Drill Kit Icon

Drill Kit

Cord Prolapse

Coordinator Information

Drill Description

Introduction

Step Up Together Drill Kits support interdisciplinary clinical teams to run emergency drills involving patient hand-offs and/or transport to a higher level facility.

Each Drill Kit can be used to run a Full Transfer Drill that tests the full, interdisciplinary process of care or a Partial Transfer Drill that involves running just one segment of the scenario (e.g. before transfer or after hospital hand-off). The toolkit includes a standardized high-fidelity case designed to test the process of transferring a birthing person or newborn from one location to another with an interdisciplinary team involved in the care. Observation criteria and a Debriefing and Action Guide are provided to elicit continuous improvement of interdisciplinary care processes and promote respectful care along the continuum.

Drill Description

This Drill Kit tests the emergency response to a cord prolapse occurring in a community birth setting including emergency transport of a laboring patient receiving midwifery care to manage the emergency during transport. 

It is appropriate for:

  • Home birth practices
  • Birth centers
  • Other facilities or units requiring patient transport for emergency surgery (e.g. emergency department)

And may further engage:

  • EMS or other emergency transport partners
  • Labor & Birth unit and other relevant units at the referral hospital

To test the process of:

  • Intrapartum Emergency Transfer

Learning Objectives:

  • Identify and respond to a cord prolapse in the community setting.
  • Perform maneuvers to reduce risk of complications related to cord prolapse during transport.
  • Review ways to promote person-focused care during emergencies.
  • Practice collaboration that adheres to relevant transfer protocols with warm hand-offs across levels of care.
  • Communicate effectively, equitably, and with dignity, with the patient, support people, and additional healthcare personnel in the event of an antepartum transfer.

Last updated: December 2024

Authored by:

Jennifer Johnson, MS, CNM

Reviewed by:

Margaret Buxton, DNP, CNM
Alexa Dougherty, MSN, PHN, CNM
Amy Romano, MBA, MSN, CNM, FACNM

You will be coodinating a...

Partial Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer, but participants are only practicing part of the scenario: either the part that happens in the community before hospitalization, or the arrival at the hospital and post-transfer management.

Who's involved?

Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.

Planning Needs

Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.

Full Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer and participants practice all phases of the transfer: care in the community, emergency transport, and arrival and management at the hospital.

Who's involved?

Full practice/facility team from the community birth setting, plus transport and hospital personnel.

Planning Needs

Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.

Setup and Procedure

Cord Prolapse

Partial Transfer Drill Instructions

Participants (Minimum of two, up to full practice/facility team):

  • *Drill Scenario Roles:
    • If conducting the drill in the community setting: 
      • assign a lead provider and a birth assistant.
      • Additional learners may be assigned to play the role of a 911 dispatcher, EMS Lead, and/or a hospital provider receiving the report. 
    • If conducting the drill at the transfer hospital, assign an attending provider and a nurse. Additional learners may be assigned to play the role of the transferring provider and/or the EMS lead.
  • Non-clinical roles: Assign learners to play the roles of 
    • the patient and partner
    • doula
    • siblings/other family
  • *Drill Coordinator presents the case scenario, tracks hand-off times,  and leads the debrief; may double as the birth assistant/nurse if this is a 2-person drill.
  • Observer(s): Unassigned learners are observers, who use Observer Worksheets to track actions and processes during the drill. 

* Required roles

Setting and supplies: 

  • Birth suite set up for birth
  • Intermittent auscultation supplies
  • Supplies to document clinical care of simulated patient (e.g. maternal and neonatal blank transfer forms, blank paper charting templates or fake/simulated patient in the electronic record system)
  • Stopwatch or timer

Instructions: 

  • If conducting a Partial Transfer Drill in the community setting, use Clinical Scenario: Drill Begins in the Community Setting, and conclude the drill with simulated handoff to EMS. If conducting a Partial TransferDrill in the hospital, use Clinical Scenario: Drill Begins at Hospital Handoff, and conclude as directed in the scenario.
  • Drill Coordinator reads Clinical Scenario.
  • When team is ready, start timer and state aloud, “begin drill.”
  • Read additional prompts on the Coordinator Prompts at the appropriate times.
  • Learners in drill scenario roles may ask for clinical values by acting out the assessment (e.g. taking a blood pressure or prepping IV supplies and simulating starting an IV). Fetal heart tones are noted as 6-second counts.
    • For visual or subjective assessments, they can ask. If assessments are abnormal or specified, they will be provided in the case. Otherwise, Drill Coordinator may provide any normal value in response.
  • Observers should use the Observer Worksheets to assess performance of clinical tasks as the drill progresses.
  • People assigned to clinical roles and the Drill Coordinator should review and complete the Observer Worksheets immediately after the drill, before Debriefing and Action Planning.

Setup and Procedure

Cord Prolapse

Full Transfer Drill Instructions

Participants (Full team plus transport and/or hospital personnel): 

Assign the following roles:

  • *Drill Scenario Roles: 
    • In the initial community setting: Assign a lead provider and a birth assistant.
    • During patient transport: Assign an EMS lead 
    • In the referral hospital: Assign an attending provider, nurse, and other roles as able.
  • Non-clinical roles: Assign learners to play the roles of the patient and partner/support person
  • *Drill Coordinator(s): Presents the case scenario, tracks hand-off times, and leads the debrief. Consider assigning a coordinator for each segment of the transfer.
  • Observer(s): Unassigned learners are observers, who use Observer Worksheets to track actions and processes during the drill. 

*Required roles

Setting and supplies: 

  • Birth suite set up for birth
  • Intermittent auscultation supplies
  • Supplies to document clinical care of simulated patient (e.g. maternal and neonatal blank transfer forms, blank paper charting templates or fake/simulated patient in the electronic record system)
  • Stopwatch or timer

Instructions: 

  • Use Clinical Scenario: Drill Begins in the Community Setting
  • Drill Coordinator reads Drill Scenario.
  • When team is ready, start timer and state aloud, “begin drill.”
  • Read additional prompts at the appropriate times.
  • Learners in drill scenario roles may ask for clinical values by acting out the assessment (e.g. taking a blood pressure or prepping IV supplies and simulating starting an IV). Fetal heart tones are noted as 6-second counts.
    •  For visual or subjective assessments, they can ask. If assessments are abnormal or specified, they will be provided in the case. Otherwise, Drill Coordinator may provide any normal value in response.
  • Restart the timer and log the time elapsed after each portion of the Full Transfer Drill: Before Transport, During Transport, and At Hospital.
  • Observers should use the Observer Worksheets to assess performance of clinical tasks as the drill progresses.
  • People assigned to primary and secondary roles and the Drill Coordinator should review and complete the Observer Worksheets immediately after the drill, before Debriefing and Action Planning.

Download & Print

Observer Worksheets

Clinical Scenario

Clinical Scenario

Drill begins in community setting

Read the following case aloud. Prior to beginning, participants may ask clarifying questions, but should not discuss their plan of care or move any supplies or equipment.

Gabriella is a 33 year old G3 P2002 at 38 weeks and 3 days who is in active labor. As of 1 hour ago, her cervical exam was 7/80/-2 with a bulging bag of water.  She is accompanied by her partner Alonso and her mother Gloria.  Her prenatal course has been uncomplicated, with a normal anatomy scan, and normal third trimester labs. Her blood type is O negative, and she received Rhogam at 28 weeks. She is GBS negative. Both of her previous pregnancies and births were uncomplicated, where she had smooth labors at another birth center before they moved to this area. They love the midwifery model of care, and are excited to meet their third daughter “Alma.” The estimated fetal weight is 6.5lbs by Leopolds, and Gabriella feels this baby is “smaller than my other two girls.” 

Gabriella has been coping well with labor, using the birth ball in the shower. Her contractions are every 2-3 minutes, lasting about a minute. She appears focused during contractions, and between contractions she is conversational with her support team. The fetal heart tones both on admission and again 30 minutes ago were normal, with a baseline of 130bpm via handheld Doppler.

Clinical Scenario

Drill begins at hospital handoff

Read the following case aloud. Prior to beginning, participants may ask clarifying questions, but should not discuss their plan of care or move any supplies or equipment.

Print copies of the completed transfer form from the community provider.

You receive the following report by phone from the on-call midwife of the nearby community practice. They introduce themself and state: 

“I am calling to initiate an emergent transfer for a cord prolapse in active labor. Gabriella is a 33yo G3P2002 at 38 weeks and 3 days with an uncomplicated pregnancy. She has been in active labor for one hour,  and has had a normal fetal heart rate of 130bpm. Rupture of membranes for clear fluid was noted 3 minutes ago. The fetal heart rate was noted to be 80bpm immediately following SROM and cervical exam was 8/100/-1 with a palpable cord prolapse into the vagina. The cord is pulsing at a rate consistent with the fetal heart rate of 70-80s, and we are providing manual displacement of the fetal head to reduce cord compression. We will be arriving by EMS and I will be accompanying the patient while trying to continue to reduce cord compression.”

Coordinator Prompts

Community Setting

Coordinator Prompts

Time Scenario (Read Aloud) Values (Share only if assessed)
00:00

Gabriella is sitting on the birth ball in the shower, eating a popsicle. A contraction starts, so Gloria holds the popsicle and Alonso gives hip squeezes. When it ends, she takes the popsicle back from her mom.

FHTs: 13, 12, 12, 13, 13, 12
UC: q 2-3 m
Vaginal exam: 7/80/-2 on admission
Maternal Vitals: BP 120/72, Pulse 98, Temp 98.8
02:00

Another contraction begins, and Gabriella breathes through it with support from Gloria and Alonso.

FHTs: 13, 12, 12, 13, 13, 12
UC: q 2-3 m
Vaginal exam: 7/80/-2 on admission
Maternal Vitals: BP 120/72, Pulse 98, Temp 98.8
05:00

Another contraction begins, and Gabriella grunts, saying “there is so much pressure but I don’t think it’s time to push yet!”

FHTs: 13, 12, 12, 13, 13, 12
UC: q 2-3 m
Vaginal exam: 7/80/-2 on admission
Maternal Vitals: BP 120/72, Pulse 98, Temp 98.8
07:00

Another contraction begins, and Gabriella breathes and grunts again. As the contraction ends she  says “I think my water just broke.”

FHTs: Unable to auscultate FHT
Unable to determine amniotic fluid leakage in current position
09:00

Gabriella stands from the ball, and a large gush of water is now clearly seen streaming down her legs.

FHTs: 8, 8, 7, 6, 7, 8
UC: q 2-3 m
Maternal Vitals:  BP 120/72, Pulse 98, Temp 98.8
Amniotic fluid: clear
Vaginal Exam: 8/100/-1, cord is palpable within the vaginal canal
10:00

Another contraction begins, Gabriella breathes and grunts through it.

FHTs: 8, 8, 7, 6, 7, 8
UC: q 2-3 m
Maternal Vitals:  BP 120/72, Pulse 98, Temp 98.8
Amniotic fluid: clear
Vaginal Exam: 8/100/-1, cord is palpable within the vaginal canal

Repeat prior prompt every 1-2 minutes until transfer process is initiated.

During Transfer

Coordinator Prompts

Time Scenario (Read Aloud) Values (Share only if assessed)
00:00

Restart timer.

Gabriella breathes steadily with contraction, reporting some increasing pressure.

FHTs: 10, 10, 9, 8, 9, 10
UC: q 2-3 m
Vaginal exam: 8/100/0, cord is palpable within the vaginal canal
Amniotic fluid: clear
Maternal Vitals: BP 132/78, Pulse 115, Temp 98.6
02:00

Another contraction with pressure, Gabriella asks what will happen when they get to the hospital

FHTs: 10, 10, 9, 8, 9, 10
UC: q 2-3 m
Vaginal exam: 8/100/0, cord is palpable within the vaginal canal
Amniotic fluid:  clear
Maternal Vitals: BP 132/78, Pulse 115, Temp 98.6

Scenario remains stable throughout transport

Receiving Hospital

Coordinator Prompts

Time Scenario (Read Aloud) Values (Share only if assessed)
00:00

Restart timer.

Gabriella breathing and grunting with a contraction, reports feeling more pressure.

FHTs: 10, 9, 10, 9, 8, 9
UC q 2-3 m
Vaginal exam: 9/100/0, cord is palpable within the vaginal canal
Amniotic fluid:  clear
Maternal Vitals: BP 128/70, Pulse 108, Temp 98.6
02:00

Next contraction begins, Gabriella continues to feel pressure.

FHTs (if using continuous monitor): baseline 105 with late decel to 80
FHTs (if using Doppler): 10, 9, 8, 8, 8, 9
UC: q 2 m
Vaginal exam: 9.5/100/+1 with palpable cord
Maternal Vitals: BP 136/78, Pulse 112, Temp 98.6
04:00

Gabriella grunting and bearing down spontaneously, asking “Can I just try to push?”

FHTs (if using continuous monitor): baseline 105 with late decel to 80
FHTs (if using Doppler): 10, 9, 8, 8, 8, 9
UC: q 2 m
Vaginal exam: 9.5/100/+1 with palpable cord
Maternal Vitals: BP 136/78, Pulse 112, Temp 98.6

Repeat prior prompt every 1-2 minutes until delivery decision is initiated.
If proceeding with cesarean delivery, the community midwife rides the gurney to the OR to continue manual replacement of the fetal head until neonate is delivered.

Debriefing and Action Guide

Reflection Questions

  • What happened here? Ask 1-2 people to give a brief high-level summary so everyone’s on the same page.
  • What went well? Give everyone a chance to share the good stuff they noticed before critiquing.
  • What needs attention or improvement? Try to focus on processes and systems, not assigning blame.
  • Are there other appropriate ways to manage this emergency or transport? Consider different approaches such as who might accompany the patient, dyad vs. separate transfers, etc.
  • Were we prepared for this emergency? The answer will help clarify the Action Steps.
  • How would this be different if the community provider is unable to ride in the EMS with the patient?
  • How would this be different if  this patient were nulliparous, rather than a multiparous?

 

Action Steps

  • What changes are needed to processes or procedures? Make sure to assign someone to follow-up on the change.
  • How should this emergency be documented in the medical record? Discuss any documentation standards and tools such as order sets or dot-phrases available to clinicians.
  • What other reporting is required for this emergency transfer? This could include accreditation or licensing bodies, malpractice carriers, and internal organizational reporting.
  • What other follow up would be expected after this emergency? Consider follow-up for patient/family or staff, or other next steps.

Documentation

Document the date, location, clinical scenario(s), time spent in drill, and attendees so you can track participation against your practice’s internal policies and accreditation and/or licensure requirements. You can document your drill using the form at https://bit.ly/4aSAVjk or the QR code to complete and receive a digital copy of your Drill Report.

This will also contribute your drill data to help improve services and identify best practices. Data identifiable to a practice or individual will never be shared without consent.

QR Code

References

Boushra M, Stone A, Rathbun KM. Umbilical Cord Prolapse. [Updated 2023 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK542241/

Khan RS, Naru T, Nizami F. Umbilical cord prolapse–a review of diagnosis to delivery interval on perinatal and maternal outcome. J Pak Med Assoc. 2007 Oct;57(10):487-91. PMID: 17990422.

Drill Kit Icon

Drill Kit

Neonatal Respiratory Distress

Coordinator Information

Drill Description

Introduction

Step Up Together Drill Kits support interdisciplinary clinical teams to run emergency drills involving patient hand-offs and/or transport to a higher level facility.

Each Drill Kit can be used to run a Full Transfer Drill that tests the full, interdisciplinary process of care or a Partial Transfer Drill that involves running just one segment of the scenario (e.g. before transfer or after hospital hand-off). The toolkit includes a standardized high-fidelity case designed to test the process of transferring a birthing person or newborn from one location to another with an interdisciplinary team involved in the care. Observation criteria and a Debriefing and Action Guide are provided to elicit continuous improvement of interdisciplinary care processes and promote respectful care along the continuum.

Drill Description

This Drill Kit tests the emergency response to neonatal respiratory distress occurring in a community birth setting including emergency transport of a neonatal patient. 

It is appropriate for:

  • Home birth practices
  • Birth centers

And may further engage:

  • EMS or other emergency transport partners
  • Labor & Birth unit and other relevant units at the referral hospital

To test the process of:

  • Neonatal emergency transport

Learning Objectives:

  • Identify and respond to neonatal respiratory distress in the community birth setting.
  • Review ways to promote person-focused care during emergencies.
  • Identify need for higher level of care and initiate appropriate hospital transfer.
  • Practice collaboration that adheres to relevant transfer protocols with warm hand-offs across levels of care.
  • Communicate effectively, and with dignity, to the patient, support people, and additional healthcare personnel in the event of a neonatal transfer.
  • Use debriefing skills to promote equity and ensure integration of individual and collective learning.

