TeamSTEPPS® Instructor Manual: Specialty Scenarios

L&D

Specialty scenario for this guide.

Contents

Scenario 85
Scenario 86
Scenario 87
Scenario 88
Scenario 89
Scenario 90
Scenario 91
Scenario 92
Scenario 93
Scenario 94
Scenario 95
Scenario 96
Scenario 97
Scenario 98
Scenario 99
Scenario 100
Scenario 101
Scenario 102
Scenario 103
Scenario 104
Scenario 105
Scenario 106
Scenario 107
Scenario 108
Scenario 109
Scenario 110
Scenario 111
Scenario 112
Scenario 113
Scenario 114
Scenario 115
Scenario 116


Scenario 85

 
Appropriate for: L&D
Setting: Hospital

 

Sue Jones a 28-year-old G1 P0 at term is undergoing an induction of labor for elevated blood pressure. The patient is receiving 14 mu of Pitocin and is experiencing contractions every 3 minutes. The fetal heart rate has a baseline of 150 bpm with recurrent variable decelerations. Her cervix is dilated 4-5 cm, and it has not changed in more than an hour. The attending obstetrician asks the primary registered nurse (RN) to increase the rate of Pitocin. The RN expresses her concerns about the variable decelerations and states there are adequate contractions. The attending obstetrician (OB) says, "The baby is OK; push the Pitocin." The RN is uncomfortable with the request. She again expresses her concerns regarding the variable decelerations but does acknowledge that the patient may need stronger contractions. She informs the attending OB that if she had more information on the baby's well-being obtained with a fetal scalp electrode (FSE) and an intrauterine pressure catheter (IUPC), she would feel more comfortable increasing the infusion of Pitocin.

The attending OB agrees to this plan and places the FSE and IUPC. The RN slowly increases the Pitocin and the patient has a vaginal delivery.

Instructor Comments

  • In this scenario, the RN expresses her concern about the physician's request and offers an alternative after using the Two-Challenge rule. A favorable outcome ensues because she advocates for the patient.

Skills Needed

  • Communication. Situation monitoring: assess status of patient. Situation awareness.

Potential Tools

  • Conflict resolution, Two-Challenge rule, Advocacy/assertion, Collaboration.

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Scenario 86

 
Appropriate for: L&D
Setting: Hospital

 

Sally Rodgers, a 25-year-old nullip in labor at term who is dilated 3 cm. This is a change from 2 cm over the previous 90 minutes. Sally is having frequent, strong to palpation contractions that are extremely uncomfortable. She is trembling, complaining of nausea, and begging her nurse for pain relief. The patient's primary nurse believes epidural anesthesia would be appropriate and informs the obstetrician (OB) attending. The OB attending states he wants the patient to be dilated 4–5 cm before she receives the epidural. The nurse reiterates to the attending OB that her assessment is that the patient is in active labor. Although Sally's cervix has not demonstrated active labor yet, her nurse believes the pain relief and relaxation resulting from an epidural would be beneficial for the patient. The attending OB agrees to the epidural placement. The patient is fully dilated and begins pushing 3 hours after the placement.

Instructor Comments

  • In this scenario, the primary nurse uses the Two-Challenge rule to advocate for a position different from that of the OB. She assertively provides information received through situation monitoring that supports her assessment that the patient should receive pain medication.

Skills Needed

  • Communication. Situation monitoring: assess status of patient. Situation awareness.

Potential Tools

  • Conflict resolution, Two-Challenge rule, Advocacy/assertion, Collaboration.

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Scenario 87

 
Appropriate for: L&D
Setting: Hospital

 

(To be read prior to discussions and slide presentation) Athena Onassis, a 36-year-old Greek-speaking G1 P0 with an in vitro fertilization (IVF) gestation at 27 weeks is admitted to L&D at 0200 from the antepartum unit with preterm labor. She is started on magnesium sulfate, and the contractions stop. Her vaginal exam at this time shows she is dilated 1 cm. The patient is transferred back to the antepartum unit at 0800. At 0915, the nurse from the antepartum unit calls the resident to come and see the patient because she is uncomfortable. The resident examines the patient and finds her to be dilated 3 cm. The attending physician is called, and the decision is made to transfer her back to L&D and perform a primary C-section (c/s). On arrival to L&D, the patient is brought to the recovery room, and the attending physician tells the charge nurse that it is not an emergent c/s and they can wait for Operating Room (OR) B to be available. An interpreter is requested. Another attending physician who speaks Greek happens to be on L&D visiting one of her patients. She is asked to act as interpreter and, because of the language barrier, is asked to perform an ultrasound and a vaginal exam on the patient. Unexpectedly she finds the patient to be 4–5 cm dilated and in an urgent clinical situation. She tells the nurse that they must go back to the OR right away, but she does not call the attending physician. The nurse states that they are waiting for the patient's husband to arrive and does not call the attending physician. The urgency of the situation is finally communicated to the appropriate people, and an emergent c/s is performed. The patient is examined in the OR and is dilated 7 cm. It is a very difficult delivery requiring a pushup from below. Seven minutes pass between uterine incision and the delivery of the baby. The baby dies from ventricular hemorrhage caused by trauma.

