Anaesthesia  >  Obstetrics  >  Scenario  1  (BL)  

 
 

ANTEPARTUM  HAEMORRHAGE  
MODULE:        OBSTETRIC  
 

TARGET:            ANAESTHETIC  CORE  TRAINEES  &  ALL  ANAESTHETISTS  

 
BACKGROUND:  
 

Major  obstetric  haemorrhage  remains  a  significant  cause  of  mortality  and  morbidity  in  the  peripartum  
period.  The  2006-­‐2008  CMACE  report  found  that  haemorrhage  was  the  sixth  most  frequent  cause  of  
mortality,  an  improvement  on  previous  triennium  reports.  Simulation-­‐based  training  of  this  emergency  is  
best  suited  to  team-­‐based  training,  and  this  scenario  can  be  modified  for  this  purpose.  However,  maternal  
haemorrhage  still  presents  a  complex  anaesthetic  challenge  and  trainee  anaesthetists  must  understand  
their  role  in  the  management  of  these  patients.  Obstetric  units  will  have  local  protocols  for  managing  major  
haemorrhage,  and  conduct  of  the  scenario  should  reflect  this.  

Version  9  –  May  2015   1    

Editor:  Dr  Andrew  Darby  Smith    
Original  Author:  Dr  P  Shanmuha,  Dr  G  Jackson  
 
 
  Anaesthesia  >  Obstetrics  >  Scenario  1  (BL)  

RELEVANT  AREAS  OF  THE  ANAESTHETIC  CURRICULUM  

 

  In  respect  of  intravenous  induction:  

  • Makes  necessary  explanations  to  the  patient  
IG_BS_08   • Demonstrates  satisfactory  practice  in  preparing  drugs  for  the  induction  of  anaesthesia  
• Demonstrates  proper  technique  in  injecting  drugs  at  induction  of  anaesthesia  
• Manages  the  cardiovascular  and  respiratory  changes  associated  with  induction  of  general  
anaesthesia  
  In  respect  of  airway  management:  
 
• Demonstrates  optimal  patient  position  for  airway  management  
 
• Manages  airway  with  mask  and  oral  airways  
 
• Demonstrates  hand  ventilation  with  bag  and  mask  
 
• Demonstrates  correct  head  positioning,  direct  laryngoscopy  and  successful  oral  
IG_BS_10  
intubation  techniques  and  confirms  correct  tracheal  tube  placement  
• Demonstrates  proper  use  of  bougies  
• Demonstrates  correct  securing  and  protection  of  LMAs/tracheal  tubes  during  
movement,  positioning  and  transfer  
• Correctly  conducts  RSI  sequence  
IO_BS_07   Demonstrates  role  as  team  player  and  when  appropriate  leader  in  the  intra-­‐operative  environment  
IO_BS_08   Communicates  with  the  theatre  team  in  a  clear  unambiguous  style  
IO_BS_09   Able  to  respond  in  a  timely  and  appropriate  manner  to  events  that  may  affect  the  safety  of  
patients    [e.g.  hypotension,  massive  haemorrhage]  [S]  
ES_BS_01   Manages  preoperative  assessment  and  resuscitation/optimisation  of  acutely  ill  patients  correctly  
ES_BS_03   Manages  rapid  sequence  induction  in  the  high  risk  situation  of  emergency  surgery  for  the  acutely  ill  
patient  
CI_BS_01   Demonstrates  good  non-­‐technical  skills  such  as:  [effective  communication,  team-­‐working,  
leadership,  decision-­‐making  and  maintenance  of  high  situation  awareness]  
CI_BS_02   Demonstrates  the  ability  to  recognise  early  a  deteriorating  situation  by  careful  monitoring  
CI_BS_05   Demonstrates  ability  to  recognise  when  a  crisis  is  occurring  
CI_BS_06   Demonstrates  how  to  obtain  the  attention  of  others  and  obtain  appropriate  help  when  in  a  crisis  
4.3   Administers  blood  and  blood  products  safely  
OB_BS_01   Undertakes  satisfactory  preoperative  assessment  of  the  pregnant  patient  
OB_BS_02   Demonstrates  the  ability  to  clearly  explain  and  prepare  an  obstetric  patient  for  surgery  
OB_BS_03   Demonstrates  the  use  of  techniques  to  avoid  aorto-­‐caval  compression  
OB_BS_07   Demonstrates  the  ability  to  provide  general  anaesthesia  for  caesarean  section  [S]  
OB_BS_11   Demonstrates  ability  to  recognise  when  an  obstetric  patient  is  sick  and  the  need  for  urgent  
assistance  
GU_IS_03   Demonstrates  the  ability  to  manage  the  effects  of  sudden  major  blood  loss  effectively  
CI_IS_01   Demonstrates  leadership  in  resuscitation  room/simulation  when  practicing  response  protocols  
with  other  healthcare  professionals  
CI_IS_02   Demonstrates  appropriate  use  of  team  resources  when  practicing  response  protocols  with  other  
healthcare  professionals  
OB_IS_09   Demonstrates  the  ability  to  provide  intra  uterine  resuscitation  for  the  “at  risk”  baby  
OB_HS_03   Demonstrates  the  ability  to  be  an  effective  part  of  a  multidisciplinary  team  
OB_HS_06   Demonstrates  skill  in  managing  emergencies  including  pre-­‐eclampsia,  eclampsia,  major  
haemorrhage  

