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Strategy Submission

Impaired Perfusion High Risk Obstetrical Simulation


Dawn Tassemeyer





M.J. Jobes, RN, MA, Assistant Professor,


University of Nebraska Medical Center College of Nursing-Lincoln Division


Competency Categories:

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: Knowledge: 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. Skills: 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. Attitudes: 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 quality 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) Healthy 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: 30 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 discussed. 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.

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