Last updated: December 2024

Authored by:

Jen Johnson, MS, CNM

Reviewed by:

Amy Romano, MBA, MSN, CNM, FACNM
Alexa Dougherty, MSN, PHN, CNM
Julie Moon, CNM

You will be coodinating a...

Partial Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer, but participants are only practicing part of the scenario: either the part that happens in the community before hospitalization, or the arrival at the hospital and post-transfer management.

Who's involved?

Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.

Planning Needs

Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.

Full Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer and participants practice all phases of the transfer: care in the community, emergency transport, and arrival and management at the hospital.

Who's involved?

Full practice/facility team from the community birth setting, plus transport and hospital personnel.

Planning Needs

Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.

Setup and Procedure

Neonatal Respiratory Distress

Partial Transfer Drill Instructions

Participants (Minimum of two, up to full practice/facility team):

  • *Drill Scenario Roles:
    • If conducting the drill in the community setting: 
      • Assign a lead provider and a birth assistant.
      • Additional learners may be assigned to play the role of a 911 dispatcher, EMS Lead, and/or a hospital provider receiving the report. 
    • If conducting the drill at the transfer hospital, assign an attending provider and a nurse. Additional learners may be assigned to play the role of the transferring provider and/or the EMS lead.
  • Non-clinical roles: Assign learners to play the roles of: 
    • the patient and partner
    • doula
    • siblings/other family
  • *Drill Coordinator: Presents the case scenario, tracks hand-off times,  and leads the debrief; may double as the birth assistant/nurse if this is a 2-person drill.
  • Observer(s): Unassigned learners are observers, who use Observer Worksheets to track actions and processes during the drill.

* Required roles

Setting and supplies: 

  • Birth suite set up for birth
  • Newborn mannequin, NRP equipment (including T-piece resuscitator, compressed air tank and regulator if available)
  • Supplies to document clinical care of simulated patient (e.g. maternal and neonatal blank transfer forms, blank paper charting templates or fake/simulated patient in the electronic record system)
  • Stopwatch or timer

Instructions: 

  • If conducting a Partial Transfer Drill in the community setting, use Clinical Scenario: Drill Begins in the Community Setting, and conclude the drill with simulated handoff to EMS. If conducting a Partial TransferDrill in the hospital, use Clinical Scenario: Drill Begins at Hospital Handoff, and conclude as directed in the scenario.
  • Drill Coordinator reads Clinical Scenario.
  • When team is ready, start timer and state aloud, “begin drill.”
  • Read additional prompts on the Coordinator Prompts at the appropriate times.
  • Learners in clinical roles may ask for clinical values by acting out the assessment (e.g. taking a blood pressure or donning gloves and simulating a vaginal exam). For visual or subjective assessments, they can ask. If assessments are abnormal or specified, they will be provided in the case. Otherwise, Drill Coordinator may provide any normal value in response.
  • Observers should use the Observer Worksheets to assess performance of clinical tasks as the drill progresses.
  • People assigned to clinical roles and the Drill Coordinator should review and complete the Observer Worksheets immediately after the drill, before Debriefing and Action Planning.

Setup and Procedure

Neonatal Respiratory Distress

Full Transfer Drill Instructions

Participants (Full team plus transport and/or hospital personnel): 

Assign the following roles:

  • *Drill Scenario Roles:
    • In the initial community setting: Assign a lead provider and a birth assistant.
    • During patient transport: Assign an EMS lead and other roles as relevant.
    • In the referral hospital: Assign an attending provider and a nurse and other roles such as transferring provider and/or the EMS lead as relevant. 
  • Non-clinical roles: Assign learners to play the roles of patient, partner, doula, siblings/other family
  • *Drill Coordinator(s): Presents the case scenario, tracks hand-off times, and leads the debrief. Consider assigning a coordinator for each segment of the transfer.
  • Observer(s): Unassigned learners are observers, who use Observer Worksheets to track actions and processes during the drill.

*Required roles

Setting and supplies: 

  • Birth suite set up for birth
  • Newborn mannequin and resuscitative equipment (including T-piece resuscitator, if available)
  • Supplies to document clinical care of simulated patient (e.g. maternal and neonatal blank transfer forms, blank paper charting templates or fake/simulated patient in the electronic record system)
  • Stopwatch or timer

Instructions: 

  • Use Clinical Scenario: Drill Begins in the Community Setting
  • Drill Coordinator reads Drill Scenario.
  • When team is ready, start timer and state aloud, “begin drill.”
  • Read additional prompts at the appropriate times.
  • Learners in clinical roles may ask for clinical values by acting out the assessment (e.g. taking a blood pressure or donning gloves and simulating a vaginal exam). For visual or subjective assessments, they can ask. If assessments are abnormal or specified, they will be provided in the case. Otherwise, Drill Coordinator may provide any normal value in response.
  • Restart the timer and log the time elapsed after each portion of the Full Transfer Drill: Before Transport, During Transport, and At Hospital.
  • Observers should use the Observer Worksheets to assess performance of clinical tasks as the drill progresses.
  • People assigned to primary and secondary roles and the Drill Coordinator should review and complete the Observer Worksheets immediately after the drill, before Debriefing and Action Planning.

Download & Print

Observer Worksheets

Clinical Scenario

Clinical Scenario

Drill Begins in Community Setting

This is a scenario that begins in the community and requires transfer to a higher level of care. It is used in mini, team, and full transfer drills that begin in the community.

Read the following case aloud. Prior to beginning, participants may ask clarifying questions, but should not discuss their plan of care or move any supplies or equipment.

Justice is a 1.5 hours old newborn who was born after an uncomplicated vaginal delivery at 38 weeks 3 days. Mother, Anna, is a 32 year old G3P3003 with an uncomplicated pregnancy. Her prenatal labs are significant for B+ blood type and GBS positive. Anna SROMed for clear fluid just minutes before the birth. She arrived to the birth center in active labor and only received 1 hour of GBS prophylaxis before delivery.  Apgars were 7 at 1 minute and 9 at 5 minutes. Newborn weight 3250g. Baby Justice has nursed once with a difficult latch. Recovery vital signs for both Anna and Justice have been within normal range thus far. Upon starting the newborn exam, you note nasal flaring, retractions, and acrocyanosis.

Clinical Scenario

Drill Begins at Receiving Hospital

This is a scenario that begins in the hospital, receiving a community transfer. This scenario is only used if a hospital team is running a mini or team drill, starting with the handoff from the community.

Read the following case aloud. Prior to beginning, participants may ask clarifying questions, but should not discuss their plan of care or move any supplies or equipment.

You receive the following report by phone from the on-call midwife of the nearby community practice. They introduce themself and state:

“I am calling to initiate a transfer of a newborn, Justice, who is 2 hours old and having persistent respiratory distress. The mother, Anna, is a 32 year old G3P3003 with an uncomplicated pregnancy and an uncomplicated birth center birth. Her prenatal labs are significant for B+ blood type, and GBS positive, for which she did not receive adequate prophylaxis due to a short active phase and second stage after arrival. Anna’s water broke for clear fluid just minutes before the birth. Apgars were 7 at 1 minute and 9 at 5 minutes. Respiratory distress began at 1.5 hours of life when Justice was noted to have nasal flaring, retractions, and low pulse oximetry. We initiated CPAP, which we are still performing. Justice continues to be tachypneic to 90, with a new temperature of 99.1F, normal heart rate of 136, and current pulse oximetry 93%. Newborn weight 3250g. EMS just arrived and we are preparing for transfer. I will accompany the newborn to the hospital with EMS.”

Print copies of the completed transfer form from the community midwife.

Coordinator Prompts

Community Setting

Coordinator Prompts

Time Scenario (Read Aloud) Values (Share only if assessed)
00:00

Scenario begins. Start timer.

Respiratory Rate: 82, spontaneous
Pulse: 128
Temp: 98.3F
SpO2: 92%
Physical exam: “wet” lung sounds, normal heart rhythm, nasal flaring, retractions, acrocyanosis
01:00

Justice continues to have nasal flaring and retractions. Cries briefly with repositioning. Anna asks about whether purple hands and feet are normal.

Respiratory Rate: 82, spontaneous
Pulse: 128
Temp: 98.3F
SpO2: 90%
Physical exam: “wet” lung sounds, normal heart rhythm, nasal flaring, retractions, acrocyanosis
02:00

Justice continues to have nasal flaring and retractions. Appears fussy.

Respiratory Rate: 84, spontaneous
Pulse: 130
Temp: 98.3F
SpO2: 91%
Blood Glucose: 71mg dL
Physical exam: nasal flaring, retractions, acrocyanosis, normal tone
04:00

Justice continues to have nasal flaring and retractions. Appears sleepy. Parents are wondering if their baby is OK and if they will have to be separated.

Respiratory Rate: 82, spontaneous
Pulse: 128
Temp: 98.3F
SpO2: 93%
Physical exam: nasal flaring, retractions, lethargic
06:00

Justice continues to have nasal flaring and retractions. Appears sleepy.

Respiratory Rate: 90, spontaneous
Pulse: 137
Temp: 99.1
SpO2: 93%
Physical exam: nasal flaring, retractions, lethargic

Repeat prior prompt every 1-2 minutes until emergency transport process is activated.

During Transfer

Coordinator Prompts

Time Scenario (Read Aloud) Values (Share only if assessed)
00:00

(Restart Timer)

Justice continues to have spontaneous respirations with nasal flaring and retractions, minimal response to stimuli.

Respiratory Rate: 88, spontaneous
Pulse: 135
Temp: 99.1
SpO2: 93%
Physical exam: nasal flaring, retractions, lethargic
01:00

Justice no longer has flaring, but continues to have retractions.

Respiratory Rate: 75, spontaneous
Pulse: 135
Temp: 99.1
SpO2: 96%
Physical exam: retractions, lethargic
03:00

Justice continues to have retractions.

Respiratory Rate: 86, spontaneous
Pulse: 120
Temp: 99.4
SpO2: 93%
Physical exam: retractions, lethargic

Repeat prior prompt every 1-2 minutes until patient reaches hospital unit.

Receiving Hospital

Coordinator Prompts

Time Scenario (Read Aloud) Values (Share only if assessed)
00:00

(Restart Timer)

Scenario begins upon the arrival of the transport team and patient.

Respiratory Rate: 86
Pulse: 120
Temp: 99.4
SpO2: 93%
Physical exam: retractions, lethargic
01:00

Justice has retractions and minimal response to stimuli.

Respiratory Rate: 86
Pulse: 140
Temp: 99.4
SpO2: 93%
Physical exam: retractions, lethargic
02:00

Justice has retractions and minimal response to stimuli.

Respiratory Rate: 88
Pulse: 140
Temp: 99.4
SpO2: 93%
Physical exam: retractions, lethargic

Repeat prior prompt every 1-2 minutes until newborn is fully admitted to the unit and care handed off to the neonatal team

Debriefing and Action Guide

Review the checklist of observed behaviors as a team and discuss subjective assessments such as communication style with team members and family, role clarity, and effectiveness at clinical tasks. 

Reflection Questions

  • What happened here? Ask 1-2 people to give a brief high-level summary so everyone’s on the same page.
  • What went well? Give everyone a chance to share the good stuff they noticed before critiquing.
  • What needs attention or improvement? Try to focus on processes and systems, not assigning blame.
  • Are there other appropriate ways to manage this emergency or transport? Consider different approaches such as who might accompany the patient, dyad vs. separate transfers, etc.
  • Were we prepared for this emergency? The answer will help clarify the Action Steps.

Action Steps

  • What changes are needed to processes or procedures? Make sure to assign someone to follow-up on the change.
  • How should this emergency be documented in the medical record? Discuss any documentation standards and tools such as order sets or dot-phrases available to clinicians.
  • What other reporting is required for this emergency transfer? This could include accreditation or licensing bodies, malpractice carriers, and internal organizational reporting.
  • What other follow up would be expected after this emergency? Consider follow-up for patient/family or staff, or other next steps.

Documentation

Document the date, location, clinical scenario(s), time spent in drill, and attendees so you can track participation against your practice’s internal policies and accreditation and/or licensure requirements. You can document your drill using the form at https://bit.ly/4aSAVjk or the QR code to complete and receive a digital copy of your Drill Report.

This will also contribute your drill data to help improve services and identify best practices. Data identifiable to a practice or individual will never be shared without consent.

QR Code

References

Castillo A, Sola A, Baquero H, et al. Pulse oxygen saturation levels and arterial oxygen tension values in newborns receiving oxygen therapy in the neonatal intensive care unit: Is 85% to 93% an acceptable range? PEDIATRICS. 2008;121(5):882-889. doi:10.1542/peds.2007-0117

Ryan O. Advocating for change to NRP policy: American Association of Birth Centers. Published February 16, 2024. 

Weiner, GM., Zaichkin, J. Neonatal Resuscitation (8th Edition). American Academy of Pediatrics;2021. doi:10.1542/9781610025256

Drill Kit Icon

Drill Kit

Delayed Postpartum Hemorrhage with Nurse and Doula Present

Coordinator Information

Drill Description

Introduction

Step Up Together Drill Kits support interdisciplinary clinical teams to run emergency drills involving patient hand-offs and/or transport to a higher level facility.

Each Drill Kit can be used to run a Full Transfer Drill that tests the full, interdisciplinary process of care or a Partial Transfer Drill that involves running just one segment of the scenario (e.g. before transfer or after hospital hand-off). The toolkit includes a standardized high-fidelity case designed to test the process of transferring a birthing person or newborn from one location to another with an interdisciplinary team involved in the care. Observation criteria and a Debriefing and Action Guide are provided to elicit continuous improvement of interdisciplinary care processes and promote respectful care along the continuum.

 

Drill Description

This Drill Kit tests the emergency response to a delayed postpartum hemorrhage in a community birth setting after departure of the primary provider, with care being provided by a nurse (or other clinical birth assistant) and a doula (or other non-clinical birth assistant.) The scenario includes initiating emergency postpartum transfer to a higher level of care for ongoing management of postpartum hemorrhage. 

It is appropriate for:

  • Home birth practices
  • Birth centers
  • Community hospitals that may initiate emergency care and/or transport when providers are not on site

And may further engage:

  • Community-based doula organizations and trainers
  • EMS or other emergency transport partners
  • Labor & Birth unit and other relevant units at the referral hospital

To test the process of:

  • Postpartum emergency transport
  • Emergency care with the initial absence of licensed midwives or physicians to direct management

Learning Objectives:

  • Identify and respond to a delayed postpartum hemorrhage in a manner consistent with the respective scopes of practice of interdisciplinary learners.
  • Identify opportunities to strengthen preparedness for perinatal emergencies when licensed midwives and physicians are not initially available to direct management.
  • Review ways to promote person-focused care during emergencies.
  • Use debriefing skills to promote equity and ensure integration of individual and collective learning.

Last updated: December 2024

Authored by:

Amy Romano, MBA, MSN, CNM, FACNM and Jennifer Johnson, MS, CNM

Reviewed by:

Alexa Dougherty, MSN, PHN, CNM
Jess Brennan, MA, CD, LCCE, C-VBACS, LMT
Beth McGovern, DNP, RNC-OB

You will be coodinating a...

Partial Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer, but participants are only practicing part of the scenario: either the part that happens in the community before hospitalization, or the arrival at the hospital and post-transfer management.

Who's involved?

Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.

Planning Needs

Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.

Full Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer and participants practice all phases of the transfer: care in the community, emergency transport, and arrival and management at the hospital.

Who's involved?

Full practice/facility team from the community birth setting, plus transport and hospital personnel.

Planning Needs

Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.

Setup and Procedure

Delayed Postpartum Hemorrhage with Nurse and Doula Present

Partial Transfer Drill Instructions

Participants (Minimum of two, up to full practice/facility team):

  • *Drill Scenario Roles roles:
    • If conducting the drill in the community setting:
      • Assign a nurse (or clinical birth assistant) and a doula for the physical scenario. 
      • Assign a lead clinical provider who attended the birth and is now only available by phone (this learner may stay inside the room and mimic phone conversation, so they can observe the drill and participate in the debrief).
      • Additional learners may be assigned to play the role of a 911 dispatcher, EMS Lead, and/or a Labor unit hospital provider receiving the report. 
    • If conducting the drill at the transfer hospital, assign an attending provider and a nurse. Additional learners may be assigned to play the role of the transferring provider and/or the EMS lead.
  • Non-clinical roles: Assign learners to play the roles of the patient and partner
  • *Drill Coordinator presents the case scenario, tracks hand-off times,  and leads the debrief; may double as one of the participants if this is a mini-drill.
  • Observer(s): Unassigned learners are observers, who use Observer Worksheets to track actions and processes during the drill. 

