error but only when new data are introduced to refute or confirm the clinical decision (during the scenario or post hoc review of performance).
The response to single cues was evident in a number of the students:
'I was looking for trauma and then rubbing the fundus to involute ... I wanted to give her oxygen and lay her down. I put the oxygen on a bit slowly. ... I was asking for full bloods as she had lost a lot of blood. I was after volume expander. I did ask for O positive, but I thought we have to get her under control first so I asked for gelafusin. We could go with O positive when the results came back' (Std 3, reflective interview).
I was palpating her fundus to assess the tone, 'cos tone is one of the factors that could contribute to a PPH ...it felt little boggy so I rubbed it to encourage it to contract to help with the bleeding (5 mins 26 secs into scenario) ... she's about to go unconscious from excessive blood loss (speaking ahead of the footage), so I wanted to change her position to elevate her legs to encourage venous return to her heart to prevent any damage ... I ordered some large bore cannulas to be inserted in case she goes into hypovolaemic shock - so we can push fluids. I popped on some oxygen to maintain her airway because obviously that is the most important thing ... then I asked for 10 units of syntocinon to try get the uterus to contract because obviously my rubbing up wasn't effective (Std 12, reflective interview).
Here the student demonstrates how she rationalises her actions but attends to elements of the problem building incrementally to first respond to the volume depletion and then go back to address the possible cause. The error in her statement about oxygen delivery demonstrates how she recalls ABC but again does not apply a systematic response following the mnemonic to guide her emergency response. Further, her comment that oxygen delivery would protect an airway might indicate a shortcut in her processing a response to airway management and oxygen delivery.
A number of the students identified that working alone was problematic and impeded their response. The importance of other people was to act as a prompt to stimulate thinking as much as provide help in the response and share the responsibility for the clinical management of the mother.
'If it was a real case more people would have been there. ... You would have more than one brain to think things through. As it was an emergency situation it was difficult for me to concentrate and hold all the ideas in one. If there was another person there this reminds me to do this and this' (3 mins 18 seconds before the students implements any treatment) (Std 6, reflective interview).
'I reached a stage where I didn't know. I was hoping the MET team would come and take over. I don't know what to do next, hopefully someone comes and saves me (3 mins 22 seconds before the student implements treatment. Calls for a Dr at 3.41, calls the MET at 6.06) (Student 9, reflective interview).
'I wanted more people there,. I wanted to put synt into her leg and get some more in a drip later. I would have liked another pair of hands (4 mins 27 secs before treatment implemented, 7.07 before she calls the MET - not other back up was called) (Std 15, reflective interview).
I was a bit jumbled up. It was really scary. In reality I would not be the only midwife there (Buzzer 3.21, starts treatment 3.48 No other back up is called). (Std 16, reflective interview).
It is easier when you have got other people. ... but I can't rely on the fact that other people would be there as there could be another emergency going on. I think I would be OK but there were some things I would still be unsure about' (Buzzer pressed 4.52, starts treatment 5.17) (Std 32 reflective interview).
The students expressed how the simulation caused them to feel stressed and how they felt this anxiety affected their performance, in terms of how they made decisions and the order in which they responded. The presence of an external and preferably senior colleague was thought to enable them to pool their knowledge about what to do but also to provide a number of interventions that were required to stabilise the mother.