Version  9  –  May  2015   2    

Editor:  Dr  Andrew  Darby  Smith  
Original  Author:  Dr  P  Shanmuha,  Dr  G  Jackson  
 
 
  Anaesthesia  >  Obstetrics  >  Scenario  1  (BL)  

 
INFORMATION  FOR  FACULTY  
 
LEARNING  OBJECTIVES:  
   

• Safe  administration  of  blood  products  for  resuscitation  during  massive  haemorrhage  
• Demonstrating  understanding  of  the  pharmacotherapy  used  in  obstetric  haemorrhage  
• Understanding  the  logistical  difficulties  and  team  interactions  involved  in  managing  major  
obstetric  haemorrhage.  
 
 
SCENE  INFORMATION:  
   

• Location:                                                                                            Theatre  (Maternity)  

• Expected  Duration  of  Scenario:              25-­‐30  mins  
• Expected  Duration  of  Debrief:                  35-­‐40  mins  
 
 
                                         EQUIPMENT  &  CONSUMABLES                                                                                                                                    PERSONS  REQUIRED  
   
• Pregnant  simulation  model  and  neonatal  model   • Anaesthetic  Junior  Trainee  
• Wedge   • Anaesthetic  Assistant  
• Anaesthetic  Senior  Trainee  
• Large  quantities  of  fake  blood  products  for  
• Midwife  
transfusion:  Packed  red  cells,  FFP  and  plt  
• Obstetrician  
• Evidence  of  major  haemorrhage:  blood-­‐stained  inco   • Scrub  Nurse  (Optional)  
pads,  kidney  bowls  full  of  blood,  suction  container  full   • Theatre  Assistant  –  runner  (Optional)  
of  blood   • Paediatrician  (Optional)  
• Checked  Anaesthetic  Machine    
• Airway  Trolley  and  intubation  equipment  
• IV  fluids  and  giving  sets  
• Self  inflating  bag-­‐valve-­‐mask  
• CTG  Monitor  
• Theatre  Drapes  
• Antenatal  paperwork  and  blank  anaesthetic  chart  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Version  9  –  May  2015   3    

Editor:  Dr  Andrew  Darby  Smith  
Original  Author:  Dr  P  Shanmuha,  Dr  G  Jackson  
 
 
  Anaesthesia  >  Obstetrics  >  Scenario  1  (BL)  

PARTICIPANT  BRIEFING:  (TO  BE  READ  ALOUD  TO  PARTICIPANT)  

 

You  are  the  anaesthetist  covering  labour  ward.  

 
You  have  been  called  urgently  to  see  a  patient  who  has  been  transferred  to  maternity  theatre  due  to  a  large  
antepartum  haemorrhage.  
 
 
FACULTY  BRIEFING:    
 

This  scenario  simulates  a  major  antepartum  haemorrhage  requiring  emergency  Caesarean  section  in  a  
patient  who  had  been  admitted  to  an  antenatal  ward  for  placenta  praevia  during  the  last  weeks  of  
pregnancy.  The  scenario  begins  with  the  patient  having  been  transferred  into  maternity  theatre  from  
delivery  suite.  A  small  PV  bleed  precipitated  her  transfer  from  the  antenatal  ward  to  labour  ward  a  few  
minutes  ago.  Initial  observations  showed  her  to  be  tachycardic.  Shortly  after  her  transfer  to  delivery  suite  
she  started  to  have  large  PV  blood  loss.  
 