* Required roles

Setting and supplies: 

  • Birth suite partially cleaned after the birth (typical set-up for the interval after the midwife/provider has left and the nurse is managing pre-discharge care and teaching).
  • Supplies to document clinical care of simulated patient (e.g. blank paper charting templates or fake/simulated patient in the electronic record system).
  • Stopwatch or timer

Instructions: 

  • Drill Coordinator reads Clinical Scenario.
  • When team is ready, start timer and state aloud, “begin drill.”
  • Read additional prompts on the Coordinator Prompts at the appropriate times.
    Learners in drill scenario roles may ask for clinical values by acting out the assessment (e.g. taking a blood pressure or prepping IV supplies and simulating starting an IV). For visual or subjective assessments, they can ask. If assessments are abnormal or specified, they will be provided in the case. Otherwise, Drill Coordinator may provide any normal value in response.
  • Observers should use the Observer Worksheets to assess performance of clinical tasks as the drill progresses.
  • People assigned to drill scenario roles and the Drill Coordinator should review and complete the Observer Worksheets immediately after the drill, before Debriefing and Action Planning.

Setup and Procedure

Delayed Postpartum Hemorrhage with Nurse and Doula Present

Full Transfer Drill Instructions

Participants (Full team plus transport and/or hospital personnel):

Assign the following roles:

  • *Drill Scenario Roles: 
    • In the initial community setting: 
      • Assign a nurse (or clinical birth assistant) and a doula for the physical scenario 
      • Assign a lead clinical provider who attended the birth and is now only available by phone. (This learner may stay inside the room and mimic phone conversation, so they can observe the drill and participate in the debrief.)  
    • During patient transport: Assign an EMS lead and other roles as relevant
    • In the referral hospital: Assign an attending provider and a nurse and other roles as relevant.
  • Non-clinical roles: Assign learners to play the roles of the patient and partner
  • *Drill Coordinator(s): Presents the case scenario, tracks hand-off times, and leads the debrief. Consider assigning a coordinator for each segment of the transfer.
  • Observer(s): Unassigned learners are observers, who use Observer Worksheets to track actions and processes during the drill. 

*Required roles

Setting and supplies: 

  • Birth suite partially cleaned after the birth (typical set-up for the interval after the midwife/provider has left and the nurse is managing pre-discharge care and teaching)
  • Supplies to document clinical care of simulated patient (e.g. blank paper charting templates or fake/simulated patient in the electronic record system)
  • Stopwatch or timer

Instructions: 

  • Use Clinical Scenario: Drill Begins in the Community Setting
  • Drill Coordinator reads Drill Scenario.
  • When team is ready, start timer and state aloud, “begin drill.”
  • Read additional prompts at the appropriate times.
  • Learners in drill scenario roles may ask for clinical values by acting out the assessment (e.g. taking a blood pressure or prepping IV supplies and simulating starting an IV). For visual or subjective assessments, they can ask. If assessments are abnormal or specified, they will be provided in the case. Otherwise, Drill Coordinator may provide any normal value in response.
  • Restart the timer and log the time elapsed after each portion of the Full Transfer Drill: Before Transport, During Transport, and At Hospital.
  • Observers should use the Observer Worksheets to assess performance of clinical tasks as the drill progresses.
  • People assigned to drill scenario roles and the Drill Coordinator should review and complete the Observer Worksheets immediately after the drill, before Debriefing and Action Planning.

Download & Print

Observer Worksheets

Clinical Scenario

Clinical Scenario

Drill begins in community setting

Read the following case aloud. Prior to beginning, participants may ask clarifying questions, but should not discuss their plan of care or move any supplies or equipment.

Veronica is a 38 year old G5 P5005 who just had an uncomplicated spontaneous vaginal birth of baby Grace at term with her midwife. She has been supported by partner Justin, and her doula. Her birth plan listed top priorities for her postpartum period including to avoid separation from her baby, and to have privacy and rest in the immediate postpartum period. Her mother-in-law is helping care for her 4 older children.

Significant Prenatal History: Blood type A pos. Anemia, last Hct/Hgb: 31%/10.1, takes daily iron supplement and prenatal vitamin

Veronica called her midwife when her water broke after two days of intermittent contractions, and then had a precipitous delivery within minutes of the midwife arriving. 

Newborn APGARs were 8 at 1 minute and 9 at 5 minutes, and the baby latched immediately after birth for 20 minutes.
Veronica received 10 units of IM pitocin for active management of the third stage of labor.
Placenta delivered spontaneously and intact within 12 minutes of birth.
QBL: 200 mL at birth. Vulva, vagina, and perineum were intact. Fundus firm @ umbilicus.
Newborn weight: 3850g 

After a normal newborn exam at 2 hours of life, the infant is now skin-to-skin again and Veronica is attempting to latch the baby on the other side. The midwife left to attend a postpartum home visit for another client, while the nurse and her doula remain with Veronica to assist with breastfeeding and for routine postpartum recovery care. Justin is also present. 

At 3 hours postpartum, Veronica asks to use the bathroom. She hands the baby to Justin, then sits up and starts to move to the edge of the bed. She suddenly reports a large gush of blood, which becomes visible as it soaks her peri-pad completely and about half of the chux pad Veronica was sitting on.

Clinical Scenario

Drill begins at hospital handoff

Read the following case aloud. Prior to beginning, participants may ask clarifying questions, but should not discuss their plan of care or move any supplies or equipment.

You receive the following report by phone from the nurse of the nearby community birth practice. They introduce themself and state:

I’m calling to initiate a transfer for a postpartum hemorrhage at 3 hours postpartum. Veronica is a 38 year old G5P5005 who had a normal spontaneous vaginal delivery this morning, no lacerations, and the placenta delivered spontaneously and intact within 12 minutes of birth. She  received 10 units of IM Pitocin for active management of the third stage of labor.  After an initial QBL of 200 ml, Veronica experienced a delayed hemorrhage for a cumulative QBL of over 1000cc and is symptomatic for blood loss with dizziness and nausea. She is transferring by ambulance for ongoing evaluation and care and likely blood transfusion. Her blood type is A positive.

Coordinator Prompts

Community Setting

Coordinator Prompts

Time Scenario (Read Aloud) Values (Share only if assessed)
00:00

Veronica is sitting at the edge of the bed with a soaked pad and about 50% chux pad soaked. 

She feels strong urge to void, asking to get up to bathroom. Chux pads continues to fill with blood-tinged fluid.

QBL of chux and peri-pad: 450cc
Fundus: 1 above umbilicus, deviated to the right, boggy
Vital signs: BP 110/62, HR 80, T 98.8
Running QBL: 650cc
01:00

When Veronica stands to walk to the bathroom, a small clot falls to the floor and a small amount of blood is seen running down her legs. She starts to report feeling dizzy but is able to ambulate to the toilet.

QBL of clot: 50cc
Fundus: at umbilicus, boggy
Vital signs: BP 96/58, HR 110, T 98.8
Running QBL: 700cc
02:00

Veronica is able to void and ambulate back to the bed with assistance. The toilet water is dark red.

Void: 100cc light yellow
EBL of bleeding in toilet: 100cc
Vital signs: BP 96/58, HR 110, T 98.8
Running QBL: 800cc
04:00

Veronica now appears pale and reports some dizziness and nausea. New chux pad is nearly half soaked again with a few dime-sized clots.

QBL of chux: 200cc
Fundus: midline, at umbilicus, firm with massage
Vital signs: BP 96/58, HR 110, T 98.8
Running QBL: 1000cc
05:00

Veronica continues to feel dizzy and nauseous.

Fundus: midline, at umbilicus, firm with massage, small gush of blood with massage
Vital signs: BP 96/58, HR 110, T 98.8
Running QBL: 1050cc

Repeat prior prompt every 1-2 minutes until transfer is initiated.

During Transfer

Coordinator Prompts

Time Scenario (Read Aloud) Values (Share only if assessed)
00:00

Veronica appears pale and continues to report some dizziness and nausea. New peripad is now halfway full of blood. She is irritable about transferring and wants to hold her baby.

Vital signs: BP 90/52, HR 115, O2 98%
Fundus: firm with small trickle
Running QBL: 1100cc
01:00

Veronica is pale, exhausted, and irritable.

Vital signs: BP 90/52, HR 115, O2 98%
Fundus: firm with small trickle
Running QBL: 1100cc
01:00

At 1 minute prior to arrival at the destination hospital.

Veronica is lethargic and pale, reports “more fluid coming out”, the chux is halfway soaked

Vital signs: BP 86/48 HR 120, O2 96%, T 99.1
Fundus: boggy at umbilicus with another large gush of blood
Running QBL: 1200cc

Receiving Hospital

Coordinator Prompts

Time Scenario (Read Aloud) Values (Share only if assessed)
00:00

Veronica is lethargic and pale, asks where her baby is.

Vital signs: BP 86/48 HR 120, O2 96%, T 99.1
Fundus: boggy at umbilicus with moderate blood on massage
Running QBL: 1250cc
02:00

Veronica reports cramping and pain.

Vital signs: BP 86/48 HR 120, O2 96%, T 99.1
Fundus: boggy at umbilicus with another large gush of blood
Bimanual exam: significant clots filling the uterus with atonic lower uterine segment
QBL of chux + clots: 150cc
Bedside US: thin stripe without color flow after manual evacuation of clots
Speculum exam: cervix intact
Running QBL: 1400cc

Repeat prior prompt until manual removal of clots is performed. Bleeding stabilizes after this is performed.

Debriefing and Action Guide

Reflection Questions

Review the checklist of observed behaviors as a team and discuss subjective assessments such as communication style with team members and family, role clarity, and effectiveness at clinical tasks. 

  • What happened here? Ask 1-2 people to give a brief high-level summary so everyone’s on the same page.
  • What went well? Give everyone a chance to share the good stuff they noticed before critiquing.
  • What needs attention or improvement? Try to focus on processes and systems, not assigning blame.
  • Are there other appropriate ways to manage this emergency or transport? Consider different approaches such as who might accompany the patient, dyad vs. separate transfers, etc.
  • Were we prepared for this emergency? The answer will help clarify the Action Steps.
  • Do all birth assistants in our practice have the same scope and skill sets (i.e. able to administer medications, able to start an IV line, etc)?
  • What would be different if the doula, although working in a doula capacity, was trained and licensed as a clinical professional (e.g. a nurse or volunteer paramedic)?
  • What would be different if the patient declined active management of the third stage?
  • What would be different if the midwife was unavailable by phone?
  • Is a dyad transfer possible in this scenario? If not, who should accompany the patient and who should remain back with the neonate?
  • What are hospital practices for transfer patients arriving with doulas?

Action Steps

  • What changes are needed to processes or procedures? Make sure to assign someone to follow-up on the change.
  • How should this emergency be documented in the medical record? Discuss any documentation standards and tools such as order sets or dot-phrases available to clinicians.
  • What other reporting is required for this emergency transfer? This could include accreditation or licensing bodies, malpractice carriers, and internal organizational reporting.
  • What other follow up would be expected after this emergency? Consider follow-up for patient/family or staff, or other next steps.

Documentation

Document the date, location, clinical scenario(s), time spent in drill, and attendees so you can track participation against your practice’s internal policies and accreditation and/or licensure requirements. You can document your drill using the form at https://bit.ly/4aSAVjk or the QR code to complete and receive a digital copy of your Drill Report.

This will also contribute your drill data to help improve services and identify best practices. Data identifiable to a practice or individual will never be shared without consent.

QR Code

References

Bateman BT, Berman MF, Riley LE, Leffert LR. The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries. Anesthesia & Analgesia. 2010;110(5):1368-1373.
doi:10.1213/ane.0b013e3181d74898

Likis FE, Sathe NA, Morgans AK, et al. Management of postpartum hemorrhage. Comparative Effectiveness Review: Number 151. Agency for Healthcare Research and Quality (US);2015. 

Obstetric Hemorrhage Patient Safety Bundle. American College of Obstetricians and Gynecologists; 2022. https://saferbirth.org/wp-content/uploads/U2-FINAL_AIM_Bundle_ObstetricHemorrhage.pdf

Oyelese Y, Ananth CV. Postpartum Hemorrhage: Epidemiology, Risk Factors, and Causes. Clinical Obstetrics and Gynecology. 2010 Mar;53(1):147-56.
doi: 10.1097/GRF.0b013e3181cc406d

Postpartum hemorrhage: Practice Bulletin 183. Obstet Gynecol. 2017 Oct;130(4):923-925.
doi: 10.1097/AOG.0000000000002346

Quantification of blood loss: AWHONN Practice Brief Number 1. J Obstet Gynecol Neonatal Nurs. 2015 Jan-Feb;44(1):158-160.
doi: 10.1111/1552-6909.12519

Drill Kit Icon

Drill Kit

Shoulder Dystocia with Neonatal Resuscitation

Coordinator Information

Drill Description

Introduction

Step Up Together Drill Kits support interdisciplinary clinical teams to run emergency drills involving patient hand-offs and/or transport to a higher level facility.

Each Drill Kit can be used to run a Full Transfer Drill that tests the full, interdisciplinary process of care or a Partial Transfer Drill that involves running just one segment of the scenario (e.g. before transfer or after hospital hand-off). The toolkit includes a standardized high-fidelity case designed to test the process of transferring a birthing person or newborn from one location to another with an interdisciplinary team involved in the care. Observation criteria and a Debriefing and Action Guide are provided to elicit continuous improvement of interdisciplinary care processes and promote respectful care along the continuum.

Drill Description

This Drill Kit tests the emergency response to a shoulder dystocia complicated by a neonatal resuscitation occurring in community birth setting including the emergency transport of a neonatal patient.

It is appropriate for:

  • Home birth practices
  • Birth centers
  • Critical access hospitals without OB services
  • Other facilities or units requiring patient transport for emergency surgery or stabilization (e.g. emergency department)

And may further engage:

  • EMS or other emergency transport partners
  • Labor & Birth unit and other relevant units at the referral hospital

To test the process of:

  • Postpartum and Neonatal emergency transport

Learning Objectives:

  • Identify and respond to risk factors and signs of a shoulder dystocia in the community setting.
  • Perform maneuvers to resolve a shoulder dystocia.
  • Review ways to promote person-focused care during emergencies.
  • Identify and respond to neonatal distress immediately following birth in the community setting.
  • Identify need for higher level of care and initiate appropriate hospital transfer.
  • Communicate effectively, and with dignity to the patient, support people, and additional healthcare personnel in the event of neonatal transfer.

Last updated: December 2024

Authored by:

Jennifer Johnson, MS, CNM

Reviewed by:

Alexa Dougherty, MSN, PHN, CNM
Julie Moon, CNM, APRN
Amy Romano MBA, MSN, CNM, FACNM

You will be coodinating a...

Partial Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer, but participants are only practicing part of the scenario: either the part that happens in the community before hospitalization, or the arrival at the hospital and post-transfer management.

Who's involved?

Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.

Planning Needs

Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.

Full Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer and participants practice all phases of the transfer: care in the community, emergency transport, and arrival and management at the hospital.

Who's involved?

Full practice/facility team from the community birth setting, plus transport and hospital personnel.

Planning Needs

Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.

Setup and Procedure

Shoulder Dystocia with Neonatal Resuscitation

Partial Transfer Drill Instructions

Participants (Minimum of two, up to full practice/facility team):

Assign the following roles:

  • *Drill Scenario Roles:
    • If conducting the drill in the community setting: 
      • Assign a lead provider and a birth assistant.
      • Additional learners may be assigned to play the role of a 911 dispatcher, EMS Lead, and/or a hospital provider receiving the report. 
    • If conducting the drill at the transfer hospital, assign an attending provider and a nurse. Additional learners may be assigned to play the role of the transferring provider and/or the EMS lead
  • Non-clinical roles: Assign learners to play the roles of: 
    • the patient and partner
    • doula
    • siblings/other family
  • *Drill Coordinator presents the case scenario, tracks hand-off times,  and leads the debrief; may double as one of the participants if this is a 2-person-drill.
  • Observer(s): Unassigned learners are observers, who use Observer Worksheets to track actions and processes during the drill. 