Instructor Comments

  • In this scenario, there is a barrier to communication related to language and multiple providers. Check-backs and handoffs are not performed, and opportunities for advocacy/assertion are missed.

Skills Needed

  • Communication. Situation monitoring. Situation awareness.

Potential Tools

  • Handoff, Check-back, Cross-monitoring, Advocacy/assertion.

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Scenario 88

 
Appropriate for: All Specialties
Setting: Hospital

 

1. Nurse: “I need Dr. Smith for a pattern check in room 2.”
Assistant: “You need Dr. Smith for a pattern check in room 2?”
Nurse: “Yes.”

2. Doctor:  “I need a fetal scalp electrode.”
Nurse: “You need a fetal scalp electrode?”
Doctor: “Yes.”

Instructor Comments

  • This scenario is a classic example of check-back.

Skills Needed

  • Communication.

Potential Tools

  • Check-back.

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Scenario 89

 
Appropriate for: All Specialties
Setting: Hospital

 

1. RN to Charge Nurse: “My patient is getting an epidural so I will not be available for one half-hour.”

2. Charge Nurse to RN: “OK, I’ve take this patient until you return.”

Instructor Comments

  • This scenario is a classic example of the communication used in a handoff.

Skills Needed

  • Communication.

Potential Tools

  • Handoff.

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Scenario 90

 
Appropriate for: L&D
Setting: Hospital

 

Ann Goodwin, a patient at term with oligohydramnios is admitted for induction of labor. She is examined by the senior resident who determines she has an unfavorable cervix and is therefore a candidate for cervical ripening. The senior resident tells the intern to order Prostin and insert it. The intern has never inserted Prostin except in second trimester terminations. He therefore orders a 20-mg Prostin suppository instead of Cervidil. The order is placed by the nurse, and the Prostin suppository is sent to L&D by the Pharmacy. The intern asks the nurse whether the Prostin has arrived. She replies that it has, and the intern inserts the suppository. The nurse thinks it is "strange" but never questions the use of a 20 mg Prostin suppository in a term pregnancy with a live fetus. The patient experiences hyperstimulation that leads to a non-reassuring fetal heart rate pattern and an emergent C-section.

Instructor Comments

  • This teamwork failure is the result of a series of communication breakdowns. A check-back is not performed, and the medical order for Prostin is never clarified for route or acknowledged for accuracy. Even when the nurse personally questions the use of a suppository, she does not use the Two-Challenge rule to voice her concern. The use of simple communication techniques taught in this module could have avoided placing this patient at unnecessary risk.

Skills Needed

  • Communication. Mutual support.

Potential Tools

  • Check-back, Two-Challenge rule, Conflict resolution.

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Scenario 91

 
Appropriate for: L&D
Setting: Hospital

 

Denise Whitaker, a 36-year-old G2 P1 with a history of a postpartum hemorrhage and who had a D&C in her first pregnancy is being managed by a family practitioner. Denise is at term and delivers vaginally but retains the placenta. A manual removal of the placenta is attempted 40 minutes after delivery. This attempt is made under conscious sedation and is unsuccessful, with a resulting 1500–2000 cc blood loss. A consultant obstetrician (OB) is contacted, and the decision is made to transfer the patient to the OB Operating Room. Under spinal anesthesia, a manual removal of the placenta is performed. Three-quarters of the placenta is removed. The remaining placenta is abnormally adhered to the uterine wall. This adherence is confirmed by ultrasound. The Operating Room (OR) team is called for a probable hysterectomy. The attending obstetrician consults with a perinatologist who agrees with the plan for a hysterectomy. Blood arrives in the OR labeled with the correct first name of the patient but the wrong last name. The nurse who ordered the blood states that the blood bank technician said, "I know the patient," before the nurse was able to give the medical record number. After a delay, the correct blood arrives, and Denise receives a transfusion.

Instructor Comments

  • An avoidable communication breakdown including lack of check-back or Two-Challenge rule causes an unnecessary delay in this patient's transfusion. Effective teams employ several standards of effective communication that are known to prevent communication related errors.

Skills Needed

  • Communication. Mutual support.

Potential Tools

  • Check-back, Two-Challenge rule, Advocacy/assertion.

