Simulation Scenario – PPH
Section 1: Case Summary
Scenario Title: PPH
Keywords: post partum hemorrhage, hypotension, shock, bleeding
A 28 year old pregnant female arrves to your ED. She is currently in the thid
trimester of her pregnancy. Her EDD was 2 days back. She has come to the ED with
Brief Description of Case: complains of pain abdomen and leaking per vaginum.
Goals and Objectives
Educational Goal: To conduct normal delivery and AMTSL
To manage post partum complications - PPH
Objectives:
(Medical and CRM)
EPAs Assessed:
Learners, Setting and Personnel
☐ Junior Learners ☐ Senior Learners ☐ Staff
Target Learners: ☐ Physicians ☐ Nurses ☐ RTs ☐ Inter-professional
☐ Other Learners:
Location: ☐ Sim Lab ☐ In Situ ☐ Other:
Instructors: Vinodha
Recommended Number
Sim Actors: Ezhil
of Facilitators:
Sim Techs: Vishwanath
Scenario Development
Date of Development: 13-12-2023
Scenario Developer(s): Vinodha and Vishwanath
Affiliations/Institutions(s): JIPMER
Contact E-mail:
Last Revision Date:
Revised By:
Version Number:
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Simulation Scenario – PPH
Section 2A: Initial Patient Information
A. Patient Chart
Patient Name: X Age: 28 Gender: F Weight: 60 kg
Presenting complaint: pain abdomen and leaking per vaginum - came here instead of going to Og casualty
Temp: 98.6 HR: 120 BP: 120/70 RR: 20 O2Sat: 97 FiO2: 21
Cap glucose: 140 GCS: (E V M ) 15
Triage note:
In severe pain - score of 7/10; G2P2L1
Allergies: Nil
Past Medical History: Current Medications:
Was told to have high BP recording during the second On T. Labetalol 100 mg od
and third trimester
Section 2B: Extra Patient Information
A. Further History
Include any relevant history not included in triage note above. What information will only be given to learners if they
ask? Who will provide this information (mannequin’s voice, sim actors, SP, etc.)?
Previous delivery - uneventful, NVD, no other complications during or after pregnancy
Curret pregnancy - was told to have high BP recordings and started on tablets. BP under control with
tablets. no other complications.
Now presented with labour pains and leaking pv since 6 hours.
B. Physical Exam
List any pertinent positive and negative findings
Cardio: S1S2 heard, no murmur Neuro: GCS-15, PUPILS -RTL
Resp: NVBS Head & Neck: NAD
Abdo: fundal height- 32 weeks, SFH-31.4CM, MSK/skin: NAD
longitudinal lie, cephalic presentation, engaged head
uterine contractions present, FHS - 160/min
Other: PV- bishops score- 9
station -+2
effacement- 90%
dilation- 10 cm
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Simulation Scenario – PPH
Section 3: Technical Requirements/Room Vision
A. Patient
☐ Mannequin (specify type and whether infant/child/adult) - Pelvic mannequin
☐ Standardized Patient
☐ Task Trainer
☐ Hybrid
B. Special Equipment Required
episiotomy scissors
towel
umbilical cord clamp
kidney tray
foley’s cathether
C. Required Medications
Oxytocin
D. Moulage
None
E. Monitors at Case Onset
☐ Patient on monitor with vitals displayed
☐ Patient not yet on monitor
F. Patient Reactions and Exam
Include any relevant physical exam findings that require mannequin programming or cues from patient
(e.g. – abnormal breath sounds, moaning when RUQ palpated, etc.) May be helpful to frame in ABCDE format.