* Required roles

Setting and supplies: 

  • Birth suite set up for birth (use  Birth Center Checklists) 
  • Newborn mannequin or doll 
  • Model pelvis or birth simulator
  • NRP algorithm and equipment (including T-piece resuscitator, if available)
  • Supplies to document clinical care of simulated patient (e.g. maternal and neonatal blank transfer forms, paper charting templates or fake/simulated patient in the electronic record system)
  • Stopwatch or timer 

Additional Resource:

Instructions: 

  • If conducting a Partial Transfer Drill in the community setting, use Clinical Scenario: Drill Begins in the Community Setting, and conclude the drill with simulated handoff to EMS. If conducting a Partial TransferDrill in the hospital, use Clinical Scenario: Drill Begins at Hospital Handoff, and conclude as directed in the scenario.
  • Drill Coordinator reads Clinical Scenario.
  • When team is ready, start timer and state aloud, “begin drill.”
  • Read additional prompts at the appropriate times.
  • Learners in drill scenario roles may ask for clinical values by acting out the assessment (e.g. taking a blood pressure or prepping IV supplies and simulating starting an IV). Fetal heart tones are noted as 6-second counts.
    •  For visual or subjective assessments, they can ask. If assessments are abnormal or specified, they will be provided in the case. Otherwise, Drill Coordinator may provide any normal value in response.
  • Observers should use the Observer Worksheets to assess performance of clinical tasks as the drill progresses.
  • People assigned to clinical roles and the Drill Coordinator should review and complete the Observer Worksheets immediately after the drill, before Debriefing and Action Planning.

Setup and Procedure

Shoulder Dystocia with Neonatal Resuscitation

Full Transfer Drill Instructions

Participants (Full team plus transport and/or hospital personnel): 

Assign the following roles:

  • *Drill Scenario Roles: 
    • In the initial community setting: 
      • Assign a lead provider and a birth assistant.
    • During patient transport: Assign an EMS lead and other roles as relevant
    • In the referral hospital: Assign an attending provider and a nurse and other roles such as transferring provider and/or the EMS lead as relevant. 
  • Non-clinical roles: Assign learners to play the roles of the patient and partner/support person
  • *Drill Coordinator(s): Presents the case scenario, tracks hand-off times, and leads the debrief. Consider assigning a coordinator for each segment of the transfer.
  • Observer(s): Unassigned learners are observers, who use Observer Worksheets to track actions and processes during the drill.
    *Required roles

Setting and supplies: 

  • Birth suite set up for birth (use  Birth Center Checklists) 
  • Newborn mannequin or doll 
  • Model pelvis or birth simulator
  • NRP algorithm and equipment (including T-piece resuscitator, if available)
  • Supplies to document clinical care of simulated patient (e.g. maternal and neonatal blank transfer forms, paper charting templates or fake/simulated patient in the electronic record system)
  • Stopwatch or timer

Additional Resource:

Instructions: 

  • Use Clinical Scenario: Drill Begins in the Community Setting
  • Drill Coordinator reads Drill Scenario.
  • When team is ready, start timer and state aloud, “begin drill.”
  • Read additional prompts at the appropriate times.
  • Learners in Drill Scenario roles may ask for clinical values by acting out the assessment (e.g. taking a blood pressure or prepping IV supplies and simulating starting an IV). Fetal heart tones are noted as 6-second counts.
    •  For visual or subjective assessments, they can ask. If assessments are abnormal or specified, they will be provided in the case. Otherwise, Drill Coordinator may provide any normal value in response.
  • Restart the timer and log the time elapsed after each portion of the Full Transfer Drill: Before Transport, During Transport, and At Hospital.
  • Observers should use the Observer Worksheets to assess performance of clinical tasks as the drill progresses.
  • People assigned to primary and secondary roles and the Drill Coordinator should review and complete the Observer Worksheets immediately after the drill, before Debriefing and Action Planning.

Download & Print

Observer Worksheets

Clinical Scenario

Clinical Scenario

Drill begins in community setting

Read the following case aloud. Prior to beginning, participants may ask clarifying questions, but should  not discuss their plan of care or move any supplies or equipment. 

Sarah is a 29 year old G2 P0010 at 39 weeks and 6 days who was admitted to the birth center overnight with an exam of 6/60/-2. She is accompanied by her partner Maeve, and their doula Allison. They are excited to meet baby “Josie”, conceived via IUI. Her prenatal course is significant for a pre-pregnancy BMI of 28, an elevated 1 hour oral glucose challenge test followed by a normal 3 hour oral glucose tolerance test.  All other routine prenatal lab work was normal. Her total weight gain in pregnancy was 42lb. She had a normal anatomy scan and a  32-week growth scan showing 79th percentile overall growth, with an abdominal circumference in the 83rd percentile.  She is GBS negative, blood type A positive. On admission, the estimated fetal weight by Leopolds is 8.5lb.

Her labor course is as follows:

  • 0400 6/60/-2
  • 0715 SROM clear
  • 0815 8/90/-2
  • 1130 lip/100/-1
  • 1230 10/100/0
  • 1300 push start

It is now 14:30, Sarah has been pushing for the last one and a half hours and  is coping well with labor, using the tub and birth ball intermittently, staying well hydrated with coconut water, but feeling exhausted. She is pushing well with minimal coaching. The amniotic fluid remains clear, the FHR with Doppler has decreased to 100s during pushes and resolved to 130s between pushes. Maternal vital signs are within normal range.  You now start to see more of the fetal head emerge with each push, though it does not stay between pushes. Sarah recently moved to the birth stool, where Maeve is sitting behind her for support. After the last contraction, Sarah exclaimed “why does she keep going back in!?”

Clinical Scenario

Drill begins at hospital handoff

Read the following case aloud. Prior to beginning, participants may ask clarifying questions, but should  not discuss their plan of care or move any supplies or equipment.

You receive the following report by phone from the on-call midwife of the nearby community practice. They introduce themself and state:

“I am calling to initiate an emergent newborn transfer for my patient. This is a term newborn at 5 minutes of life with signs of respiratory distress and motor function concerns following a 2 minute  shoulder dystocia. One and five minute apgars were 7 and 8. Neonate is showing mild retractions; all vital signs are stable. Current newborn vital signs are: HR 140, RR 58, T 99.2, pulse ox 92%. The right arm has less spontaneous movement than the rest of the extremities, and I am concerned for a brachial plexus injury. On brief physical exam, the clavicles palpate intact. The neonate will be arriving by EMS.”

Print copies of the completed transfer form from the community midwife.

Coordinator Prompts

Community Setting

Coordinator Prompts

Time Scenario (Read Aloud) Values (Share only if assessed)
00:00

Sarah sitting on the birth stool with Maeve sitting behind her on a chair.

FHT’s: 13, 12, 12, 13, 13, 12
UC: q 2-3 m
Vaginal exam: 10/100/+3 between contractions, head visible with pushing
Maternal Vitals: BP 120/72, Pulse 105, Temp 99.4
Any other value: normal
03:00

Contraction begins, Sarah starts pushing, head starts to crown, and remains crowning at the end of the contraction. Sarah says “it burns!”

FHT’s: 9, 8, 9, 10, 12, 13
Vaginal exam: crowning
Maternal Vitals:  BP 120/72, Pulse 105, Temp 99.4
Any other value: normal
06:00

Contraction begins, Sarah starts pushing, head slowly emerges up to nose level by end of the contraction. Sarah is exclaiming “I can’t do it!” and tries to recoil.

FHT’s: 8, 7, 8, 9, 10, 9, 10
Vaginal exam: neonate with partial head delivered
Maternal Vitals:  BP 120/72, Pulse 105, Temp 99.4
Any other value: normal
08:00

Another contraction begins and with the second push, the rest of the head is born and Sarah is crying. The neonatal head appears tight at the perineum, no restitution noted. With the next push, there is still no restitution and the anterior shoulder does not emerge despite Sarah’s effort and gentle downward traction.

FHT’s: unable to auscultate
Vaginal exam: no nuchal cord, unable to palpate anterior shoulder at the pubic bone
Maternal Vitals:  BP 120/72, Pulse 105, Temp 99.4
Any other value: normal
09:00

Sarah repositions as instructed by the midwife and pushes again. The anterior shoulder does not emerge. Sarah repositions as instructed by the midwife. She pushes again but the anterior shoulder does not emerge.

FHT’s: unable to auscultate
Vaginal exam: no nuchal cord, unable to palpate anterior shoulder at the pubic bone.

Learner may request as many / whichever maneuvers come to mind.

Any other value: normal
10:00

Another maneuver is utilized and the rest of the neonate is born. Baby Josie appears floppy and blue with mucous around the nose and minimal respiratory effort.

Total time of shoulder dystocia: 2min
Neonatal Tone: poor
Neonatal Color: blue
Neonatal HR: 100
Neonatal RR: RR 36, gasping, breath sounds coarse and equal  bilaterally
All maternal values: normal
10:30

Josie is dried with warm blanket and stimulated by care team.

Neonatal Tone: poor
Neonatal Color: blue
Neonatal HR: 100
Neonatal RR: RR 36, gasping, breath sounds coarse and equal  bilaterally, O2 60%
11:00

1 minute since birth.

Josie responds to additional efforts with spontaneous respirations, sputters, appears more pink in color with some flexion of extremities, less so in her right arm. Mild retractions noted. Sarah appears exhausted.

 

Neonatal assessment:

  • Activity/tone: some flexion with less in right arm (1 pt)
  • Pulse/HR: 120 (2 pts)
  • Grimace: weak cry (1 pts)
  • Appearance/color: pink, with blue extremities (1 pt)
  • Respiration: RR 48, irregular, breath sounds coarse and equal bilaterally, O2 65%  (1 pt)

(1 min APGAR = 6)

Maternal vitals: BP 124/78, Pulse 105, Temp 98.9, uterine bleeding absent
Any other value: normal
12:00

Josie coughs and cries, appears more vigorous in both legs and left arm. Right arm with minimal movement.

Neonatal assessment:

  • Activity/tone:  flexion in 3/4 extremities
  • Pulse/HR: 120
  • Grimace: good cry with some coughing
  • Appearance/color: pink, with blue extremities
  • Respiration: RR 48, breath sounds equal bilaterally, O2 68%

Maternal Vitals: BP 124/78, Pulse 105, Temp 98.9, uterine bleeding absent

Any other value: normal
13:00

Josie continues to have some “wet” breathing. Sarah reports some pressure and cramping. Cord is lengthening, a gush of blood is noted.

Neonatal assessment:

  • Activity/tone:  flexion in 3/4 extremities
  • Pulse/HR: 130
  • Grimace: good cry with sneeze
  • Appearance/color: pink, with blue extremities
  • Respiration: RR 52, breath sounds coarse and equal bilaterally, O2 75%

Maternal Vitals:
BP 118/68, Pulse 96, Temp 98.7
Gush 1  = 50cc
Any other value: normal
14:00

Placenta delivers in another small gush of blood. Josie continues to have some “wet” breathing.

Neonatal assessment:

  • Activity/tone:  flexion in 3/4 extremities
  • Pulse/HR: 130
  • Grimace: responds to stimuli
  • Appearance/color: pink, with blue extremities
  • Respiration: RR 58, O2 86%
    Breath sounds coarse and equal bilaterally

Maternal Vitals:
BP 118/68, Pulse 96, Temp 98.7, fundus firm,  midline at umbilicus
Vaginal/perineal exam: no visible lacerations.
Gush  2 = 50cc
QBL = 100
Any other value: normal
15:00

5 minutes since birth.

Allison asks about Josie’s right arm and breathing “weird”.

Repeat prompt until transfer initiated.

Neonatal assessment:

  • Activity/tone:  flexion in 3/4 extremities, Moro reflex diminished on right, clavicles intact (1 pt)
  • Pulse/HR: 130 (2 pts)
  • Grimace: soft cries with wet gurgling (2 pt)
  • Appearance/color: pink, with blue extremities  (1 pt)
  • Respiration: RR 58, breath sounds coarse and equal bilaterally, O2 86% (2 pts)

(5 min apgar = 8)

Maternal Vitals:
BP 118/68, Pulse 96, Temp 98.7, fundus firm,  midline at umbilicus
Vaginal/perineal exam: no visible lacerations, bleeding minimal without clots
Any other value: normal

Repeat prior prompt every 1-2 minutes until transfer initiated.

During Transfer

Coordinator Prompts

Time Scenario (Read Aloud) Values (Share only if assessed)
00:00

Restart Timer.

Josie appears pink and vigorous except in right arm. Mild retractions with some wet breath sounds.

Neonatal Vital Signs: HR 140, RR 62, T 99.2, O2 92%
Any other value: normal

Scenario remains stable throughout transport to hospital.

Receiving Hospital

Coordinator Prompts

Time Scenario (Read Aloud) Values (Share only if assessed)
00:00

Restart Timer.

Josie appears pink and vigorous except in right arm. Mild retractions seen with some audible wet breath sounds.

Neonatal Vitals: HR 140, RR 62, T 99.2, O2 92%
Any other value: normal
01:00

Retractions continue. Right arm appears hypotonic. Reduced moro reflex on the right side.

Neonatal Vitals: HR 140, RR 62, T 99.2, O2 92%.
Clavicles intact.
Blood glucose: 54
Any other value: normal
02:00

Repeat prompt until neonate taken for imaging then moved to observation

Debriefing and Action Guide

Reflection Questions

  • What happened here? Ask 1-2 people to give a brief high-level summary so everyone’s on the same page.
  • What went well? Give everyone a chance to share the good stuff they noticed before critiquing.
  • What needs attention or improvement? Try to focus on processes and systems, not assigning blame. Pay special attention to evaluating the handoffs from midwife to EMS, EMS to hospital staff, midwife to physician.
  • Are there other appropriate ways to manage this emergency or transport? Consider different approaches such as who might accompany patient, etc.
  • Were we prepared for this emergency? The answer will help clarify the Action Steps

 

Action Steps

  • What changes are needed to processes, procedures? Make sure to assign someone to follow-up on the change.
  • How should this emergency be documented in the medical record? Discuss any documentation standards and tools such as order sets or dot-phrases available to clinicians.
  • What other reporting is required for this emergency transfer? This could include accrediting or licensing bodies, malpractice carriers, and internal organizational reporting.
  • What other follow up would be expected after this emergency? Consider follow-up for patient/family or staff, or other next steps.

Documentation

Document the date, location, clinical scenario(s), time spent in drill, and attendees so you can track participation against your practice’s internal policies and accreditation and/or licensure requirements. You can document your drill using the form at https://bit.ly/4aSAVjk or the QR code to complete and receive a digital copy of your Drill Report.

This will also contribute your drill data to help improve services and identify best practices. Data identifiable to a practice or individual will never be shared without consent.

QR Code

References

Shoulder dystocia: Practice Bulletin 178. Obstet Gynecol. 2017 May;129(5):e123-e133.
doi: 10.1097/AOG.0000000000002043

Weiner, GM., Zaichkin, J. Neonatal Resuscitation (8th Edition). American Academy of Pediatrics;2021.
doi:10.1542/9781610025256

Drill Kit Icon

Drill Kit

Birth with Postpartum Hemorrhage

Coordinator Information

Drill Description

Introduction

Step Up Together Drill Kits support interdisciplinary clinical teams to run emergency drills involving patient hand-offs and/or transport to a higher level facility.

Each Drill Kit can be used to run a Full Transfer Drill that tests the full, interdisciplinary process of care or a Partial Transfer Drill that involves running just one segment of the scenario (e.g. before transfer or after hospital hand-off). The toolkit includes a standardized high-fidelity case designed to test the process of transferring a birthing person or newborn from one location to another with an interdisciplinary team involved in the care. Observation criteria and a Debriefing and Action Guide are provided to elicit continuous improvement of interdisciplinary care processes and promote respectful care along the continuum.

Drill Description

This Drill Kit tests the emergency response to an immediate postpartum hemorrhage occurring in a community birth setting including emergency transport of a postpartum patient.

It is appropriate for:

  • Home birth practices
  • Birth centers
  • Critical access hospitals without OB services
  • Other facilities or units requiring patient transport for emergency surgery or stabilization (e.g. emergency department)

And may further engage:

  • EMS or other emergency transport partners
  • Labor & Birth unit and other relevant units at the referral hospital

To test the process of:

  • Postpartum emergency transport

Learning Objectives:

  • Identify and respond in a timely and evidence-based manner to imminent birth and immediate postpartum hemorrhage in the community setting.
  • Review ways to promote person-focused care during emergencies.
  • Identify and respond to social and clinical risk factors for postpartum hemorrhage.
  • Identify need for higher level of care and initiate appropriate hospital transfer.
  • Practice collaboration that adheres to relevant transfer protocols with warm hand-offs across levels of care.
  • Communicate effectively, and with dignity to the patient, support people, and additional healthcare personnel in the event of a postpartum transfer.
  • Use debriefing skills to promote equity and ensure integration of individual and collective learning.

Last updated: December 2024

Authored by:

Alexa Dougherty, MSN, PHN, CNM

Reviewed by:

Debra Bingham, DrPH, RN, FAAN
Jen Johnson, MSN, CNM
Amy Romano, MBA, MSN, CNM, FACNM

You will be coodinating a...