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Scenario 92

 
Appropriate for: L&D
Setting: Hospital

 

At a team meeting, one of the attending physicians states that he is going to the Operating Room to perform a C-section. He also states that he has another patient, Mary, in labor with her second child, dilated 8 cm. Another attending physician offers to be available in case Mary delivers. This information is shared with the RN caring for Mary so she knows whom to call. Mary is slowly progressing and may end up requiring a C-section. The anesthesiologist meets with the covering obstetrician and the RN caring for the patient to tell them that the patient has a class 3 airway and therefore she does not want to administer general anesthesia to this patient if it can be avoided. The nurse repeats back that general anesthesia should be avoided, and it is confirmed. The team decides that it is best to monitor the patient's epidural carefully so that general anesthesia can be avoided if the patient requires a C-section.

Instructor Comments

  • In this scenario, the use of effective communication and team structure includes handoff, check-back, and the team huddle, resulting in the delivery of optimal care.

Skills Needed

  • Team Structure. Communication.

Potential Tools

  • Huddle, Handoff, Check-back

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Scenario 93

 
Appropriate for: L&D
Setting: Hospital

 

The Triage nurse is overloaded with the arrival of three patients within 15 minutes of each other. She calls the registered nurse (RN) team leader seeking help. A second RN arrives in the Triage unit to offer assistance. The Triage nurse asks this second RN to perform an assessment, initiate electronic fetal monitoring, and obtain blood and urine specimens on a patient presenting for a pre-eclampsia evaluation. This process takes approximately 15 minutes, and the second RN then reports her findings to the resource nurse, signs off the case, and returns to her patient in L&D once she is sure the resource nurse has assumed care of the patient.

Instructor Comments

  • This scenario depicts the proper use of delegation in which specific tasks are delegated to those who have the skills to complete them.
  • Also, followup and adequate communication ensure a positive outcome.

Skills Needed

  • Communication. Shared mental model. Situation awareness. Situation monitoring: assess environment. Mutual support.

Potential Tools

  • Handoff, Cross-monitoring, Prioritization, Advocacy/assertion, Collaboration, Task assistance, Delegation.

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Scenario 94

 
Appropriate for: L&D
Setting: Hospital

 

Annie Compton is admitted at term for an induction of labor. The attending physician asks the patient's nurse to assist him with the placement of Prostin gel (3 mg). The nurse replies, "I am not available at this time, the deck is too busy." The physician then asks a uniformed LPN assigned to the Triage area to obtain a Prostin suppository for induction. The physician then places the Prostin suppository vaginally, not aware that it is a 20 mg dose. Within 10 minutes, there is a prolonged deceleration of the fetal heart rate that does not respond to resuscitative measures. The patient requires an emergency C-section.

Instructor Comments

  • An unmanaged workload situation within the team resulted in the OB's requesting assistance from someone outside the team without communicating essential information or using a check-back. Effective use delegation is essential to manage workload, but you must determine that the individual to whom work is being delegated has all the essential information and the skills to complete the task without risk.

Skills Needed

  • Communication.

Potential Tools

  • Check-back.

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Scenario 95

 
Appropriate for: All Specialties
Setting: Hospital

 

The nurse thinks the patient needed an intrauterine catheter, but the attending physician is not present. The nurse asks the resident to insert the catheter.

The resident thinks that the attending has been notified and inserts the catheter. When the attending finds out, he is angry at the nurse and yells at her in front of other staff.

D: I (nurse) am sensing that you (attending) are upset with me for asking the resident to place an intrauterine pressure catheter in your patient.

E: When you question my nursing judgment in the middle of the nursing station, it makes me very uncomfortable and embarrassed.

S: If you are concerned or have a question regarding my nursing care, I would appreciate it if you would speak to me in private.

C: A private conversation would be much more beneficial and educational to me because I would feel less embarrassed and would be able to ask questions and supply information.

Instructor Comments

  • This example shows a good approach to Conflict resolution and use of the DESC script.

Skills Needed

  • Communication.

Potential Tools

  • DESC script, Conflict resolution.

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Scenario 96

 
Appropriate for: All Specialties
Setting: Hospital

 

Carol McCarthy, a 32-year-old Gravida 4 Para 2 patient is admitted to labor and delivery with vaginal bleeding at 32 weeks. She is diagnosed with a placenta previa. The attending physician holds a team meeting with the charge nurse, anesthesiologist, and chief resident outside the patient's room. The decision is made to deliver Carol by C-section in the Main Operating Room (OR) rather than in the Labor and Delivery Operating Room, and blood is ordered from the blood bank. The primary nurse caring for Carol is not included in the team meeting because she is with Carol. The primary nurse is not apprised of the new plan and feels completely out of the loop. After Carol is delivered and in the Recovery Room, the nurse asks the attending physician if she can speak with her and says, "When the plan was made to deliver your patient by C-section in the main OR, I was not informed until we were going to the OR. I had no idea that blood had been ordered already. I felt out of the loop, and it was difficult for me to take good care of your patient without being informed of the plan."