 
‘VOICE  OF  MANIKIN’  BRIEFING:  
 

You  are  terrified  for  the  safety  of  your  baby  and  are  becoming  increasingly  drowsy.  Repeatedly  ask  if  your  
baby  is  going  to  be  ok.  
 
32  year  old.  Second  baby.  35/40  weeks  gestation.  Known  placenta  praevia,  having  been  admitted  to  
hospital  for  the  last  week  –  with  a  planned  date  for  an  elective  section  in  one  week.  
 
Had  an  episode  of  mild  bleeding  30  minutes  ago.  Moved  from  antenatal  ward  to  labour  ward.  Large  bleed  on  
labour  ward.  
 
First  pregnancy  was  an  uneventful  vaginal  delivery.  
 
Medically  well  otherwise.  On  ferrous  sulphate  for  anaemia  in  pregnancy.  No  allergies.  
 
 
OTHER  IN-­‐SCENARIO  PERSONNEL  BRIEFING:  
 

OBSTETRICIAN:  
Anxious.  Delivery  of  baby  needs  to  be  as  soon  as  possible.  No  time  for  regional  anaesthesia.  
Increasingly  impatient  if  there  is  perceived  delay  from  the  anaesthetist.  
 
Midwife:    
Tense.  Monitor  CTG  while  anaesthetist  performs  assessment.  The  CTG  trace  shows  sustained  
bradycardia.  
 
 
ADDITIONAL  INFORMATION:  
 

Help  will  arrive  as  the  induction  takes  place  (after  drugs  have  been  given).    
2  units  O-­‐ve  blood  is  available  immediately.  
Fully  cross-­‐matched  blood  will  take  10  mins.  
 
See  below  for  ABG  &  Pathology  Reports:  
 
 
 

Version  9  –  May  2015   4    

Editor:  Dr  Andrew  Darby  Smith  
Original  Author:  Dr  P  Shanmuha,  Dr  G  Jackson  
 
 
  Anaesthesia  >  Obstetrics  >  Scenario  1  (BL)  

 
 
 
 

 
 
Version  9  –  May  2015   5    
Editor:  Dr  Andrew  Darby  Smith  
Original  Author:  Dr  P  Shanmuha,  Dr  G  Jackson  
 
 
  Anaesthesia  >  Obstetrics  >  Scenario  1  (BL)  

 
 

 
 
 
 
 
 
 
 
 
Version  9  –  May  2015   6    
Editor:  Dr  Andrew  Darby  Smith  
Original  Author:  Dr  P  Shanmuha,  Dr  G  Jackson  
 
 
  Anaesthesia  >  Obstetrics  >  Scenario  1  (BL)  

CONDUCT  OF  SCENARIO  

 
   
EXPECTED  ACTIONS  
  INITIAL  SETTINGS  
   
• Wedge.      
  A:  Patient  and  Self-­‐maintained.  
• Focused  history.  
  B:  RR  28.  SaO2  96%  
• Call  for  help.  
•
 
Fluid  resuscitation.  
C:  HR  120  BP  90/60.  Weak  pulses    
D:  Drowsy.  Anxious.  Eyes  open  
• Send  F  BC,  clotting  etc  
  blood  for  transfusion  –   E:  Evidence  of  heavy  blood  loss  on  bed  and  in  kidney  bowl.  
• Arrange  
  activation  of  Major  
consider  
 
Haemorrhage   Protocol   IV  ACCESS  LOST.  IO  OR  CENTRAL  ACCESS  REQUIRED  
• PreO2.      
• RSI    
  INDUCTION  
• Establish     maintenance
   
 
anaesthesia.  
A:  ET  tube  to  be  inserted  
• Expedited     delivery  of  neonate.   B:  IPPV.  SaO2  falls  to  94%  during  induction.  
• Commence     O-­‐ve  blood  through   C:  HR  135.  BP  80/50  
fluid  w  armer   D:  GCS  3.  Eyes  closed.  Fasciculations  if  sux  used.  
• Pharmacotherapy  
  of  uterine atony   E:  Obstetrician  performs  C-­‐Section.  Uterine atony  –  ongoing  haemorrhage.  
–  syntocinon,  
  e rgometrine,  
haemabate  
 
• If  IV  access  lost  –  failed  attempts  
 
to  resite.    
  to  perform central  or  IO     ONGOING  HAEMORRHAGE  
• Decide  
     
access.  
  A:  ET  Tube  in  situ.    
 