Partial Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer, but participants are only practicing part of the scenario: either the part that happens in the community before hospitalization, or the arrival at the hospital and post-transfer management.

Who's involved?

Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.

Planning Needs

Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.

Full Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer and participants practice all phases of the transfer: care in the community, emergency transport, and arrival and management at the hospital.

Who's involved?

Full practice/facility team from the community birth setting, plus transport and hospital personnel.

Planning Needs

Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.

Setup and Procedure

Birth with Postpartum Hemorrhage

Partial Transfer Drill Instructions

Participants (Minimum of two, up to full practice/facility team):

  • *Drill Scenario Roles:
    • If conducting the drill in the community setting: 
      • Assign a lead provider and a birth assistant.
      • Additional learners may be assigned to play the role of a 911 dispatcher, EMS Lead, and/or a hospital provider receiving the report. 
    • If conducting the drill at the transfer hospital, assign an attending provider and a nurse. Additional learners may be assigned to play the role of the transferring provider and/or the EMS lead.
  • Non-clinical roles: Assign learners to play the roles of: 
    • the patient and partner
    • doula
    • siblings/other family
  • *Drill Coordinator: Presents the case scenario, tracks hand-off times,  and leads the debrief; may double as the birth assistant/nurse if this is a 2-person drill.
  • Observer(s): Unassigned learners are observers, who use Observer Worksheets to track actions and processes during the drill.

* Required roles

Setting and supplies: 

  • Birth suite set up for birth
  • Newborn mannequin or doll
  • Scale for quantifying blood loss
  • Dry weight of key elements in the birth pack, e.g., lap sponges, peripads, chux
  • Supplies to document clinical care of simulated patient (e.g. maternal and neonatal blank transfer forms, blank paper charting templates or fake/simulated patient in the electronic record system)
  • Stopwatch or timer
  • Optional: fake blood, red fabric to simulate blood, or blood volume flash cards

Additional Resource:

Instructions: 

  • If conducting a Partial Transfer Drill in the community setting, use Clinical Scenario: Drill Begins in the Community Setting, and conclude the drill with simulated handoff to EMS. If conducting a Partial TransferDrill in the hospital, use Clinical Scenario: Drill Begins at Hospital Handoff, and conclude as directed in the scenario.
  • Drill Coordinator reads Clinical Scenario.
  • When team is ready, start timer and state aloud, “begin drill.”
  • Read additional prompts on the Coordinator Prompts at the appropriate times.
  • Learners in drill scenario roles may ask for clinical values by acting out the assessment  (e.g. taking a blood pressure or prepping IV supplies and simulating starting an IV). Fetal heart tones are noted as 6-second counts.
    •  For visual or subjective assessments, they can ask. If assessments are abnormal or specified, they will be provided in the case. Otherwise, Drill Coordinator may provide any normal value in response.
  • Observers should use the Observer Worksheets to assess performance of clinical tasks as the drill progresses.
  • People assigned to clinical roles and the Drill Coordinator should review and complete the Observer Worksheets immediately after the drill, before Debriefing and Action Planning.

Setup and Procedure

Birth with Postpartum Hemorrhage

Full Transfer Drill Instructions

Participants (Full team plus transport and/or hospital personnel): 

Assign the following roles:

  • *Drill Scenario Roles: 
    • In the initial community setting: Assign a lead provider and a birth assistant.
    • During patient transport: Assign an EMS lead and other roles as relevant.
    • In the referral hospital: Assign an attending provider and a nurse and other roles such as transferring provider and/or the EMS lead as relevant. 
  • Non-clinical roles: Assign learners to play the roles of the patient and partner/support person.
  • *Drill Coordinator(s): Presents the case scenario, tracks hand-off times, and leads the debrief. Consider assigning a coordinator for each segment of the transfer.
  • Observer(s): Unassigned learners are observers, who use Observer Worksheets to track actions and processes during the drill.

*Required roles

Setting and supplies: 

  • Birth suite set up for birth
  • Newborn mannequin or doll
  • Scale for quantifying blood loss
  • Dry weight of key elements in the birth pack, e.g., lap sponges, peripads, chux
  • Supplies to document clinical care of simulated patient (e.g. maternal and neonatal blank transfer forms, blank paper charting templates or fake/simulated patient in the electronic record system)
  • Stopwatch or timer
  • Optional: fake blood, red fabric to simulate blood, or blood volume flash cards

Additional Resource:

Instructions: 

  • Use Clinical Scenario: Drill Begins in the Community Setting
  • Drill Coordinator reads Drill Scenario.
  • When team is ready, start timer and state aloud, “begin drill.”
  • Read additional prompts at the appropriate times.
  • Learners in clinical roles may ask for clinical values by acting out the assessment  (e.g. taking a blood pressure or prepping IV supplies and simulating starting an IV). Fetal heart tones are noted as 6-second counts.
    • For visual or subjective assessments, they can ask. If assessments are abnormal or specified, they will be provided in the case. Otherwise, Drill Coordinator may provide any normal value in response.
  • Restart the timer and log the time elapsed after each portion of the Full Transfer Drill: Before Transport, During Transport, and At Hospital.
  • Observers should use the Observer Worksheets to assess performance of clinical tasks as the drill progresses.
  • People assigned to primary and secondary roles and the Drill Coordinator should review and complete the Observer Worksheets immediately after the drill, before Debriefing and Action Planning.

Download & Print

Observer Worksheets

Clinical Scenario

Clinical Scenario

Drill Begins in Community Setting

Read the following case aloud. Prior to beginning, participants may ask clarifying questions, but should not discuss their plan of care or move any supplies or equipment.

Amara is a 38 year old G5P4004 at 39w4d who has been in prodromal labor for 2 days. She had a normal prenatal course with the exception of anemia. Her last Hematocrit was 31% and Hemoglobin 10.1 at 36 weeks. She is GBS negative. Blood type: O+. Her prenatal Blood Pressure was typically 110s/70s. She called the birth center to report “things are getting much stronger.” She lives 45 minutes away, and made plans to come to the center. Upon arrival, she is very stoic and not speaking. She is able to ambulate with support to the birth suite. As she leans over the bed with a strong contraction, her water breaks for clear fluid, and she states, “I think the baby is coming out!”

Clinical Scenario

Drill Begins at Hospital Handoff

Read the following case aloud. Prior to beginning, participants may ask clarifying questions, but should not discuss their plan of care or move any supplies or equipment.

You receive the following report by phone from the on-call midwife of the nearby community practice. They introduce themself and state:

“I am calling in regards to a transfer for a postpartum hemorrhage. Our patient, Amara, is a 38 year old G5P4004 at 39w4d who presented to the birth center in active labor and had a normal vaginal delivery of a viable male infant within minutes of arriving. Birth occurred 10 minutes ago, her quantified blood loss (QBL) is currently 1000cc with a persistent trickle. We are transferring for continued management of, and recovery from, her postpartum hemorrhage. She was noted to have a large gush of blood 5 minutes after delivery, the placenta was delivered intact and she continued to have bleeding. She has received 10u IM pitocin, 800mcg sublingual Misoprostol and 0.2mg IM methergine. She was straight cathed for 300cc urine. She has an 18G IV in her right forearm with 20 units Pitocin in 500mL normal saline infusing. Her QBL is 1100cc at this time. She is slightly tachycardic and hypotensive and had one episode of dizziness that resolved. We are transferring for continued management and observation during her postpartum stay. EMS just arrived and we are preparing to transport her to your facility. I will accompany the patient to the hospital with EMS.”

Print copies of the completed transfer form from the community midwife.

Significant Prenatal Hx: GBS neg; O+; Anemia, last Hct/Hgb: 31%/10.1 at 36wks. No hx of asthma or hypertension. Uncomplicated pregnancy and previous deliveries. See transfer form. 

It is now 15 minutes after delivery. No changes in clinical scenario since initial SBAR.

Coordinator Prompts

Community Setting

Coordinator Prompts

Time Scenario (Read Aloud) Values (Share only if assessed)
00:00

Scenario begins. Start timer.

Adult Vitals: HR 95, BP unable to auscultate
FHTs: 130s
Vaginal exam: 10cm/100%/+3
01:00

Patient has another contraction after SROM and feels the need to push.

Adult Vitals: HR 95, BP unable to auscultate
FHTs: unable to auscultate
Vaginal exam: crowning
Other: SROM, clear
02:00

After 2 pushes, she delivers the baby who is vigorous with spontaneous cry.

Adult Vitals: HR 95, BP unable to auscultate
Newborn Vitals: HR >100, active, +grimace, pink, respirations spontaneous but irregular.
03:00

Baby is vigorous, appears LGA, baby is placed skin-to-skin.

Adult Vitals: HR 94, BP 104/68, Temp 98.0F
Newborn Vitals: HR 120, RR 62, pink, acrocyanosis, good tone. 1-minute Apgar 8.
04:00

You begin to see cord lengthening. Patient reports strong cramping.

Adult Vitals: HR 94, BP 104/68, Temp 98.0F
Newborn Vitals: HR 120, RR 62, pink, good tone
Vaginal/perineal exam: no visible lacerations
Other: Minimal bleeding
05:00

You note a large gush of blood on chux pad with a persistent trickle of blood after the initial gush.

Adult Vitals: HR 94, BP 104/68, Temp 98.0F
Newborn Vitals: HR 124, RR 58, Temp 98.8F
Vaginal/perineal exam: no visible lacerations
Other: QBL 500cc
05:30

You are able to assist the placenta to deliver with gentle traction. There is a large gush after the placenta which soaks most of the chux pad.

Adult Vitals: HR 94, BP 104/68, fundus boggy, unresponsive to massage
Newborn Vitals: HR 124, RR 58, Temp 98.8F
Vaginal/perineal exam: Clots noted in vagina and lower uterine segment; no visible lacerations
Other: Additional 300cc QBL;  Total QBL 800cc
06:30

A tangerine sized clot of blood is noted from vagina. A persistent slow trickle of blood continues.

Patient says she is feeling dizzy and asks if someone else can hold the baby.

Adult Vitals: HR 104, BP 99/56, SpO2 @97%, fundus boggy, 2fb above umbilicus and deviated
Newborn Vitals: HR 124, RR 58, Temp 98.8F,  5-minute Apgar 9
Vaginal/perineal exam: clots noted in vagina and lower uterine segment, no visible lacerations
Other: Additional 200cc QBL; Total QBL 1000cc
07:30

Bleeding slows down & fundus is now firm to massage. Patient denies dizziness.

Adult Vitals: HR 110, BP 94/55, fundus firm, midline, 2fb below umbilicus
Newborn Vitals: HR 124, RR 58, Temp 98.8F
Vaginal/perineal exam: no visible lacerations
Other: Minimal bleeding; Total QBL 1000cc
09:30

Upon visual inspection, perineal pad is now soaked. Persistent trickle of blood noted.

Adult Vitals: HR 112, BP 92/56, fundus firm, midline 1fb below umbilicus
Newborn Vitals: HR 124, RR 58, Temp 98.8F
Vaginal/perineal exam: Persistent trickle of blood, no clots noted, no visible lacerations
Other: Additional 100cc QBL; Total QBL 1100cc

Repeat prior prompt every 1-2 minutes until transfer process is initiated

During Transfer

Coordinator Prompts

Time Scenario (Read Aloud) Values (Share only if assessed)
00:00

Restart Timer.

Transport begins. Amara is secured on the stretcher, alert and oriented, feeling ok. There is a new pad on Amara’s perineum that now has a quarter-sized spot of blood noted.

Adult Vitals: HR 115, BP 95/52, SpO2 97%, fundus firm 1fb below umbilicus
Vaginal/perineal exam: deferred
Other: No persistent trickling
02:00

Amara reports significant cramping.

Adult Vitals: HR 115, BP 95/52, SpO2 97%, fundus firm 1fb below umbilicus
Vaginal/perineal exam: deferred
Other: minimal bleeding, no clots
03:00

Amara is anxious, wondering if she is OK and what will happen at the hospital. Denies dizziness.

Adult Vitals: HR 112, BP 96/54, SpO2 97%
fundus firm 1fb below umbilicus
Vaginal exam: deferred
Other: minimal bleeding, no clots

Repeat prior prompt every 1-2 minutes until patient reaches hospital unit.

Receiving Hospital

Coordinator Prompts

Time Scenario (Read Aloud) Values (Share only if assessed)
00:00

Restart timer.

Scenario begins upon the arrival of the transport team and patient.

Adult Vitals: HR 118, BP 94/54, SpO2 97%
fundus firm 1fb below umbilicus
Vaginal Exam: No visible lacerations
Other: QBL 1100cc
01:30

You transfer Amara from the stretcher to the hospital bed. She requests to stand to transfer and reports some dizziness as she stands. A golf ball sized clot of blood is noted upon standing. No further trickling.

Adult Vitals: HR 118, BP 94/54, SpO2 98%
fundus firm 1fb below umbilicus
Vaginal exam: golf ball sized clot from vagina. No visible lacerations.
Other: +100cc blood loss, Total QBL: 1200cc
03:00

Amara again reports feeling slightly dizzy.

Adult Vitals: HR 120, BP 92/52, SpO2 97%
Fundus firm at 2fb below umbilicus
Vaginal Exam: no further clots noted in vagina or lower uterine segment. No visible lacerations.
Other: No clots visualized on bedside ultrasound. Dizziness improves when supine. QBL 1200cc
04:00

Patient resting in bed now, feeling better. Denies dizziness.

Adult Vitals: HR 116, BP 96/58, SpO2 98%. Fundus firm at 2fb below umbilicus
Vaginal Exam: Perineal pad with nickel sized area of blood
Other: QBL 1200cc
06:00

Patient continues to feel well, denying dizziness. Minimal bleeding noted on perineal pad and chux.

Adult Vitals: HR 100, BP 96/58, SpO2 97%
Fundus firm at 2fb below umbilicus
Vaginal exam: Perineal pad with nickel sized area of blood
Other: QBL 1200cc

End scenario. Document time elapsed.

Debriefing and Action Guide

Reflection Questions

  • What happened here? Ask 1-2 people to give a brief high-level summary so everyone’s on the same page.
  • What went well? Give everyone a chance to share the good stuff they noticed before critiquing.
  • What needs attention or improvement? Try to focus on processes and systems, not assigning blame.
  • Are there other appropriate ways to manage this emergency or transport? Consider different approaches such as who might accompany the patient, dyad vs. separate transfers, etc.
  • Were we prepared for this emergency? The answer will help clarify the Action Steps.

Action Steps

  • What changes are needed to processes or procedures? Make sure to assign someone to follow-up on the change.
  • How should this emergency be documented in the medical record? Discuss any documentation standards and tools such as order sets or dot-phrases available to clinicians.
  • What other reporting is required for this emergency transfer? This could include accreditation or licensing bodies, malpractice carriers, and internal organizational reporting.
  • What other follow up would be expected after this emergency? Consider follow-up for patient/family or staff, or other next steps.

Documentation

Document the date, location, clinical scenario(s), time spent in drill, and attendees so you can track participation against your practice’s internal policies and accreditation and/or licensure requirements. You can document your drill using the form at https://bit.ly/4aSAVjk or the QR code to complete and receive a digital copy of your Drill Report.

This will also contribute your drill data to help improve services and identify best practices. Data identifiable to a practice or individual will never be shared without consent.

QR Code

References

Bateman BT, Berman MF, Riley LE, Leffert LR. The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries. Anesthesia & Analgesia. 2010;110(5):1368-1373.
doi:10.1213/ane.0b013e3181d74898

Likis FE, Sathe NA, Morgans AK, et al. Management of postpartum hemorrhage. Comparative Effectiveness Review: Number 151. Agency for Healthcare Research and Quality (US);2015. 

Obstetric Hemorrhage Patient Safety Bundle. American College of Obstetricians and Gynecologists; 2022. https://saferbirth.org/wp-content/uploads/U2-FINAL_AIM_Bundle_ObstetricHemorrhage.pdf

Oyelese Y, Ananth CV. Postpartum Hemorrhage: Epidemiology, Risk Factors, and Causes. Clinical Obstetrics and Gynecology. 2010 Mar;53(1):147-56.
doi: 10.1097/GRF.0b013e3181cc406d

Postpartum hemorrhage: Practice Bulletin 183. Obstet Gynecol. 2017 Oct;130(4):923-925.
doi: 10.1097/AOG.0000000000002346

Quantification of blood loss: AWHONN Practice Brief Number 1. J Obstet Gynecol Neonatal Nurs. 2015 Jan-Feb;44(1):158-160.
doi: 10.1111/1552-6909.12519

Drill Kit Icon

Drill Kit

First Stage Fetal Bradycardia

Coordinator Information

Drill Description

Introduction

Step Up Together Drill Kits support interdisciplinary clinical teams to run emergency drills involving patient hand-offs and/or transport to a higher level facility.