Instructor Comments

  • In this case, a shared mental model is not formed, and lack of communication results in a conflict. The conflict is resolved by using feedback that was timely (directly following the delivery when the patient was stable), behavioral (the plan of care needs to be communicated to the nurse caring for the patient), specific (it was important for patient care for the nurse to know that the patient would be delivered by C-section in the main OR and that blood had been ordered), directed toward improvement (suggestions for future conduct provided), and nonjudgmental (said respectfully in a manner focused on patient care/safety not personality).

Skills Needed

  • Communication.

Potential Tools

  • Conflict resolution.

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Scenario 97

 
Appropriate for: L&D
Setting: Hospital

 

Amy Bliss, a 31-year-old s/p primary C-section for triplets at 32 weeks gestation returns to L&D 18 hours after delivery with a heart rate (HR) in the 120s, a blood pressure (BP) of 110/70, and an oxygen saturation (O2 sat) of 97 percent. Amy is pale and diaphoretic. Her hematocrit has fallen from 37 to 30. After evaluating Amy, her primary nurse (registered nurse [RN]) discusses the plan of care with the third-year resident. The plan includes a 12-lead electrocardiogram (EKG), repeat lab work, a vaginal exam, and an abdominal ultrasound. The RN is unable to obtain the blood work and asks for assistance from an anesthesiologist. Within minutes, the resident and anesthesiologist are called to the Operating Room (OR) for an emergency C-section and are therefore unavailable to help with the venipuncture and placement of a second intravenous line. The RN discovers that the EKG machine is broken and calls the EKG Lab to come to L&D to perform a "formal" EKG. After the EKG is completed, the RN approaches a second resident to follow up with the planned vaginal exam and abdominal ultrasound. The second resident states that she will call the attending obstetrician for input to the plan, but she gets called to a delivery. The RN wonders why she has not received any feedback. A short time later, Amy's status deteriorates. Her BP is 86/52, HR is 132, and her O2 sat is 95 percent. The patient is complaining of shortness of breath with a RR of 32. The RN stat pages the obstetrician attending and the anesthesiologist. The patient's BP is now 70/40, and she is rushed to the OR with the anesthesiologist providing volume resuscitation. An exploratory laparotomy reveals massive intra-abdominal hemorrhage requiring a hysterectomy and blood product transfusions to stabilize Amy.

Instructor Comments

  • This teamwork failure depicts the absence of a clearly defined leader and lack of handoff or check-backs. Although the nurse attempts to engage several physicians during the course of the patient's unfolding event, no one assumes leadership for the case and the patient is placed at unnecessary risk.

Skills Needed

  • Team structure. Communication. Situation monitoring. Situation awareness. Shared mental model. Mutual support. Leadership

Potential Tools

  • Huddle, Call-out, Check-back, Handoff, Cross-monitoring, Prioritization, Advocacy/assertion, Collaboration.

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Scenario 98

 
Appropriate for: L&D
Setting: Hospital

 

Juanita Juarez 23-year-old G1 P0 at 42 weeks gestation presents to Triage in questionable labor. Juanita and her family speak limited English. The busy Triage nurse does a quick assessment and determines that the patient can wait for an empty stretcher. Forty-five minutes later, Juanita is escorted to a stretcher in Triage and given a hospital gown. The Triage nurse places the patient on an electronic fetal monitor and is then urgently called away by a patient having an asthma attack. The Triage nurse returns to Juanita 30 minutes later and is concerned that there is a nonreassuring fetal heart rate (FHR) tracing. She decides that Juanita should be further evaluated in the L&D suite. The Triage nurse seeks out the registered nurse (RN) team leader in L&D, who is occupied with an active labor patient. The Triage nurse says, “I have a nullip at 42 weeks in questionable labor with some pattern issues who needs to come down to L&D.” The RN team leader makes a quick decision to have Nurse A care for this patient. The RN team leader informs Nurse A that Juanita needs “monitoring.” Nurse A had a delivery about an hour previously and is about to transfer that patient and baby to the postpartum unit. Nurse A asks Nurse B if she could “settle” the new patient for her and she will be right back. Nurse B, with two other patients, places the patient back on the fetal monitor. She is concerned with her assessment of the FHR pattern and decides to place an IV. She is unsuccessful in her first two attempts, but then Nurse A returns and places an IV. Nurse A is also concerned with the FHR pattern and notifies a resident who is in the Operating Room completing a C-section. After completion of the C-section, the resident evaluates Juanita and decides to perform an ultrasound. The ultrasound is performed more than 3 hours after the patient’s arrival at the Triage desk. Based on the ultrasound and the FHR pattern, an emergency C-section is performed for a live born male with low Apgar scores.