B:  IPPV.  SaO2  95%.  
 
C:  HR  150.  BP  falls  to  70/40  over  4  mins.    
   
ADDITIONAL   INFO   D:  GCS  3.  Eyes  closed.  
      E:  Estimated  blood  loss  of  2.5-­‐3L.  
     
• See  Bloods  &  ABG  
 

  EXPECTED  ACTIONS  
   
• Activation  of  the  Major  Haemorrhage Protocol  
• Further  blood  products  through  warmer  
2+   2+
• Correction  of  hypoCa and  hypoMg  
• Consideration  of  recombinant  factor  VII  and  tranexamic  acid,  cell  saver  
 

  LOW  DIFFICULTY     NORMAL  DIFFICULTY     HIGH  DIFFICULTY  

           
• Pharmacotherapy  and   • Uterine  atony  refractory  to   Either  
resuscitation  achieves   treatment.   • Need  for  Caesarean  hysterectomy,  
hameostasis   • Surgical  control  achieved  with  B-­‐ profound  hypotension,  inotropes  and  
• Haemodynamics  improve  with   Lynch  suture  and  Rusch  balloon.   pressor  requirement  
effective  resuscitation   • Planning  for  HDU/ICU  admission.   Or  
    • Blood  transfusion  reaction  

  RESOLUTION  
   
At  discretion  of  faculty:  Haemodynamic  improvement  or  continuing  hypotension  and  need  for  ITU  transfer  
 
Version  9  –  May  2015   7    
Editor:  Dr  Andrew  Darby  Smith  
Original  Author:  Dr  P  Shanmuha,  Dr  G  Jackson  
 
 
  Anaesthesia  >  Obstetrics  >  Scenario  1  (BL)  

 
DEBRIEFING  
 
 

POINTS  FOR  FURTHER  DISCUSSION:  

 
Technical:  
• Airway  difficulties  in  obstetric  patients  
• Management  of  major  antepartum  haemorrhage    
o Physical  
o Pharmacological    
o Anaesthetic  strategies    
o Surgical  techniques  
• Performing  emergency  RSI  in  the  obstetric  patient  
 
Non-­‐technical:  
• Based  on  established  non-­‐technical  skills  frameworks  e.g.  ANTS,  NOTECHS  etc  
• Appropriate  communication  with  patient,  obstetric  theatre  team,  blood  bank  and  haematologists.  
 
 
 
 

DEBRIEFING  RESOURCES  
 
Management  of  obstetric  haemorrhage  
[Link]  
 
Massive  Haemorrhage  in  Pregnancy.  Banks  A,  Norris  
A.  CEACCP  5  (6)  195-­‐198.  Dec  2005.  
[Link]  
 
 
Prevention  and  Management  of  Postpartum  Haemorrhage  
RCOG  Green-­‐top  Guideline  No.  52.  May  2009.  
[Link]  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Version  9  –  May  2015   8    

Editor:  Dr  Andrew  Darby  Smith  
Original  Author:  Dr  P  Shanmuha,  Dr  G  Jackson  
 
 
  Anaesthesia  >  Obstetrics  >  Scenario  1  (BL)  

INFORMATION  FOR  PARTICIPANTS  

 
 

KEY  POINTS:  
• Safe  administration  of  blood  products  for  resuscitation  during  massive  haemorrhage  
• Demonstrating  understanding  of  the  pharmacotherapy  used  in  obstetric  haemorrhage  
• Understanding  the  logistical  difficulties  and  team  interactions  involved  in  managing  major  
obstetric  haemorrhage.  
• How  to  call  for  help  –  Major  Obstetric  Haemorrhage  (MOH)  calls  and  what  is  achieved  them  
 
 