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Simulation Scenario – PPH
Section 4: Sim Actor and Standardized Patients
Sim Actor and Standardized Patient Roles and Scripts
Role Description of role, expected behavior, and key moments to intervene/prompt learners. Include any script
required (including conveying patient information if patient is unable)
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Simulation Scenario Template
Section 5: Scenario Progression
Scenario States, Modifiers and Triggers
Patient State/Vitals Patient Status Learner Actions, Modifiers & Triggers to Move to Next State Facilitator Notes
1. Baseline State See above Expected Learner Actions Modifiers
Rhythm: sinus ☐ Triage to Level 2 Changes to patient condition based on
tachycardia ☐ Connect multipara monitors learner action
HR: 120 ☐ Connect CTG - If not checking for
BP: 120/70 ☐ Place IV line, send samples for effacement/dilation/station,
RR: 20 CBC, CXM crowning occurs
O2SAT: 97% ☐ ABCDE - Abdomen and PV -
T: 98 F examination Triggers
GCS: 15/15 ☐ Asks for Speculum For progression to next state
☐ Asks for effacement/ dilation - If they correctly identify that the
and station patient is in second stage
☐ Identifies patient is in second
stage
☐ Informs OG team
2. Conduct Vitals stable Expected Learner Actions Modifiers
delivery of the ☐ Prepares required equipments - If no support to perineum and
fetus ☐ Identifies crowning occiput, will be able to visualise a
☐ Verbalised restitution, vaginal tear once baby is delivered.
external rotation. Supports the - If AMTSL not done, starts
perineum and the occiput bleeding profusely vaginally
☐ Gives Oxytocin 10 U IM at the -
delivery of anteror shouler Triggers
☐ Cord clamping - delayed - After 20 mins, patient becomes
☐ Controlled cord traction after drowsy.
checking for signs of placental
separation
☐ Uterine massage
☐ Observes the mother and baby
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Simulation Scenario Template
3. Identifies and BP - 80/50mmHg Expected Learner Actions Modifiers
manages PPH PR - 140/min, ☐ Identifies patient is in shock - If oxytocin not given, blood does
sinus rhythm and evaluates cause of shock not arrive
SpO2 - 93% ☐ Identifies hemorrhagic shock, - If oxytocin adminstration takes
Activates MTP more than 10 mins, patient
☐ Identifies PPH and evaluates collapses
cause for PPH - Checks tone, - No blood products if MTP
trauma, tissue(for retained activation is not told
placenta), thrombin Triggers
☐2 large bore iv line - If oxytocin, TXA, blood
☐starts fluid resuscitation, products are administered,
catheterizes the patient patient will be stable
☐ Oxytoxin 5 U iv followed by enough for OG team to take
20-40U in 500mL NS at 60 over and the simulation
drops/min concludes
☐ Inj. TXA 1g over 10 mins - If any step missed, patient
☐ Transfuses 1st pack will collapse
☐Re-informs OG team
☐Monitor hemodynamics and
monitor urine output
☐ Consider other samples for
HELLP
4. Patient cardiac arrest Expected Learner Actions Modifiers
collapses ☐ ACLS -
☐ Blood transfusion as cause of -
arrest is hemorrhage -
☐ Triggers
☐ -
☐ -
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Simulation Scenario Template
Appendix A: Laboratory Results - Awaited - Instructor choice
CBC Cardiac/Coags
WBC Trop
Hgb D-dimer
Plt INR
aPTT
Lytes
Na Biliary
K AST
Cl ALT
HCO3 GGT
AG ALP
Urea Bili
Cr Lipase
Glucose
Tox
Extended Lytes EtOH
Ca ASA
Mg Tylenol
PO4 Dig level
Albumin Osmols
TSH
Other
VBG B-HCG
pH
pCO2
pO2
HCO3
Lactate
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Simulation Scenario Template
Appendix B: ECGs, X-rays, Ultrasounds and Pictures
Paste in any auxiliary files required for running the session. Don’t forget to include their source so you can find them later!
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Simulation Scenario Template
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Simulation Scenario Template
Appendix C: Facilitator Cheat Sheet & Debriefing Tips
Include key errors to watch for and common challenges with the case. List issues expected to be part of the debriefing discussion.
Supplemental information regarding any relevant pathophysiology, guidelines, or management information that may be reviewed
during debriefing should be provided for facilitators to have as a reference.
References
1. FIGO and RCOG guidelines for PPH prevention and management
2. Books - Dutta and Sheila Balakrishnan
3. CTG and TEG graph from online source
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