Instructor Comments

  • Several work overload situations within the team created a dangerous delay in this patient's treatment. Effective teams use huddles, handoffs, check-backs, and cross-monitoring to manage workload situations that compromise patient safety.

Skills Needed

  • Several work overload situations within the team created a dangerous delay in this patient's treatment. Effective teams use huddles, handoffs, check-backs, and cross-monitoring to manage workload situations that compromise patient safety.

Potential Tools

  • Huddle, Call-out, Check-back, Handoff, Cross-monitoring, Prioritization, Delegation, Task assistance, Advocacy/assertion, Collaboration.

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Scenario 99

 
Appropriate for: All Specialties
Setting: Hospital

 

The L&D Triage nurse approaches a second-year resident to work up a clinic patient. The patient presented to the Triage unit 30 minutes earlier with vague complaints of abdominal pain at 34 weeks gestation. The Triage nurse has established that the patient is not contracting, does not have ruptured membranes, has no urinary symptoms, and does not have a fever. A brief workup, some reassurance, and development of a followup plan are all that is needed for this patient. The resident asks whether she can have “15 minutes to eat lunch.” Agreeing to this, the Triage nurse tells the patient she will be seen soon by the doctor. Forty-five minutes later, the resident has not shown up, but the nurse does nothing. Sixty minutes later, the resident begins the workup on the patient. At exactly that moment, the Triage nurse receives a call that a high-risk patient in acute distress is being brought up from the Emergency Department. This high-risk patient ties up three nurses, two residents, and a covering attending obstetrician for the next hour. More than 3 hours after her arrival in the Triage unit, an unhappy, disgruntled patient is seen and discharged home.

Instructor Comments

  • In this scenario, the 3-hour delay of the patient in Triage could have been avoided if staff had used their slow period to stay ahead of the workload, or if the nurse had shown stronger advocacy/assertion to get the patient seen by the resident.

Skills Needed

  • Situation awareness. Mutual support. Communication.

Potential Tools

  • Conflict resolution, Advocacy/assertion, Cross-monitoring.

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Scenario 100

 
Appropriate for: L&D
Setting: Hospital

 

The Triage registered nurse (RN) is on busy evening shift with four patients—a pregnant asthmatic that the Emergency Department said “was stable,” a patient awaiting pre-eclampsia evaluation lab results, a patient with abdominal pain awaiting medical workup, and a patient with ruled out ruptured membranes ready to go home. The Triage nurse is paged to the registration desk for a non-English-speaking patient who at 42 weeks gestation is in labor. The nurse determines that the patient can wait for an available stretcher in the Triage unit. Forty-five minutes later, the nurse places the patient on fetal monitor and is urgently called away, without a handoff, by the asthmatic patient. The nurse returns 30 minutes later to identify a nonreassuring fetal heart rate pattern.

Instructor Comments

  • The use of several resource management strategies such as handoff, prioritization, delegation, and workload redistribution could have effectively avoided placing this patient at risk.

Skills Needed

  • Communication. Mutual support.

Potential Tools

  • Handoff, Delegation, Collaboration, Task assistance.

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Scenario 101

 
Appropriate for: L&D
Setting: Hospital

 

Christine Joseph, a 37-year-old G4 P3 at 39 weeks gestation enters L&D in labor. Christine is dilated 6 cm with intact membranes. Christine receives regional anesthesia and states, "My water just broke." The fetal heart rate baseline, which had been 140, begins to fall. A prolonged deceleration occurs, and the registered nurse (RN) calls in a resident. The resident examines Christine and feels a pulsating umbilical cord. The presenting part is elevated, the patient is placed in knee-chest position, and a "stat" C-section is called. Christine's primary nurse remains with the patient, and the RN team leader becomes the situational leader assigning and confirming tasks (scrubbing, setting up sterile field, assisting with transporting the patient to the Operating Room, prepping patient, placing Foley catheter, etc.) to all available personnel (nurses and scrub technicians). Within minutes, the C-section is begun, and extra personnel are no longer needed. When formally released, the nurses then return to the care of their own patients.

Instructor Comments

  • This scenario depicts workload management through a reallocation of resources and the proper delegation of tasks to members of the newly formed contingency team. It includes the use of handoffs, check-backs, situation awareness, and cross-monitoring to develop a shared mental model.

Skills Needed

  • Communication. Situation monitoring: assess status of patients, team, and environment. Situation awareness. Shared mental model. Mutual support.