Each Drill Kit can be used to run a Full Transfer Drill that tests the full, interdisciplinary process of care or a Partial Transfer Drill that involves running just one segment of the scenario (e.g. before transfer or after hospital hand-off). The toolkit includes a standardized high-fidelity case designed to test the process of transferring a birthing person or newborn from one location to another with an interdisciplinary team involved in the care. Observation criteria and a Debriefing and Action Guide are provided to elicit continuous improvement of interdisciplinary care processes and promote respectful care along the continuum.

Drill Description

This Drill Kit tests the emergency response to fetal bradycardia in the first stage of labor occurring in a community birth setting including emergency transport of a laboring patient.

It is appropriate for:

  • Home birth practices
  • Birth centers

And may further engage:

  • EMS or other emergency transport partners
  • Labor & Birth unit and other relevant units at the referral hospital

To test the process of:

  • Intrapartum emergency transport

Learning Objectives:

  • Identify and respond to fetal heart rate abnormalities in the context of intermittent auscultation in planned community birth.
  • Review ways to promote person-focused care during emergencies.
  • Perform initial steps to attempt to resolve fetal bradycardia in the first stage of labor.
  • Identify need for higher level of care and initiate appropriate hospital transfer.
  • Practice collaboration that adheres to relevant transfer protocols with warm hand-offs across levels of care.
  • Communicate effectively, and with dignity, to the patient, support people, and additional healthcare personnel in the event of an intrapartum transfer.

Last updated: December 2024

Authored by:

Amy Romano, MBA, MSN, CNM, FACNM

Reviewed by:

Alexa Dougherty, MSN, PHN, CNM
Wendy Gordon, DM, MPH, CPM
Jen Johnson, MSN, CNM

You will be coodinating a...

Partial Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer, but participants are only practicing part of the scenario: either the part that happens in the community before hospitalization, or the arrival at the hospital and post-transfer management.

Who's involved?

Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.

Planning Needs

Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.

Full Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer and participants practice all phases of the transfer: care in the community, emergency transport, and arrival and management at the hospital.

Who's involved?

Full practice/facility team from the community birth setting, plus transport and hospital personnel.

Planning Needs

Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.

Setup and Procedure

First Stage Fetal Bradycardia

Partial Transfer Drill Instructions

Participants (Minimum of two, up to full practice/facility team):

  • *Drill Scenario Roles:
    • If conducting the drill in the community setting: 
      • Assign a lead provider and a birth assistant.
      • Additional learners may be assigned to play the role of a 911 dispatcher, EMS Lead, and/or a hospital provider receiving the report. 
    • If conducting the drill at the transfer hospital, assign an attending provider and a nurse. Additional learners may be assigned to play the role of the transferring provider and/or the EMS lead.
  • Non-clinical roles: Assign learners to play the roles of: 
    • The patient and partner
    • doula
    • siblings/other family
  • *Drill Coordinator: Presents the case scenario, tracks hand-off times,  and leads the debrief; may double as the birth assistant/nurse if this is a 2-person drill.
  • Observer(s): Unassigned learners are observers, who use Observer Worksheets to track actions and processes during the drill.

* Required roles

Setting and supplies: 

Additional Resource:

Instructions: 

  • If conducting a Partial Transfer Drill in the community setting, use Clinical Scenario: Drill Begins in the Community Setting, and conclude the drill with simulated handoff to EMS. If conducting a Partial TransferDrill in the hospital, use Clinical Scenario: Drill Begins at Hospital Handoff, and conclude as directed in the scenario.
  • Drill Coordinator reads Clinical Scenario.
  • When team is ready, start timer and state aloud, “begin drill.”
  • Read additional prompts on the Coordinator Prompts at the appropriate times.
  • Learners in clinical roles may ask for clinical values by acting out the assessment  (e.g. taking a blood pressure or prepping IV supplies and simulating starting an IV). Fetal heart tones are noted as 6-second counts.
    •  For visual or subjective assessments, they can ask. If assessments are abnormal or specified, they will be provided in the case. Otherwise, Drill Coordinator may provide any normal value in response.
  • Observers should use the Observer Worksheets to assess performance of clinical tasks as the drill progresses.
  • People assigned to clinical roles and the Drill Coordinator should review and complete the Observer Worksheets immediately after the drill, before Debriefing and Action Planning.

Setup and Procedure

First Stage Fetal Bradycardia

Full Transfer Drill Instructions

Participants (Full team plus transport and/or hospital personnel): 

Assign the following roles:

  • *Drill Scenario Roles:
    • In the initial community setting: Assign a lead provider and a birth assistant.
    • During patient transport: Assign an EMS lead and other roles as relevant.
    • In the referral hospital: Assign an attending provider and a nurse and other roles such as transferring provider and/or the EMS lead as relevant. 
  • Non-clinical roles: Assign learners to play the roles of patient, partner, doula, siblings/other family
  • *Drill Coordinator(s): Presents the case scenario, tracks hand-off times, and leads the debrief. Consider assigning a coordinator for each segment of the transfer.
  • Observer(s): Unassigned learners are observers, who use Observer Worksheets to track actions and processes during the drill.

*Required roles

Setting and supplies: 

  • Birth suite set up for birth
  • Intermittent auscultation supplies
  • Supplies to document clinical care of simulated patient (e.g. maternal and neonatal blank transfer forms, blank paper charting templates or fake/simulated patient in the electronic record system)
  • Stopwatch or timer

Additional Resource:

Instructions: 

  • Use Clinical Scenario: Drill Begins in the Community Setting
  • Drill Coordinator reads Drill Scenario.
  • When team is ready, start timer and state aloud, “begin drill.”
  • Read additional prompts at the appropriate times.
  • Learners in clinical roles may ask for clinical values by acting out the assessment  (e.g. taking a blood pressure or prepping IV supplies and simulating starting an IV). Fetal heart tones are noted as 6-second counts.
    •  For visual or subjective assessments, they can ask. If assessments are abnormal or specified, they will be provided in the case. Otherwise, Drill Coordinator may provide any normal value in response.
  • Restart the timer and log the time elapsed after each portion of the Full Transfer Drill: Before Transport, During Transport, and At Hospital.
  • Observers should use the Observer Worksheets to assess performance of clinical tasks as the drill progresses.
  • People assigned to primary and secondary roles and the Drill Coordinator should review and complete the Observer Worksheets immediately after the drill, before Debriefing and Action Planning.

Download & Print

Observer Worksheets

Clinical Scenario

Clinical Scenario

Drill begins in community setting

Deirdra is a 38 year old G3P0020 at 40 5/7 weeks in active labor who was admitted into your care 1 hour ago at 6cm / 70% / -2. Membranes ruptured with the admission exam for copious clear fluid. Deirdra has had a normal pregnancy and all labs are normal. Nonstress test yesterday was reactive with baseline 128. EFW 7lbs. She is GBS negative and Rh positive. Admission vital signs are stable, BP 132/78, HR 84, Temp 98.9F.  Baseline fetal heart tones via handheld Doppler were 140 bpm with no audible accelerations noted. FHT check 30 minutes ago was 136 with no audible increases or decreases noted.

Deirdra is standing in the shower coping well with hydrotherapy and support from her partner, Taylor and doula, Sandra, when you return to perform auscultation. As the contraction subsides and goes away, you listen and obtain the following values for 6-second counts: (read at 6 second intervals) 10, 9, 9, 10, 8, 9.

Clinical Scenario

Drill begins at hospital handoff

You receive the following report by phone from the on-call midwife of the nearby community practice. They introduce themself and state:

“I’m calling to initiate an emergency intrapartum transfer for repetitive fetal heart rate decelerations for a nullip in active labor remote from delivery. Deidra is a 38 year-old G3P0020 at 40 weeks 5 days gestation with a normal, uncomplicated pregnancy who was admitted 1 hour ago at 6cm / 70% / -2. Membranes ruptured with the admission exam for copious clear fluid. Admission VS were BP 132/78, HR 84, Temp 98.9F.   Admission FHT baseline was 140 with no accelerations or decelerations noted, and FHT check 30 minutes after admission was normal at 136 with no accelerations or decelerations noted. On a routine check 7 minutes ago, a deceleration to the 80’s lasting at least 30 seconds was noted during a contraction. FHTs returned gradually to the 120s and 130s and then decelerated to the 60’s – 70’s with the next contraction, and have remained below 100 despite position changes. Contractions are Q2-3 minutes x 60 seconds, and the most recent cervical exam was 7cm / 90% / -1. An IV with 18g was initiated in the left arm, infusing normal saline. I am transferring her for continuous fetal monitoring and likely emergency cesarean birth. She will be accompanied by myself, her partner Taylor, and her doula Sandra.”

Print copies of the completed transfer form from the community midwife.

Coordinator Prompts

Community Setting

Coordinator Prompts

Time Scenario (Read Aloud) Values (Share only if assessed)
00:00

Scenario begins. Start timer.

Pulse: 88
Recheck FHTs: 6-second count is 11
Vaginal exam: 7/90/-1
Any other value: normal
01:00

Deidra coping well with contractions but reports feeling them much more intensely

Pulse: 96
Recheck FHTs: 6-second counts between contractions are: 11, 11, 12, 13, 12, 11
Vaginal exam: 7/90/-1
Any other value: normal
02:30

Another contraction has started.

Pulse: 98
Recheck FHTs: 6-second counts starting at the peak of the contraction:  9, 8, 7, 8, 9, 10,
Vaginal exam: 7/90/-1
Any other value: normal
03:30

Deidra complains of being lightheaded.

Pulse: 96
Recheck FHTs: 6-second count is 10
Vaginal exam: 7/90/-1
Any other value: normal
04:30

Another contraction begins.

Pulse: 100
Recheck FHTs: 6-second counts are: 6, 7, 6, 7, 8, 7
Vaginal exam: 7/90/-1, copious bloody show
Any other value: normal

Repeat prior prompt every 1-2 minutes until emergency transport process is activated.

During Transfer

Coordinator Prompts

Time Scenario (Read Aloud) Values (Share only if assessed)
00:00

Restart timer.

A contraction begins as the ambulance leaves the birth center. Deidra is breathing and moaning heavily with contractions and wants to change positions.

Pulse: 100
FHTs: 6-second count is 10
Any other value: normal
02:00

Another contraction begins. Deidra is asking if her baby is going to be OK.

Pulse: 100
FHTs: 6-second count is 10
Any other value: normal
04:00

Another contraction begins. Deidra is asking what is going to happen to her when she gets to the hospital.

Pulse: 94
FHTs: 6-second count is 10
Any other value: normal

Repeat prior prompt every 1-2 minutes until patient reaches hospital unit.

Receiving Hospital

Coordinator Prompts

Time Scenario (Read Aloud) Values (Share only if assessed)
00:00

Restart timer.

Scenario begins upon the arrival of the transport team and patient.

Pulse: 92
FHTs: 6-second count is 9
Toco: no readings yet
Vaginal exam: 7cm/90%/0
Any other value: normal
02:00

Deidra begins having a contraction. On EFM, FHT baseline is 94 with minimal variability.

Pulse: 90
Continuous EFM: Baseline 94, minimal variability
Toco: q2-3min
Vaginal exam: 7cm/90%/0
Any other value: normal
03:00

The contraction is over. FHT deceleration noted to 68.

Pulse: 90
Continuous EFM: Baseline 94, minimal variability,  late decelerations to the 60’s.
Toco: q 2-3min
Vaginal exam: 7cm/90%/0
Any other value: normal
04:00

Another contraction begins. Yellow-tinged fluid is noted on the pad under Deidra.

Pulse: 90
Continuous EFM: Baseline 94, minimal variability,  late decelerations to the 60’s.
Toco: q2-3min
Vaginal exam: 7cm/90%/0
Any other value: normal

Repeat prior 2 prompts every 1-2 minutes until patient is fully admitted to the unit and stat-cesarean is initiated.

Debriefing and Action Guide

Reflection Questions

  • What happened here? Ask 1-2 people to give a brief high-level summary so everyone’s on the same page.
  • What went well? Give everyone a chance to share the good stuff they noticed before critiquing.
  • What needs attention or improvement? Try to focus on processes and systems, not assigning blame. Pay special attention to evaluating the handoffs from midwife to EMS, EMS to hospital staff, midwife to physician.
  • Are there other appropriate ways to manage this emergency or transport? Consider different approaches such as who might accompany patient, etc.
  • Were we prepared for this emergency?The answer will help clarify the Action Steps

 

Action Steps

  • What changes are needed to processes, procedures? Make sure to assign someone to follow-up on the change.
  • How should this emergency be documented in the medical record? Discuss any documentation standards and tools such as order sets or dot-phrases available to clinicians.
  • What other reporting is required for this emergency transfer? This could include accrediting or licensing bodies, malpractice carriers, and internal organizational reporting.
  • What other follow up would be expected after this emergency? Consider follow-up for patient/family or staff, or other next steps.

Documentation

Document the date, location, clinical scenario(s), time spent in drill, and attendees so you can track participation against your practice’s internal policies and accreditation and/or licensure requirements. You can document your drill using the form at https://bit.ly/4aSAVjk or the QR code to complete and receive a digital copy of your Drill Report.

This will also contribute your drill data to help improve services and identify best practices. Data identifiable to a practice or individual will never be shared without consent.

QR Code

References

Fahey, JO. The recognition and management of intrapartum fetal heart rate emergencies: Beyond definitions and classification. J Midwifery Women’s Health. 2014;59(6):616-623. doi:10.1111/jmwh.12256

Intermittent auscultation for intrapartum fetal heart rate surveillance: American College of Nurse Midwives. J Midwifery & Women’s Health. 2015;60(5):626-632. doi: 10.1111/jmwh.12372

Romano AM., Buxton M. A Multimethod Improvement Project to Strengthen Intermittent Auscultation Practice Among Nurse-Midwives and Nurses. J Midwifery Womens Health. 2020 May;65(3):362-369. doi:10.1111/jmwh.13113

Wisner, K., & Holschuh, C. Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) Position Statement: Fetal heart rate auscultation. Nursing for Women’s Health. 2018; 22(6), e1-e32. doi: 10.1016/j.nwh.2024.03.001

Drill Kit Icon

Drill Kit

Second Stage Fetal Bradycardia

Coordinator Information

Drill Description

Introduction

Step Up Together Drill Kits support interdisciplinary clinical teams to run emergency drills involving patient hand-offs and/or transport to a higher level facility.

Each Drill Kit can be used to run a Full Transfer Drill that tests the full, interdisciplinary process of care or a Partial Transfer Drill that involves running just one segment of the scenario (e.g. before transfer or after hospital hand-off). The toolkit includes a standardized high-fidelity case designed to test the process of transferring a birthing person or newborn from one location to another with an interdisciplinary team involved in the care. Observation criteria and a Debriefing and Action Guide are provided to elicit continuous improvement of interdisciplinary care processes and promote respectful care along the continuum.

Drill Description

This Drill Kit tests the emergency response to a second stage fetal bradycardia occurring in a community birth setting including emergency transport of an intrapartum patient.

It is appropriate for:

  • Home birth practices
  • Birth centers
  • Other facilities or units requiring patient transport for emergency surgery or stabilization (e.g. emergency department)

And may further engage:

  • EMS or other emergency transport partners
  • Labor & Birth unit and other relevant units at the referral hospital

To test the process of:

  • Intrapartum emergency transport

Learning Objectives:

  • Identify and respond to fetal heart rate abnormalities in the context of intermittent auscultation in planned community birth.
  • Review ways to promote person-focused care during emergencies.
  • Perform initial steps to attempt to resolve fetal bradycardia in the second stage of labor.
  • Identify need for higher level of care and initiate appropriate hospital transfer.
  • Practice collaboration that adheres to relevant transfer protocols with warm hand-offs across levels of care.
  • Communicate effectively, and with dignity, to the patient, support people, and additional healthcare personnel in the event of an intrapartum transfer.

Last updated: December 2024

Authored by:

Alexa Dougherty, MSN, PHN, CNM

Reviewed by:

Jen Johnson, MS, CNM
Amy Romano, MBA, MSN, CNM, FACNM
Laura Thielke, MS, CNM

You will be coodinating a...

Partial Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer, but participants are only practicing part of the scenario: either the part that happens in the community before hospitalization, or the arrival at the hospital and post-transfer management.

Who's involved?

Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.

Planning Needs

Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.

Full Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer and participants practice all phases of the transfer: care in the community, emergency transport, and arrival and management at the hospital.

Who's involved?

Full practice/facility team from the community birth setting, plus transport and hospital personnel.

Planning Needs

Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.

