How to Run a Postpartum Hemorrhage Nursing Simulation Scenario
When a high-fidelity obstetric simulator is available, the simulated postpartum hemorrhage (PPH) can be rather dramatic and provides nursing staff members with a chance to experience the reality of massive fluid loss in a safe environment. However, birthing simulators can cost upwards of $100,000, and sometimes educators just need to put together a quick in-situ drill on the unit. Budget and time constraints often mean that simulationists must be creative and rely on more readily available equipment and supplies. If the objective of the nursing simulation is to promote teamwork, therapeutic communication, or locate emergency supplies quickly, then one may not need the financial investment of high-fidelity manikins or moulage kits at all. Instead, this HealthySimulation.com article provides alternative ideas on how to best run a postpartum hemorrhage nursing simulation scenario.
Important to note, PPH is one of the leading causes of maternal mortality and morbidity worldwide and is often preventable. While there are varied causes, the most frequent cause is uterine atony, or the inability of the uterus to contract sufficiently after birth. As PPH can be unpredictable, the obstetric team must be vigilant in preparing for, recognizing, and treating hemorrhage promptly. As regular drills are recommended, the unit educator or healthcare simulation educator can employ creative measures to make the process effective, but not cost or resource-prohibitive.
Since an actual PPH involves large amounts of blood, the experience can be frightening for a nurse to witness if the nurse has not previously experienced this scenario through clinical simulation. The practice requires quick thinking, prompt action, and mobilization of the team on the unit to treat effectively. Healthcare simulation offers the best option for preparing for this relatively rare event (3% to 5% of births).
High-fidelity birthing manikins can simulate active bleeding with uterus modules that simulate a boggy (not contracted) or firm (contracted) uterus. These manikins can also be programmed to simulate physiologic changes appropriate to the level of blood loss. They offer the highest degree of realism, but are complex to program and run, requiring medical simulation staff to do so. The educator on the obstetric unit will typically not have the expertise required to use this type of manikin nor does the typical unit have the means to store and maintain this equipment.
The obstetric pelvic task trainer is more commonly available at the hospital unit level and requires no special expertise or training to use. The educator on the unit can easily set up the trainer and be ready for times when a quick in-situ drill is needed. Depending on the objectives, this may require little to no moulage or prep time.
An obstetric hemorrhage can be simulated using water, thickened with corn starch or gelatin if desired, tinted with food coloring, poured onto a towel or pad, and put in a 1- or 2-gallon zippered plastic bag. This can be placed under a pelvis or low-fidelity manikin to simulate blood loss in varying amounts. By using a plastic bag, there’s no risk of staining, and linens or chux won’t have to be constantly changed.
Alternatively, a length of red silky fabric purchased at a fabric or craft store can also be tucked under the pelvis and the facilitator may pull out a little at a time to adjust the clinical simulation of moderate to massive blood loss. Having that silky fabric spill off the bed and puddle onto the floor can also make a powerful impact. A benefit of this fabric is that the material is a one-time purchase that can be used indefinitely.
The healthcare simulation educator may consider using a standardized patient (SP) and manikin/task trainer combo to increase realism without additional moulage. Along with assessing appropriate clinical management of the hemorrhage, this adds the element of therapeutic communication with the patient and family members.
By using SP’s (or healthcare simulation nursing staff members) as the patient and family members, a learner can get a more realistic representation of patient symptoms (dizziness, shortness of breath, impending doom), instead of relying on the visual cue of vital sign changes on the monitor. Realistically, vital signs in the postpartum woman generally don’t change dramatically until the hemorrhage is well underway. Once the hemorrhage is recognized, the learners can switch to an adjacent bed with a manikin or task trainer to complete the fundal massage practice and medication administration.
Having the added element of patients and family members being able to ask questions and relay concerns provides the learner with the opportunity to meet a therapeutic communication objective. This further enables them to respond clinically to the hemorrhage itself. This works best for those who have a team of learners so that one or two can focus on the family members while the others manage the hemorrhage. For the in-situ team building simulation, this can be invaluable.
Another angle the healthcare simulation educator can take on the postpartum hemorrhage simulation is to set up a quantified blood loss station that doesn’t require a manikin or task trainer at all. For this, they only need items that can be ‘bloodied’ such as linen-saver pads, peri pads, towels, washcloths, gauze pads, and under buttocks drape. One of the most dangerous aspects of hemorrhage of any kind is the unreliable use of estimated blood loss to guide assessment and management. The quantified measurement of blood loss has been shown to be far superior to the standard practice of estimation or “eyeballing” (The American College of Obstetrics and Gynecologists, 2019).
Ultimately, all that is needed is a scale and colored water (thickened or not) to pour on the items. Gelatin can also be used to simulate large and small clots, which are often grossly underestimated in the amount due to varying sizes and shapes. When setting up a station such as this, surfaces must be prepared to prevent staining of floors, tables, etc. that may encounter fake blood. Water soluble paints like those used for finger painting may be much easier to clean up than food coloring, depending on the type of surface.
Having a printed table handy of pre-measured dry weights of each item used is helpful as well. Learners can weigh each bloodied item, then subtract the dry weight to get the most accurate weight. One gram is roughly equal to one milliliter of blood. Clinical simulation educators should include an exercise at the beginning of the clinical simulation station in which the learners write down their estimation of blood in the room/station and then compare that to the amount that is obtained by weight. This is usually a very eye-opening comparison and a solid argument for making quantified blood loss standards on the unit.
Overall, PPH is relatively rare but can be life-threatening if not recognized and treated promptly. If the postpartum uterus can not sufficiently contract to close off the placental site vessels, a woman can lose up to 400 milliliters of blood every minute. Medical simulation staff can be invaluable in preventing a tragedy by having multiple tools at their disposal to prepare nurses on the unit. By having PPH drills in simulation available and convenient, the obstetric staff can be confident in their ability to handle such an emergency.
Tina Hayes, MSN, RN, RNC-OB is a nurse with over 20 years of experience in practice and staff development. She is certified in Inpatient Obstetrics and Electronic Fetal Monitoring and is an instructor of Advanced Life Support in Obstetrics. She is also an instructor of BLS and ACLS.
She began her career in general medical/surgical nursing and became an obstetrics nurse in 2004. She has held positions as a staff nurse, charge nurse, preceptor, nurse manager, and clinical educator. Hayes became involved in simulation while working as a nurse manager and training staff in postpartum hemorrhage response and drills. The visual enhancement provided by simulation and the benefit of hands-on practice was inspiring.
She moved into a full-time position as a simulation educator in 2017 at Northeast Georgia Medical Center where a large educational and simulation center was built in 2019 to support a new Graduate Medical Education program. She served as the obstetric subject matter expert in simulation and participated in the development of a mobile simulation unit at NGHS, making simulation education available to areas throughout northeast Georgia.
Hayes moved to Miami, FL in 2022 and currently works as a Simulation Educator at Miami University’s School of Nursing and Health Studies.