RELEVANCE  TO  AREAS  OF  THE  ANAESTHETIC  CURRICULUM  

 
  In  respect  of  intravenous  induction:  
  • Makes  necessary  explanations  to  the  patient  
IG_BS_08   • Demonstrates  satisfactory  practice  in  preparing  drugs  for  the  induction  of  anaesthesia  
• Demonstrates  proper  technique  in  injecting  drugs  at  induction  of  anaesthesia  
• Manages  the  cardiovascular  and  respiratory  changes  associated  with  induction  of  general  
anaesthesia  
  In  respect  of  airway  management:  
 
• Demonstrates  optimal  patient  position  for  airway  management  
 
• Manages  airway  with  mask  and  oral  airways  
 
• Demonstrates  hand  ventilation  with  bag  and  mask  
 
• Demonstrates  correct  head  positioning,  direct  laryngoscopy  and  successful  oral  
IG_BS_10  
intubation  techniques  and  confirms  correct  tracheal  tube  placement  
• Demonstrates  proper  use  of  bougies  
• Demonstrates  correct  securing  and  protection  of  LMAs/tracheal  tubes  during  
movement,  positioning  and  transfer  
• Correctly  conducts  RSI  sequence  
IO_BS_07   Demonstrates  role  as  team  player  and  when  appropriate  leader  in  the  intra-­‐operative  environment  
IO_BS_08   Communicates  with  the  theatre  team  in  a  clear  unambiguous  style  
IO_BS_09   Able  to  respond  in  a  timely  and  appropriate  manner  to  events  that  may  affect  the  safety  of  
patients    [e.g.  hypotension,  massive  haemorrhage]  [S]  
ES_BS_01   Manages  preoperative  assessment  and  resuscitation/optimisation  of  acutely  ill  patients  correctly  
ES_BS_03   Manages  rapid  sequence  induction  in  the  high  risk  situation  of  emergency  surgery  for  the  acutely  ill  
patient  
CI_BS_01   Demonstrates  good  non-­‐technical  skills  such  as:  [effective  communication,  team-­‐working,  
leadership,  decision-­‐making  and  maintenance  of  high  situation  awareness]  
CI_BS_02   Demonstrates  the  ability  to  recognise  early  a  deteriorating  situation  by  careful  monitoring  
CI_BS_05   Demonstrates  ability  to  recognise  when  a  crisis  is  occurring  
CI_BS_06   Demonstrates  how  to  obtain  the  attention  of  others  and  obtain  appropriate  help  when  in  a  crisis  
4.3   Administers  blood  and  blood  products  safely  
OB_BS_01   Undertakes  satisfactory  preoperative  assessment  of  the  pregnant  patient  
OB_BS_02   Demonstrates  the  ability  to  clearly  explain  and  prepare  an  obstetric  patient  for  surgery  
OB_BS_03   Demonstrates  the  use  of  techniques  to  avoid  aorto-­‐caval  compression  

Version  9  –  May  2015   9    

Editor:  Dr  Andrew  Darby  Smith  
Original  Author:  Dr  P  Shanmuha,  Dr  G  Jackson  
 
 
  Anaesthesia  >  Obstetrics  >  Scenario  1  (BL)  

OB_BS_07   Demonstrates  the  ability  to  provide  general  anaesthesia  for  caesarean  section  [S]  
OB_BS_11   Demonstrates  ability  to  recognise  when  an  obstetric  patient  is  sick  and  the  need  for  urgent  
assistance  
GU_IS_03   Demonstrates  the  ability  to  manage  the  effects  of  sudden  major  blood  loss  effectively  
CI_IS_01   Demonstrates  leadership  in  resuscitation  room/simulation  when  practicing  response  protocols  
with  other  healthcare  professionals  
CI_IS_02   Demonstrates  appropriate  use  of  team  resources  when  practicing  response  protocols  with  other  
healthcare  professionals  
OB_IS_09   Demonstrates  the  ability  to  provide  intra  uterine  resuscitation  for  the  “at  risk”  baby  
OB_HS_03   Demonstrates  the  ability  to  be  an  effective  part  of  a  multidisciplinary  team  
OB_HS_06   Demonstrates  skill  in  managing  emergencies  including  pre-­‐eclampsia,  eclampsia,  major  
haemorrhage  
 