Setup and Procedure

Second Stage Fetal Bradycardia

Partial Transfer Drill Instructions

Participants (Minimum of two, up to full practice/facility team):

  • *Drill Scenario Roles
    • If conducting the drill in the community setting: 
      • Assign a lead provider and a birth assistant.
      • Additional learners may be assigned to play the role of a 911 dispatcher, EMS Lead, and/or a hospital provider receiving the report. 
    • If conducting the drill at the transfer hospital, assign an attending provider and a nurse. Additional learners may be assigned to play the role of the transferring provider and/or the EMS lead.
  • Non-clinical roles: Assign learners to play the roles of:
    • patient and partner
    • doula
    • siblings/other family
  • *Drill Coordinator: Presents the case scenario, tracks hand-off times,  and leads the debrief; may double as the birth assistant/nurse if this is a 2-person drill.
  • Observer(s): Unassigned learners are observers, who use Observer Worksheets to track actions and processes during the drill.

* Required roles

Setting and supplies: 

Additional Resource:

Instructions: 

  • If conducting a Partial Transfer Drill in the community setting, use Clinical Scenario: Drill Begins in the Community Setting, and conclude the drill with simulated handoff to EMS. If conducting a Partial TransferDrill in the hospital, use Clinical Scenario: Drill Begins at Hospital Handoff, and conclude as directed in the scenario.
  • Drill Coordinator reads Clinical Scenario.
  • When team is ready, start timer and state aloud, “begin drill.”
  • Read additional Coordinator Prompts at the appropriate times.
  • Learners in drill scenario roles may ask for clinical values by acting out the assessment (e.g. taking a blood pressure or prepping IV supplies and simulating starting an IV). Fetal heart tones are noted as 6-second counts.
    •  For visual or subjective assessments, they can ask. If assessments are abnormal or specified, they will be provided in the case. Otherwise, Drill Coordinator may provide any normal value in response.
  • Observers should use the Observer Worksheets to assess performance of clinical tasks as the drill progresses.
  • People assigned to clinical roles and the Drill Coordinator should review and complete the Observer Worksheets immediately after the drill, before Debriefing and Action Planning.

Setup and Procedure

Second Stage Fetal Bradycardia

Full Transfer Drill Instructions

Participants (Full team plus transport and/or hospital personnel): 

Assign the following roles:

  • *Drill Scenario Roles: 
    • In the initial community setting: Assign a lead provider and a birth assistant.
    • During patient transport: Assign an EMS lead and other roles as relevant.
    • In the referral hospital: Assign an attending provider and a nurse and other roles such as transferring provider and/or the EMS lead as relevant. 
  • Non-clinical roles: Assign learners to play the roles of patient, partner, doula, siblings/other family
  • *Drill Coordinator(s): Presents the case scenario, tracks hand-off times, and leads the debrief. Consider assigning a coordinator for each segment of the transfer.
  • Observer(s): Unassigned learners are observers, who use Observer Worksheets to track actions and processes during the drill.

*Required roles

Setting and supplies: 

  • Birth suite set up for birth
  • Intermittent auscultation supplies
  • Supplies to document clinical care of simulated patient (e.g. maternal and neonatal blank transfer forms, blank paper charting templates or fake/simulated patient in the electronic record system)
  • Stopwatch or timer

Additional Resource:

Instructions: 

  • Use Clinical Scenario: Drill Begins in the Community Setting
  • Drill Coordinator reads Drill Scenario.
  • When team is ready, start timer and state aloud, “begin drill.”
  • Read additional Coordinator Prompts at the appropriate times.
  • Learners in drill scenario roles may ask for clinical values by acting out the assessment  (e.g. taking a blood pressure or prepping IV supplies and simulating starting an IV). Fetal heart tones are noted as 6-second counts.
    • For visual or subjective assessments, they can ask. If assessments are abnormal or specified, they will be provided in the case. Otherwise, Drill Coordinator may provide any normal value in response.
  • Restart the timer and log the time elapsed after each portion of the Full Transfer Drill: Before Transport, During Transport, and At Hospital.
  • Observers should use the Observer Worksheets to assess performance of clinical tasks as the drill progresses.
  • People assigned to primary and secondary roles and the Drill Coordinator should review and complete the Observer Worksheets immediately after the drill, before Debriefing and Action Planning.

Download & Print

Observer Worksheets

Clinical Scenario

Clinical Scenario

Drill begins in community setting

This is a scenario that begins in the community and requires transfer to a higher level of care.

Read the following case aloud. Prior to beginning, participants may ask clarifying questions, but should not discuss their plan of care or move any supplies or equipment.

Avery is a 36 year old G4P2012 who presents at 40 weeks 5 days in active labor. Avery was admitted one hour ago and found to be 6cm/80%/-2 with intact membranes. Avery had an uncomplicated pregnancy with routine prenatal care. GBS negative and Rh positive. EFW 8.5lb. Admission vital signs stable, BP 122/72, HR 92, Temp 98.4F. 

Avery progressed quickly to 10/100%/0 with the urge to push. Membranes ruptured 30 min ago for clear fluid, shortly after Avery began bearing down.  FHTs have been in the 130s to 140s with audible accelerations and no audible decelerations throughout the first stage of labor. Avery is currently in a semi-sitting position in the tub, supported by her partner.  You perform intermittent auscultation over 60 seconds as the contraction subsides and goes away, and obtain the following values for 6-second counts: 11, 12, 11, 13, 12, 11..

Clinical Scenario

Drill begins at hospital handoff

This is a scenario that begins in the hospital, receiving a community transfer.

Read the following case aloud. Prior to beginning, participants may ask clarifying questions, but should not discuss their plan of care or move any supplies or equipment.

You receive the following report by phone from the on-call midwife of the nearby community practice. They introduce themself and state:

“I’m calling to initiate an emergent intrapartum transfer in the second stage of labor for fetal bradycardia. Avery is a 36 year old G4P2012 at 40 weeks 5 days gestation with an uncomplicated pregnancy and routine prenatal care. She was admitted a little over one hour ago and made quick progress to 10cm dilated and SROM for clear fluid. She has been spontaneously bearing down for 35 minutes. FHTs on admission and until recently have been 130s to 140s with audible accelerations and no decelerations, by intermittent auscultation. FHTs have been in the 80s for the last 3+ minutes despite position changes and coaching the patient to push more effectively to expedite delivery. Cervical exam is 10/100/+1 with no change in descent over the last several contractions. I am transferring her for continuous fetal monitoring and possible operative or instrumental delivery. I will accompany the patient to the hospital, along with her partner.”

Print copies of the completed transfer form from the community midwife.

Coordinator Prompts

Community Setting

Coordinator Prompts

Time Scenario (Read Aloud) Values (Share only if assessed)
00:00

Scenario begins. Start timer.

Maternal Pulse:  92
FHTs:  6-second counts are: 11, 12, 11, 13, 12, 12,.
Vaginal Exam: 10/100/0
01:00

Another contraction begins. Avery asking to change position, vocalizing and bearing down at a high pitch.

Maternal Pulse:  94
FHTs:  6-second counts are:  9, 8, 8, 9, 7, 8
Vaginal Exam: 100/100/0
03:00

Another contraction begins. Avery continues to bear down strongly. You begin to see labial parting but no fetal hair or head.

Maternal Pulse: 90
FHTs: 6-second counts are: 10, 9, 11, 12, 11, 9
Vaginal Exam: 10/100/+1
Any other value: normal
05:00

Another contraction begins and Avery resumes pushing. You again see labial parting but do not yet see fetal hair or head.

Maternal Pulse: 94
FHTs: 6-second counts are: 7, 8, 8, 9, 8, 7
Vaginal Exam: 10/100/+1
Any other value: normal
06:00

Another contraction begins. Avery shouting “I can’t!” and not pushing effectively.

Maternal Pulse: 98
FHTs: not audible
Vaginal Exam: 10/100/+1, +caput
Any other value: normal
07:30

Another contraction begins, Avery vocalizing at high pitch. Partner encouraging her.

Maternal Pulse: 94
FHTs: 6-second counts are: 8, 7, 7, 8, 9, 7
Vaginal Exam: 10/100/+1, +caput
Any other value: normal

Repeat prior prompt every 1-2 minutes until emergency transport process is activated.

During Transfer

Coordinator Prompts

Time Scenario (Read Aloud) Values (Share only if assessed)
00:00

Restart timer

Avery appears exhausted and nervous on the stretcher in between contractions, asking “will the baby be ok?”

Maternal Pulse: 90
FHTs: 6-second counts are: 10, 9, 8, 9, 11
Vaginal Exam: 10/100/+1, +caput
Any other value: normal
02:00

Another contraction begins, Avery bearing down occasionally but encouraged to breathe through the contractions as best as possible.

Maternal Pulse: 94
FHTs: 6-second counts are: 9, 8, 10, 9, 9, 8
Vaginal Exam: 10/100/+1, +caput
Any other value: normal

Repeat prior prompt every 1-2 minutes until patient reaches hospital unit.

Receiving Hospital

Coordinator Prompts

Time Scenario (Read Aloud) Values (Share only if assessed)
00:00

Restart timer.

Avery stands up from the stretcher and ambulates a few steps to the hospital bed.

Maternal Pulse: 88
FHTs: 6-second counts are: 9, 8, 10, 9, 9, 8, 9
Vaginal Exam: 10/100/+1, +caput
Any other value: normal
02:00

Another contraction begins. Avery has a much stronger, uncontrollable urge to bear down. Reports feeling much more pressure.

Maternal Pulse: 96
FHTs (doppler): 6-second counts are: 7, 6, 8, 7, 9, 8
FHTs (Continuous EFM): baseline 70, mod variability, no accels
Vaginal Exam: 10/100/+3, +caput
Any other value: normal
03:00

Fetal head becomes visible at introitus with pushing.

Maternal Pulse: 94
FHTs (doppler): 6-second counts are: 8, 7, 8, 6, 7, 8
FHTs (Continuous EFM): baseline 70, mod variability, no accels
Vaginal Exam: 10/100/+3, +caput
Any other value: normal

Repeat prior prompt every 1-2 minutes until patient is fully admitted and operative vaginal delivery is initiated.

Debriefing and Action Guide

Reflection Questions

Review the checklist of observed behaviors as a team and discuss subjective assessments such as communication style with team members and family, role clarity, and effectiveness at clinical tasks. 

  • What happened here? Ask 1-2 people to give a brief high-level summary so everyone’s on the same page.
  • What went well? Give everyone a chance to share the good stuff they noticed before critiquing.
  • What needs attention or improvement? Try to focus on processes and systems, not assigning blame.
  • Are there other appropriate ways to manage this emergency or transport? Consider different approaches such as who might accompany the patient, dyad vs. separate transfers, etc.
  • Were we prepared for this emergency? The answer will help clarify the Action Steps.

Action Steps

  • What changes are needed to processes or procedures? Make sure to assign someone to follow-up on the change.
  • How should this emergency be documented in the medical record? Discuss any documentation standards and tools such as order sets or dot-phrases available to clinicians.
  • What other reporting is required for this emergency transfer? This could include accreditation or licensing bodies, malpractice carriers, and internal organizational reporting.
  • What other follow up would be expected after this emergency? Consider follow-up for patient/family or staff, or other next steps.

Documentation

Document the date, location, clinical scenario(s), time spent in drill, and attendees so you can track participation against your practice’s internal policies and accreditation and/or licensure requirements. You can document your drill using the form at https://bit.ly/4aSAVjk or the QR code to complete and receive a digital copy of your Drill Report.

This will also contribute your drill data to help improve services and identify best practices. Data identifiable to a practice or individual will never be shared without consent.

QR Code

References

American College of Nurse‐Midwives (ACNM). Intermittent auscultation for intrapartum fetal heart rate surveillance. Journal of Midwifery & Women’s Health. 2015;60(5):626-632. doi:10.1111/jmwh.12372

Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), Wisner, K., & Holschuh, C. (2018). Fetal heart rate auscultation. Nursing for Women’s Health, 22(6), e1-e32.

Fahey JO. The recognition and management of intrapartum fetal heart rate emergencies: Beyond definitions and classification. J Midwifery Women’s Health. 2014;59(6):616-623. https://api.istex.fr/ark:/67375/WNG-P3H8X07D-K/fulltext.pdf. doi:10.1111/jmwh.12256.

Romano AM, Buxton M. A Multimethod Improvement Project to Strengthen Intermittent Auscultation Practice Among Nurse-Midwives and Nurses. J Midwifery Womens Health. 2020 May;65(3):362-369. doi:10.1111/jmwh.13113. Epub 2020 May 18. PMID: 32424909.

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Download

Birth Center Stakeholder Map

Coordinator Information

Drill Description

A tool to systematically assess different community birth center stakeholders and identify approaches to address their concerns and/or interests.

Learning Objectives:

Last updated:

Authored by:

Reviewed by:

You will be coodinating a...

Partial Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer, but participants are only practicing part of the scenario: either the part that happens in the community before hospitalization, or the arrival at the hospital and post-transfer management.

Who's involved?

Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.

Planning Needs

Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.

Full Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer and participants practice all phases of the transfer: care in the community, emergency transport, and arrival and management at the hospital.

Who's involved?

Full practice/facility team from the community birth setting, plus transport and hospital personnel.

Planning Needs

Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.

Download & Print

Observer Worksheets

Clinical Scenario

Coordinator Prompts

Debriefing and Action Guide

Documentation

Document the date, location, clinical scenario(s), time spent in drill, and attendees so you can track participation against your practice’s internal policies and accreditation and/or licensure requirements. You can document your drill using the form at https://bit.ly/4aSAVjk or the QR code to complete and receive a digital copy of your Drill Report.

This will also contribute your drill data to help improve services and identify best practices. Data identifiable to a practice or individual will never be shared without consent.

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References

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Birth Center Checklists

Coordinator Information

Drill Description

Sample checklists for birth center admission, second stage of labor, discharge, and transfer. Download an editable version and adapt to the specific needs of your practice.

Learning Objectives:

Last updated:

Authored by:

Reviewed by:

You will be coodinating a...

Partial Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer, but participants are only practicing part of the scenario: either the part that happens in the community before hospitalization, or the arrival at the hospital and post-transfer management.

Who's involved?

Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.

Planning Needs

Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.

Full Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer and participants practice all phases of the transfer: care in the community, emergency transport, and arrival and management at the hospital.

Who's involved?

Full practice/facility team from the community birth setting, plus transport and hospital personnel.

Planning Needs

Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.

Download & Print

Observer Worksheets

Clinical Scenario

Coordinator Prompts

Debriefing and Action Guide

Documentation

Document the date, location, clinical scenario(s), time spent in drill, and attendees so you can track participation against your practice’s internal policies and accreditation and/or licensure requirements. You can document your drill using the form at https://bit.ly/4aSAVjk or the QR code to complete and receive a digital copy of your Drill Report.

This will also contribute your drill data to help improve services and identify best practices. Data identifiable to a practice or individual will never be shared without consent.

QR Code

References

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Download

Transfer Planning Template

Coordinator Information

Drill Description

Learning Objectives:

Last updated:

Authored by:

Reviewed by:

You will be coodinating a...

Partial Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer, but participants are only practicing part of the scenario: either the part that happens in the community before hospitalization, or the arrival at the hospital and post-transfer management.

Who's involved?

Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.

Planning Needs

Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.

Full Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer and participants practice all phases of the transfer: care in the community, emergency transport, and arrival and management at the hospital.

Who's involved?

Full practice/facility team from the community birth setting, plus transport and hospital personnel.

Planning Needs

Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.

Download & Print

Observer Worksheets

Clinical Scenario

Coordinator Prompts

Debriefing and Action Guide

Documentation

Document the date, location, clinical scenario(s), time spent in drill, and attendees so you can track participation against your practice’s internal policies and accreditation and/or licensure requirements. You can document your drill using the form at https://bit.ly/4aSAVjk or the QR code to complete and receive a digital copy of your Drill Report.

This will also contribute your drill data to help improve services and identify best practices. Data identifiable to a practice or individual will never be shared without consent.

QR Code

References

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Birth Center Eligibility and Midwife-Physician Collaborative Care Guidelines

Coordinator Information

Drill Description

A sample document to help you establish eligibility for birth center or hospital-based midwifery management. The document is organized by body systems (cardiovascular and hematologic health, endocrine, etc.) and provides sections for pre-pregnancy conditions/factors and for conditions present in the current pregnancy.

Learning Objectives:

Last updated:

Authored by:

Reviewed by:

You will be coodinating a...

Partial Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer, but participants are only practicing part of the scenario: either the part that happens in the community before hospitalization, or the arrival at the hospital and post-transfer management.

Who's involved?

Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.

Planning Needs

Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.

