Impaired Perfusion High Risk Obstetrical Simulation

Submitter Information

Author: Dawn Tassemeyer, RN, MSN
Title: Instructor
Institution: University of Nebraska Medical Center College of Nursing-Lincoln Division
Coauthors: M.J. Jobes, RN, MA, Assistant Professor,

Competency Category(s)
Patient-Centered Care, Safety, Teamwork and Collaboration

Learner Level(s)
Pre-Licensure BSN

Learner Setting(s)
Skills or Simulation Laboratories

Strategy Type
General Strategy

Learning Objectives

Impaired Perfusion High Risk Obstetrical Simulation

Learning Objectives

At the end of this clinical simulation experience, the learner will be able to:


1. List the actions of three common obstetrical medications (Pitocin, MG SO4, and Methergine).

2. Define and identify TeamStepps key principles (Team Structure, Leadership, Situation Monitoring, Mutual Support, and Communication) and give examples.

3. Verbalize the learning opportunities that Simulation provides.

4. Explain how the concept of perfusion relates to the high risk obstetrical (OB) patient.

5. Discuss the pathophysiology, assessment, nursing diagnoses, nursing and medical treatment, and outcomes of the following obstetrical complications:

   a. Placental problems.

   b. Post-partum bleeding.

   c. High risk pregnancy.

   d. High risk neonate.

   e. HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome.

   f. Pre-eclampsia.

   g. Eclampsia.

   h. Disseminated intravascular coagulation (DIC).

6. Identify and explain the rationale for the risk factors of a high-risk pregnancy.

7. Using the American Academy of Pediatrics newborn resuscitation algorithm, identify intrauterine resuscitation criteria and methods for intervention.

8. Using the case study of a 30-week primigravida, identify signs and symptoms, labs., nursing diagnoses, nursing and medical interventions, and outcomes of the following complications:

   a. Pre-eclampsia.

   b. HELLP syndrome.

   c. Eclampsia.

   d. Grand mal seizures.

   e. Intrauterine resuscitation.

9. During the Simulation experience, identify the pathophysiology, assessments, nursing diagnoses, nursing and medical interventions, and outcomes of obstetrical bleeding disorders.


10. Perform psycho-motor skills safely (venipuncture, prime IV tubing, program IV pump, administer IVPB medication, and insert Foley catheter) in the Simulation laboratory.

11. Using clinical models, determine the dilation of the cervix (in cms.) and presence of shoulder dystocia.


12. Reflect and record in clinical journal individual student reactions to the Simulation experience. Comment specifically on individual student changes in abilities in confidence, knowledge, critical thinking, organization, prioritization, teamwork, and psycho-motor skills.

Strategy Overview

Impaired Perfusion High Risk Obstetrical Simulation

Because of low patient census and the inability to ensure
high risk obstetrical patient experiences, securing student clinical opportunities
is difficult. Using the principles of a “flipped classroom”, an eight hour high
risk obstetrical simulation clinical was developed for fourth semester, senior
level nursing students. The content focused on the concept of impaired
perfusion. This learning strategy allowed for student learning in a
safe environment (where student could
do no harm) while focusing on
patient-centered care.


Power point presentation (outlined the agenda, outcomes,
and expectations).

Outcomes included prioritization, critical thinking, becoming more
comfortable in the clinical setting, being confident in one’s own nursing
skills, and knowing when to ask for help from others in order to ensure patient safety.

Discussion on the patient safety initiative TeamSTEPPS. The key principles of team
structure, leadership, situation monitoring, mutual support, and communication
were highlighted.

The reasons for simulation clinical instead of
clinical at the hospital were explained (see above).

Power point continued with a review of
obstetrical content presented in past semesters.

The concept of perfusion as it relates to OB
high risk situations were presented.

Preeclampsia (how it effects the body systems and organs, assessment, management
and treatment) and hypertension in pregnancy were explained. Risks for other
disorders (HELLP syndrome and Eclampsia) and intrauterine resuscitation methods
were discussed.

Laboratory/Simulation Experience

Group 1 independent paperwork

Case studies of high risk OB situations–Drug
use and domestic violence, preeclampsia, placental problems (abruption
placentae and placenta previa, DIC and HELLP syndrome)

people 2020 objectives (as they relate to the postpartum period)

Fetal monitoring tracing

Group 2 Skills Laboratory

Simulation–students assigned to a “patient”
being prepped for a cesarean section.

Start an IV, prime tubing, program a pump, secondary
(piggyback) and insert a Foley catheter (problem solve with minimal assistance
from the instructor).

“Trouble shooting” with IV pumps, piggybacks,
and tubing and Foley catheter insertion.

Unfolding Case Study:

week primigravida patient, determine if symptoms were normal or abnormal for
gestation. Identify abnormal vital signs, key lab values, important nursing
interventions, and plan ahead for emergencies. Role play calling doctor using
SBAR. Patient progressed from preeclampsia, HELLP syndrome, to eclampsia with a
grand mal seizure.  Demonstrate nursing
care and interventions (seizure precautions and intrauterine resuscitation). Demonstration
of assessing deep tendon reflexes and clonus.

Group 1 and 2 switched and the above was repeated.


“Noelle” 4 hours post-partum, “just did not feel
very well and was a little lightheaded.”
During the fundal assessment, the students discovered a large amount of
blood on the chux pad.

Student expectations: perform nursing
interventions to assist with postpartum hemorrhage, implementation of hemorrhage
management (calling doctor, IV start, medication administration, physical
assessment, fundal massage). Instructor challenged students by asking critical
thinking questions.


Vaginal examinations using cervical models.
Determination of dilatation at 1, 3, 5, 8, & 10 centimeters (baby in vertex,
footling breech positions, and prolapsed cord presentations). Interventions

Shoulder dystocia demonstrated using a
mannequin, pelvic model and baby. Turtle sign, McRoberts maneuver, and
suprapubic pressure were shown. Brachial plexus injury and the Zavanelli
maneuver were discussed.

Precipitous labor, precipitous delivery and
nursing interventions were examined.

Neonatal resuscitation was discussed. Principles
such as initial assessment, oxygen administration, PPV, chest compressions and
AGPAR scoring were demonstrated using a baby model. The Newborn resuscitation
algorithm was shown and discussed in terms of routine vs. resuscitative care.

Students demonstrated skills.

NCLEX Review

NCLEX review was done using clickers and
consisted of 14 questions involving high risk OB situations. After the review faculty
clarified the reasoning for the correct answer.


Debriefing was done as well as faculty shared
personal experience and answered questions throughout each teaching session.

A final debriefing was done with all students at
the end of the day. Paperwork and fetal monitoring strips were reviewed.


Submitted Materials

Additional Materials

Evaluation Description


Student Evaluation

Students completed a clinical journal discussing
their impression of the clinical day, what they learned, and what they would
change (if anything).

Students commented that this type of learning
was beneficial to them, being able to call on their peers for help or advice
instead of being put on the spot when they felt stressed. Students remarked
that the clinical experience was helpful as many had not had the opportunity to
practice the skills in the clinical setting.

Overall the feedback from the clinical journals,
emails, and verbal comments from the students was positive. A few students did
express the desire to have this simulation clinical along with a clinical day
spent at the hospital.