Potential Tools

  • Call-out, Check-back, Handoff, Prioritization, Delegation, Task assistance, Advocacy/assertion, Collaboration.

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Scenario 102

 
Appropriate for: L&D
Setting: Hospital

 

S: Dr. Smith, I am concerned about Mrs. L’s fetal heart rate tracing.
B: She is a primip who is being induced for post dates.
A: I think she is having late decelerations. I have stopped the Pitocin, and she is on her left side with oxygen on.
R: I would like you to come evaluate her tracing. When can I expect you?

Instructor Comments

  • This scenario is a classic example of using SBAR (Situation, Background, Assessment, and Recommendation).

Skills Needed

  • Team structure. Communication.

Potential Tools

  • SBAR

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Scenario 103

 
Appropriate for: L&D
Setting: Hospital

 

Lauren Jobst, a 30-year-old nullip is experiencing protracted labor with clearly inadequate contractions, and her temperature is beginning to rise. The obstetrician (OB) decides to augment her labor and orders Oxytocin. Whenever the nurse tries to increase the Oxytocin, the baby exhibits heart rate abnormalities, so the contractions remain inadequate. The OB becomes frustrated with the slow progress and states that he just wants the nurse to "push the pit." If Lauren gets into better labor, that is great. Alternatively, if the baby "declares" itself, then they will need to do a C-section. The nurse understands and repeats the order but also suggests that an intrauterine pressure catheter, fetal scalp electrode, and an epidural might make this situation safer. He agrees to her suggestions, and they then carry out the plan.

Instructor Comments

  • The nurse confirms the initial plan using check-back but also advocates by sharing her assessment of the situation with the OB. As a result of this discussion, they have a shared mental model for the care for this patient.

Skills Needed

  • Communication. Situation monitoring: assess status of patient. Mutual support.

Potential Tools

  • Check-back, Advocacy/assertion, Collaboration

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Scenario 104

 
Appropriate for: L&D
Setting: Hospital

 

A diabetic multiparous patient is about to deliver a baby thought to weigh more than 9 pounds. The registered nurse (RN) team leader overhears the obstetrician attending discussing with the resident the possibility of shoulder dystocia. As the physicians walk toward the labor room for the delivery, the team leader asks, "Would you like an anesthesiologist and a second RN in the room for the delivery in case you have trouble with shoulder dystocia? Should we have the OR on standby?"

Instructor Comments

  • In this situation, the RN team leader becomes aware of a potential risk for the patient through the process of cross-monitoring. She advocates for the patient by her intervention and by offering resources to help manage the situation. Cross-monitoring goes beyond situation awareness in that the monitoring individual takes action to interrupt or avoid an impending error.

Skills Needed

  • Situation awareness. Mutual support. Shared mental model.

Potential Tools

  • Cross-monitoring, Advocacy/assertion, Collaboration.

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Scenario 105

 
Appropriate for: L&D
Setting: Hospital

 

The nurse team leader arrives in the operating room 2 minutes after the uterine incision is made on a patient undergoing a C-section. She notes that the clinicians are having a difficult time delivering the infant's head. Two more minutes elapse, and the clinicians are still struggling. The nurse asks whether they would like her to call in another attending obstetrician to assist. She asks whether they might apply forceps to facilitate the delivery and calls the pediatric team to be on standby for the baby.

Instructor Comments

  • In this scenario, the nurse team leader is cross-monitoring the actions of the team as they struggle to deliver the infant's head. She is aware of the time lapse and intervenes by asking a question that initiates a new course of action.

Skills Needed

  • Situation awareness. Mutual support.

Potential Tools

  • Cross-monitoring, Advocacy/assertion, Collaboration.

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Scenario 106

 
Appropriate for: All Specialties
Setting: Hospital

 

During an initial evaluation of a patient in active labor, the nurse determines that there is a noncephalic presentation. The only obstetrical physician in house is engaged in a C-section. The nurse proceeds to notify an anesthesia and pediatric provider, as well as the Operating Room team of the pending C-section. Once the physician verifies the diagnosis, the team is prepared to quickly proceed to surgical intervention.

Instructor Comments

  • In the absence of the only obstetrician, the nurse emerges as a situational leader, organizes a team to manage the patient's impending C-section, thus creating a shared mental model.

Skills Needed

  • Situation awareness. Mutual support. Shared mental model. Leadership.

Potential Tools

  • Cross-monitoring, Advocacy/assertion, Collaboration.