 
WORKPLACE-­‐BASED  ASSESSMENTS  
 
• Basic  Competencies  for  Obstetric  Anaesthesia  –  conduct  general  anaesthesia  for  
OB_BTC_A03  
caesarean  section  [12-­‐24  months][S]  
Administer  anaesthesia  for  caesarean  section  to  a  patient  with  a  complicated  pregnancy  
OBI_A01  
[hypertensive  disease,  placenta  praevia  etc]  
Undertake  the  management  of  caesarean  section  in  a  complex  obstetric  case  such  as  twin  
 
delivery,  moderate  to  severe  pre-­‐eclampsia,  placenta  praevia,  obstetric  haemorrhage,  foetal  
OBH_A01  
distress,  etc  –  using  GA  or  RA  as  appropriate.  
Undertake  anaesthesia  for  a  patient  in  whom  massive  haemorrhage  is  expected  including  
OBH_D04  
organising  venous  access,  infusion  equipment,  cell  saver  and  appropriate  blood  products.  
 
 
FURTHER  RESOURCES  
 
Management  of  obstetric  haemorrhage  
[Link]  
 
Massive  Haemorrhage  in  Pregnancy.  Banks  A,  Norris  
A.  CEACCP  5  (6)  195-­‐198.  Dec  2005.  
[Link]  
 
Prevention  and  Management  of  Postpartum  Haemorrhage  
RCOG  Green-­‐top  Guideline  No.  52.  May  2009.  
[Link]  
 

 
 
 
 
 
 
 
 
 
 
Version  9  –  May  2015   10    
Editor:  Dr  Andrew  Darby  Smith  
Original  Author:  Dr  P  Shanmuha,  Dr  G  Jackson  
 
 
  Anaesthesia  >  Obstetrics  >  Scenario  1  (BL)  

 
PARTICIPANT  REFLECTION:  
 
What  have  you  learnt  from  this  experience?  (Please  try  to  list  3  things)  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
How  will  your  practice  now  change?  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
What  other  actions  will  you  now  take  to  meet  any  identified  learning  needs?  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Version  9  –  May  2015   11    
Editor:  Dr  Andrew  Darby  Smith  
Original  Author:  Dr  P  Shanmuha,  Dr  G  Jackson  
 
 
  Anaesthesia  >  Obstetrics  >  Scenario  1  (BL)  

PARTICIPANT  FEEDBACK  
 
 
Date  of  training  session:...........................................................................................................................................  
 
 
Profession  and  grade:...............................................................................................................................................  
 
 
What  role(s)  did  you  play  in  the  scenario?  (Please  tick)  
 
 
Primary/Initial  Participant    

Secondary  Participant  (e.g.  ‘Call  for  Help’  responder)    

Other  health  care  professional  (e.g.  nurse/ODP)    

Other  role  (please  specify):    

 
Observer    

 
 
  Strongly   Neither  agree   Strongly  
Agree   Disagree  
Agree   nor  disagree   Disagree  
I  found  this  scenario  useful            

I  understand  more  about  the            

scenario  subject  
I  have  more  confidence  to            
deal  with  this  scenario  
The  material  covered  was            
relevant  to  me  
 
Please  write  down  one  thing  you  have  learned  today,  and  that  you  will  use  in  your  clinical  practice.  
 
 
 
 
 
 
 
How  could  this  scenario  be  improved  for  future  participants?    
(This  is  especially  important  if  you  have  ticked  anything  in  the  disagree/strongly  disagree  box)  
 
 
 

 
 
 
 
 
 
Version  9  –  May  2015   12    
Editor:  Dr  Andrew  Darby  Smith  
Original  Author:  Dr  P  Shanmuha,  Dr  G  Jackson  
 
 
  Anaesthesia  >  Obstetrics  >  Scenario  1  (BL)  

FACULTY  DEBRIEF  –  TO  BE  COMPLETED  BY  FACULTY  TEAM  

 
 
What  went  particularly  well  during  this  scenario?  
 
 
 
 
 
 
 
 
 
What  did  not  go  well,  or  as  well  as  planned?  
 
 
 
 
 
 
 
 
 
 
 
 
Why  didn’t  it  go  well?  
 
 
 
 
 
 
 
 
 
 
 
 
How  could  the  scenario  be  improved  for  future  participants?  
 
 
 
 
 
 
 
 
 
 
 
 

Version  9  –  May  2015   13    

Editor:  Dr  Andrew  Darby  Smith  
Original  Author:  Dr  P  Shanmuha,  Dr  G  Jackson