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Scenario 107

 
Appropriate for: L&D
Setting: Hospital

 

A patient with an arrest of dilation is brought to the Operating Room in preparation for a C-section under a regional block. Before any anesthetic can be administered, the obstetrical physician and nurse are called to an emergency delivery, leaving the anesthesia provider alone with the patient. While the anesthesia provider is alone with the patient, the fetal heart rate (FHR) exhibits a prolonged deceleration. The anesthesiologist repositions the patient, increases the intravenous rate, and administers oxygen. As a last intervention, he places the patient into a knee-chest position. The FHR recovers.

Instructor Comments

  • In the absence of the designated team leader, the anesthesia provider recognizes a dangerous change in the clinical status and assumes a situational leader role in managing the patient's deteriorating condition. Any member of the team with the skills to manage the situation at hand can become a situational leader.

Skills Needed

  • Situation monitoring: assess status of patient. Team structure. Leadership.

Potential Tools

  • Prioritization, Advocacy/Assistance.

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Scenario 108

 
Appropriate for:

L&D

Setting: Hospital

 

Dr. Allen, a tired anesthesiologist, is asked to place an epidural at 0300. Midway through the procedure, Mary, the nurse, notices that the anesthesiologist is drawing up lidocaine into the epidural syringe instead of saline. She states, "Dr. Allen, would you like me to hand you the saline?" The anesthesiologist looks at his hands, notices the error, and corrects it.

Instructor Comments

  • In this scenario, the nurse, using cross-monitoring, notices that the anesthesiologist is exhausted and mistakenly selects the wrong medication. The nurse is able to provide the appropriate support to the anesthesiologist by alerting him to the error.

Skills Needed

  • Situation awareness. Mutual support. Shared mental model.

Potential Tools

  • Cross-monitoring, Advocacy/assertion, Collaboration, Two-Challenge rule.

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Scenario 109

 
Appropriate for: L&D
Setting: Hospital

 

A nurse notices that a colleague is assigned to care for the next C-section patient, but that the colleague also must care for another patient who recently delivered. The nurse asks her colleague if she can assist in placing the IV for the C-section to help get things moving.

Instructor Comments

  • In this scenario, the nurse is able to provide useful support to her colleague by paying attention to the global situation of the unit.

Skills Needed

  • Situation awareness. Mutual support. Shared mental model.

Potential Tools

  • Cross-monitoring, Advocacy/assertion, Collaboration.

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Scenario 110

 
Appropriate for: All Specialties
Setting: Hospital

 

A coordinating team meeting is held at 0900, with the charge nurse, chief resident, attending physician, and attending anesthesiologist present. They discuss the situation: L&D is full; three of the patients are delivered but cannot go to the postpartum floor because that is also full and no discharges have left yet. Rooms need to be made available for the laboring patients who are expected. The coordinating team decides to convert the Triage unit into a temporary postpartum unit with one nurse to care for the three delivered patients. This will free three labor rooms. All patients being admitted to L&D will be sent directly to L&D instead of to the Triage unit until the postpartum patients can be transferred.

Instructor Comments

  • In this scenario, the coordinating team assesses the reality of the situation on the unit and is able to reorganize the flow of patients to deal with the room shortage.

Skills Needed

  • Team structure. Communication. Situation awareness. Shared mental model. Mutual support.

Potential Tools

  • Huddle, Conflict resolution, Handoffs, Prioritization, Delegation, Task assistance, Collaboration.

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Scenario 111

 
Appropriate for: L&D
Setting: Hospital

 

Sandy Bliss, a 30-year-old nulliparous woman is in active, spontaneous labor. She plans childbirth without an epidural. The baby begins to experience frequent, deep, variable decelerations, raising concerns that an emergency C-section may be needed. The anesthesia provider evaluates Sandy and determines that the airway is unfavorable, and a difficult intubation is likely if general anesthesia is required. The team discusses the situation, and the obstetrician then speaks with Sandy and they agree that an epidural will be used.

Instructor Comments

  • In this scenario, the team assesses the patient's condition and possible alternatives. Having agreed in their assessment of the situation, they are able to inform the patient of their concerns. The anesthesia provider discussed the problems with the OB and charge nurse to develop a shared mental model for the plan to properly ensure a safe delivery for the patient.

Skills Needed

  • Team structure. Situation monitoring: assess status of patient. Shared mental model. Communication.

Potential Tools

  • Huddle, Advocacy/assertion.

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Scenario 112

 
Appropriate for: L&D
Setting: Hospital

 

A C-section is being performed at 0300. The placenta does not detach, the uterus fails to contract, and massive hemorrhage ensues. Many staff are needed to resuscitate the patient, leaving the rest of the unit understaffed. The team gets together, and the decision is made to adjust the Oxytocin infusions on all the remaining patients on the unit.

Instructor Comments

  • In this scenario, the coordinating team has assessed the situation and is able to make changes in the care plans for other patients on the unit to ensure adequate use of human resources.

Skills Needed

  • Team structure. Situation awareness. Shared mental model. Mutual support.

Potential Tools

  • Huddle, Prioritization, Collaboration.

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Scenario 113

 
Appropriate for: L&D
Setting: Hospital

 

During the intake of evaluation of a multip patient in spontaneous labor, the obstetric nurse asks the patient about her last labor at another hospital. The patient states that it was strange because "people were running all over, they pulled my legs way back, and someone started pushing down on my belly really hard." The nurse asks whether anyone had said she had "shoulder dystocia." The patient says "yes." The nurse relays this information to the team and confirms that they have received and understand the message so they can be prepared for possible recurrent shoulder dystocia.

Instructor Comments

  • In this scenario, the nurse learns vital information about the patient's past pregnancy that may impact the progression of this current delivery. The nurse appropriately relays and confirms receipt and understanding of this information by other team members.

Skills Needed

  • Communication. Shared mental model. Situation awareness. Situation monitoring: assess status of patient. Mutual support.

Potential Tools

  • Handoff, Cross-monitoring, Advocacy/assertion, Collaboration.

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Scenario 114

 
Appropriate for: L&D
Setting: Hospital

 

Jane Meyers, a 36-year-old G3 P2 patient at 35 weeks gestation enters the L&D Triage unit from her obstetrician's office for evaluation of elevated blood pressure. In the physician's office, her blood pressure (BP) was 140/96; on admission it is 130/88. Jane denies any symptoms and has no clinical evidence of pre-eclampsia. The Triage nurse reviews Jane's prenatal record and notes that the patient's BP at her first prenatal visit was 120/84 with several subsequent diastolic readings in the 80s. The Triage registered nurse calls the attending obstetrician (OB) and relays her observations. She states, "Could this be chronic hypertension not pre-eclampsia?" The OB replies, "It could be. Let's complete the workup and consider treating her with an antihypertensive."

Instructor Comments

  • In this scenario, the Triage nurse offers information to the OB that alters his mental model of the patient's presenting problem. A shared mental model between members of the team is reached through open and direct dialogue.

Skills Needed

  • Shared mental model. Mutual support.

Potential Tools

  • Advocacy/assertion, Collaboration.

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Scenario 115

 
Appropriate for: L&D
Setting: Hospital

 

During a delivery, the obstetrician (OB) experiences difficulty delivering the infant's shoulders. He asks the registered nurse (RN) to provide fundal pressure. The RN states, "Don't you mean suprapubic pressure?" The OB replies, "I said fundal pressure!" The RN says, "Once again, don't you mean suprapubic pressure? Fundal pressure could trap the shoulders even more." The OB replies, "Oh, you are right. I meant to say, suprapubic pressure."

Instructor Comments

  • In this scenario, the nurse, detecting what she believes is a simple error, questions the physician's operational order. When her challenge is rejected, she vocalizes her concern a second time to ensure that it has been heard. The OB, realizing his error, takes corrective action. It is the responsibility of every team member to challenge any course of action that they believe may place the patient at risk.

Skills Needed

  • Situation awareness. Shared mental model. Mutual support.

Potential Tools

  • Two-Challenge rule, Collaboration.

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Scenario 116

 
Appropriate for: L&D
Setting: Hospital

 

Dora Johnson, a G1 P0 patient in second stage is 41, 4 to 7 weeks gestation, in spontaneous labor. A reactive non-stress test is administered on admission, and a reassuring fetal heart rate (FHR) pattern occurs throughout the first stage of labor. Dora has a prolonged second stage with a resulting FHR tachycardia with decelerations. The attending obstetrician (OB) and the nurse are both present during the last 2 hours of the second stage. Both are coaching Dora and viewing the FHR pattern. The resource nurse on the unit is concerned about the FHR pattern and expresses concern to the OB attending and the nurse at the patient's door. Both providers in the room state that everything is OK and that delivery is imminent. After a 3-hour second stage, a severely compromised infant is delivered from a posterior occipital position. The infant subsequently dies.

Instructor Comments

  • In this scenario, the team has developed diminished situation awareness. Through situation monitoring, the resource nurse becomes aware of the FHR and expresses her concern. The error occurs when the team dismisses this information and is allowed to continue on their current course of action, which leads to a disastrous outcome.

Skills Needed

  • Situation awareness. Situation monitoring: assess status of patient, status of team, and progress toward a goal. Communication. Mutual support. Team structure.

Potential Tools

  • Cross-monitoring, Conflict resolution, Two-Challenge rule, Advocacy/assertion

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Current as of March 2014
Internet Citation: TeamSTEPPS® Instructor Manual: Specialty Scenarios: L&D. March 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/labordel.html