Full Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer and participants practice all phases of the transfer: care in the community, emergency transport, and arrival and management at the hospital.

Who's involved?

Full practice/facility team from the community birth setting, plus transport and hospital personnel.

Planning Needs

Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.

Download & Print

Observer Worksheets

Clinical Scenario

Coordinator Prompts

Debriefing and Action Guide

Documentation

Document the date, location, clinical scenario(s), time spent in drill, and attendees so you can track participation against your practice’s internal policies and accreditation and/or licensure requirements. You can document your drill using the form at https://bit.ly/4aSAVjk or the QR code to complete and receive a digital copy of your Drill Report.

This will also contribute your drill data to help improve services and identify best practices. Data identifiable to a practice or individual will never be shared without consent.

QR Code

References

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Birth Center Staffing Model

Coordinator Information

Drill Description

An editable modeling tool to help you identify birth center staffing needs based on information specific to your practice.

Learning Objectives:

Last updated:

Authored by:

Reviewed by:

You will be coodinating a...

Partial Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer, but participants are only practicing part of the scenario: either the part that happens in the community before hospitalization, or the arrival at the hospital and post-transfer management.

Who's involved?

Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.

Planning Needs

Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.

Full Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer and participants practice all phases of the transfer: care in the community, emergency transport, and arrival and management at the hospital.

Who's involved?

Full practice/facility team from the community birth setting, plus transport and hospital personnel.

Planning Needs

Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.

Download & Print

Observer Worksheets

Clinical Scenario

Coordinator Prompts

Debriefing and Action Guide

Documentation

Document the date, location, clinical scenario(s), time spent in drill, and attendees so you can track participation against your practice’s internal policies and accreditation and/or licensure requirements. You can document your drill using the form at https://bit.ly/4aSAVjk or the QR code to complete and receive a digital copy of your Drill Report.

This will also contribute your drill data to help improve services and identify best practices. Data identifiable to a practice or individual will never be shared without consent.

QR Code

References

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Birth Center Job Descriptions

Coordinator Information

Drill Description
Screenshot

A sample, and editable template, of birth center job descriptions. Adapt and change to fit your birth center and state regulatory environment.

Learning Objectives:

Last updated:

Authored by:

Reviewed by:

You will be coodinating a...

Partial Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer, but participants are only practicing part of the scenario: either the part that happens in the community before hospitalization, or the arrival at the hospital and post-transfer management.

Who's involved?

Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.

Planning Needs

Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.

Full Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer and participants practice all phases of the transfer: care in the community, emergency transport, and arrival and management at the hospital.

Who's involved?

Full practice/facility team from the community birth setting, plus transport and hospital personnel.

Planning Needs

Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.

Download & Print

Observer Worksheets

Clinical Scenario

Coordinator Prompts

Debriefing and Action Guide

Documentation

Document the date, location, clinical scenario(s), time spent in drill, and attendees so you can track participation against your practice’s internal policies and accreditation and/or licensure requirements. You can document your drill using the form at https://bit.ly/4aSAVjk or the QR code to complete and receive a digital copy of your Drill Report.

This will also contribute your drill data to help improve services and identify best practices. Data identifiable to a practice or individual will never be shared without consent.

QR Code

References

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Hospital – Birth Center Transfer Agreement

Coordinator Information

Drill Description

A sample transfer agreement between birth center and hospital. The purpose of this agreement is to facilitate the continuity of care and timely transfer of patients and medical records, and to establish a mutually beneficial collaborative arrangement between the parties.

Learning Objectives:

Last updated:

Authored by:

Reviewed by:

You will be coodinating a...

Partial Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer, but participants are only practicing part of the scenario: either the part that happens in the community before hospitalization, or the arrival at the hospital and post-transfer management.

Who's involved?

Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.

Planning Needs

Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.

Full Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer and participants practice all phases of the transfer: care in the community, emergency transport, and arrival and management at the hospital.

Who's involved?

Full practice/facility team from the community birth setting, plus transport and hospital personnel.

Planning Needs

Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.

Download & Print

Observer Worksheets

Clinical Scenario

Coordinator Prompts

Debriefing and Action Guide

Documentation

Document the date, location, clinical scenario(s), time spent in drill, and attendees so you can track participation against your practice’s internal policies and accreditation and/or licensure requirements. You can document your drill using the form at https://bit.ly/4aSAVjk or the QR code to complete and receive a digital copy of your Drill Report.

This will also contribute your drill data to help improve services and identify best practices. Data identifiable to a practice or individual will never be shared without consent.

QR Code

References

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Download

Perinatal Safety Scavenger Hunt

Coordinator Information

Drill Description

 

Use this fun and engaging activity to ensure your team is prepared for emergencies.

Learning Objectives:

Last updated:

Authored by:

Reviewed by:

You will be coodinating a...

Partial Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer, but participants are only practicing part of the scenario: either the part that happens in the community before hospitalization, or the arrival at the hospital and post-transfer management.

Who's involved?

Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.

Planning Needs

Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.

Full Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer and participants practice all phases of the transfer: care in the community, emergency transport, and arrival and management at the hospital.

Who's involved?

Full practice/facility team from the community birth setting, plus transport and hospital personnel.

Planning Needs

Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.

Download & Print

Observer Worksheets

Clinical Scenario

Coordinator Prompts

Debriefing and Action Guide

Documentation

Document the date, location, clinical scenario(s), time spent in drill, and attendees so you can track participation against your practice’s internal policies and accreditation and/or licensure requirements. You can document your drill using the form at https://bit.ly/4aSAVjk or the QR code to complete and receive a digital copy of your Drill Report.

This will also contribute your drill data to help improve services and identify best practices. Data identifiable to a practice or individual will never be shared without consent.

QR Code

References

Drill Kit Icon

Drill Kit

Postpartum Mental Health Crisis

Coordinator Information

Drill Description

Introduction

Step Up Together Drill Implementation Toolkits support interdisciplinary clinical teams to run emergency drills involving transfer of care.

Each toolkit can be used to run a Full Transfer Drill that begins in the community, travels by ambulance or private vehicle, and ends in the hospital or to run just one segment of the drill (e.g. before transfer or after hospital hand-off). The toolkit includes a standardized high-fidelity case designed to test the process of transferring a postpartum person from one location to another with an interdisciplinary team involved in the care. Observation criteria and a Debriefing and Action Guide are provided to elicit continuous improvement of transfer processes and respectful care along the continuum.

Drill Description

This Drill Kit tests the emergency response to a postpartum mental health crisis occurring in an outpatient care setting including urgent transport of a postpartum client either by EMS or private vehicle to the Emergency Department.  

It is appropriate for:

  • Home birth practices
  • Birth centers
  • Outpatient care facilities
  • Urgent care centers
  • Critical access hospitals without OB services
  • Other facilities or units requiring patient transport for emergency surgery (e.g. emergency department)

And may further engage:

  • EMS or other emergency transport partners, if appropriate
  • Emergency Department, Neonatologist, and other relevant units at the referral hospital

To test the process of:

  • Outpatient Emergency Transfer

Learning Objectives:

  • Identify and respond to a postpartum mental health crisis in the community setting
  • Utilize appropriate tools and referrals for assessing perinatal mental health
  • Identify and respond to social and clinical risk factors for perinatal mood disorders
  • Review ways to promote person-focused care during emergencies
  • Use debriefing skills to promote equity and ensure integration of individual and collective learning

Last updated: December 2024

Authored by:

Jennifer Johnson, MS, CNM

Reviewed by:

Alexa Dougherty, MSN, PHN, CNM
Deborah Flam, M.A., LPC, PMH-C
Amy Romano, MBA, MSN, CNM, FACNM
Laura Winters, LCSW, PMH-C

You will be coodinating a...

Partial Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer, but participants are only practicing part of the scenario: either the part that happens in the community before hospitalization, or the arrival at the hospital and post-transfer management.

Who's involved?

Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.

Planning Needs

Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.

Full Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer and participants practice all phases of the transfer: care in the community, emergency transport, and arrival and management at the hospital.

Who's involved?

Full practice/facility team from the community birth setting, plus transport and hospital personnel.

Planning Needs

Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.

Setup and Procedure

Postpartum Mental Health Crisis

Partial Transfer Drill Instructions

Participants (Minimum of two, up to full practice/facility team):

  • *Drill Scenario Roles:
    •  If conducting the drill in the community setting
      • Assign a lead provider and a birth assistant/medical assistant. 
      • Additional learners may be assigned to play the role of a 911 dispatcher and/or a hospital provider receiving the report. 
    • If conducting the drill at the transfer hospital, assign an attending provider and a nurse. Additional learners may be assigned to play the role of the transferring provider and/or the EMS lead
  • Non-clinical roles: Assign learners to play the roles of patient and partner
  • *Drill Coordinator presents the case scenario, tracks hand-off times,  and leads the debrief; may double as the birth assistant/nurse if this is a 2-person drill.
  • Observer(s): Unassigned learners are observers, who use Observer Worksheets to track actions and processes during the drill. 

* Required roles

Setting and supplies: 

  • Room set up for postpartum visit
  • Supplies to document clinical care of simulated patient (e.g. blank paper charting templates or fake/simulated patient in the electronic record system)
  • Stopwatch or timer

Instructions: 

  • If conducting a Partial Transfer Drill in the community setting, use Clinical Scenario: Drill Begins in the Community Setting, and conclude the drill with simulated handoff to EMS. If conducting a Partial TransferDrill in the hospital, use Clinical Scenario: Drill Begins at Hospital Handoff, and conclude as directed in the scenario.
  • Drill Coordinator reads Clinical Scenario.
  • When team is ready, start timer and state aloud, “begin drill.”
  • Read additional prompts on the Coordinator Prompts at the appropriate times.
  • Learners in drill scenario roles may ask for clinical values by acting out the assessment (e.g. taking a blood pressure or donning gloves and simulating a vaginal exam). For visual or subjective assessments, they can ask. If assessments are abnormal or specified, they will be provided in the case. Otherwise, Drill Coordinator may provide any normal value in response.
  • Observers should use the Observer Worksheets to assess performance of clinical tasks as the drill progresses.
  • People assigned to clinical roles and the Drill Coordinator should review and complete the Observer Worksheets immediately after the drill, before Debriefing and Action Planning.

Setup and Procedure

Postpartum Mental Health Crisis

Full Transfer Drill Instructions

Participants (Full team plus transport and/or hospital personnel):

Assign the following roles:

  • *Drill Scenario Roles: 
    • In the initial community setting 
      • Assign a lead provider and assistant.
    • During patient transport: Assign an EMS lead and other roles as relevant.
    • In the referral hospital: Assign an attending provider and a nurse and other roles such as transferring provider and/or the EMS lead as relevant. 
  • Non-clinical roles: Assign learners to play the roles of the patient and partner/support person.
  • *Drill Coordinator(s): Presents the case scenario, tracks hand-off times, and leads the debrief. Consider assigning a coordinator for each segment of the transfer.
  • Observer(s): Unassigned learners are observers, who use Observer Worksheets to track actions and processes during the drill. 

*Required roles

Setting and supplies: 

  • Room set up for postpartum visit
  • Supplies to document clinical care of simulated patient (e.g. blank paper charting templates or fake/simulated patient in the electronic record system)
  • Stopwatch or timer

Instructions: 

  • Use Clinical Scenario: Drill Begins in the Community Setting
  • Drill Coordinator reads Drill Scenario.
  • When team is ready, start timer and state aloud, “begin drill.”
  • Read additional prompts at the appropriate times.
  • Learners in drill scenario roles may ask for clinical values by acting out the assessment (e.g. taking a blood pressure or donning gloves and simulating a vaginal exam). For visual or subjective assessments, they can ask. If assessments are abnormal or specified, they will be provided in the case. Otherwise, Drill Coordinator may provide any normal value in response.
  • Restart the timer and log the time elapsed after each portion of the Full Transfer Drill: Before Transport, During Transport, and At Hospital.
  • Observers should use the Observer Worksheets to assess performance of clinical tasks as the drill progresses.
  • People assigned to primary and secondary roles and the Drill Coordinator should review and complete the Observer Worksheets immediately after the drill, before Debriefing and Action Planning.

Download & Print

Observer Worksheets

Clinical Scenario

Clinical Scenario

Drill Begins in Community Setting

Read the following case aloud. Prior to beginning, participants may ask clarifying questions, but should not discuss their plan of care or move any supplies or equipment.

Olivia is a 32 year old G1P1001 who is seeking postpartum mental health care at your office. Her pregnancy was uncomplicated, with a remote history of anxiety and depression in college that she said was a one-time issue that improved when she started exercising more. Throughout her pregnancy, she strongly desired an unmedicated labor and birth. After several days of prodromal labor without dilating past 1cm, she reluctantly decided to seek pain management options at the hospital.  After getting an epidural, the fetal heart tracing showed intermittent signs of fetal distress.  She was then augmented with Pitocin when the contractions spaced out, but it was discontinued several times. She had an unexpected cesarean delivery of baby “Annie” due to non reassuring fetal heart tracing remote from delivery.  

At her 2 week postpartum visit, she was tearful about her birth experience, she felt like her body failed her. She said that breastfeeding was going poorly and the baby was very colicky. Her nipples were cracked and the baby took forever to latch. She has been to the lactation center several times since the birth, “but nothing seems to  help”. Olivia said that none of her close friends have babies, either their kids are older or they are childfree, so she feels that no one can relate to her. Her mother, who flew in to help out with the baby, “has been really unhelpful, keeps telling me to look on the bright side”. Olivia told her to leave, even though they don’t have any other family nearby.  She says the baby cries all the time, “even when she’s sleeping, I can hear the crying in my head and I can’t sleep”.  Alex, her partner, has been cooking for them, soothing the baby, and encouraging her to rest and care for herself. However, Alex then had to return to work after 2 weeks, so Olivia was on the verge of being home alone.  A  plan was made to look for new-parent groups, ask friends for help, even a takeout meal train, and to continue working with lactation support.

Olivia is now 3 weeks postpartum. Alex called your office this morning with concerns about Olivia’s behavior, remarking “She said she realized last night that she just isn’t ‘cut out’ to be a mom, that the baby ‘hates’ her and likes me better, and that she knows we would be happier without her”.  Alex says that Olivia has been distant today.  You advised they all come in together for a visit today to make a plan together. 

On arrival, Olivia appears tired, with a flat affect. Her EPDS score is 18, answering “yes” to the question about contemplating self-harm.

Clinical Scenario

Drill Begins at Hospital Handoff

Read the following case aloud. Prior to beginning, participants may ask clarifying questions, but should not discuss their plan of care or move any supplies or equipment.

Print copies of the completed transfer form from the community provider.

You receive the following report by phone from the on-call midwife of the nearby community practice. They introduce themself and state:

“I’m calling to initiate a transfer for a patient experiencing a postpartum mental health crisis who needs emergent evaluation for suicidal ideation. Olivia is a 32 year old G1 P1001 who is 3 weeks postpartum following  an unexpected Cesarean delivery for non-reassuring fetal status. She has had an uncomplicated post-op recovery, and both she and the baby were discharged home after 3 days. The family has minimal home support and her partner is already back to work. Olivia has had elevated EPDS for the last week, and today expressed suicidal ideation with a plan. She agrees to present to the Emergency Department for care, but is concerned about being separated from the baby. She will arrive by private vehicle with her partner and newborn.”

Coordinator Prompts

Community Setting

Coordinator Prompts

Time Scenario (Read Aloud) Values (Share only if assessed)
00:00

Olivia sits with a flat affect. Alex holds baby Annie, who is asleep in their arms.

Vitals: BP 118/68, HR 70

Physical exam:
Breast: bilateral nipple breakdown and bruising, otherwise soft without tenderness or masses

EPDS: 18
03:00

Olivia becomes tearful, saying how tired she is. Says the baby “always sleeps for Alex but never for me. She probably hates me”.

Vitals: BP 118/68, HR 70, RR 14

Physical exam:
Breast: bilateral nipple breakdown and bruising, otherwise soft without tenderness or masses

EPDS: 18
05:00

Olivia agrees to discuss more of her intrusive thoughts, but not in front of Alex.  Alex leaves the room with baby Annie.

C-SSRS score of 5 for Suicidal Ideation, score of 0 for Suicidal Behavior, if administered
VS remain stable.
07:00

Olivia is flat again, admits that she has considered taking “a few extra oxycodone tablets they sent me home with after the c-section, and if we’re all lucky, I won’t wake up”.

Vitals remain stable

Make plan for hospital transfer to ED according to practice protocol.

During Transfer

Coordinator Prompts

Time Scenario (Read Aloud) Values (Share only if assessed)
00:00

Olivia is tearful and flat intermittently.

Vitals: BP 132/82, HR 88, RR 16

Lochia: minimal

Receiving Hospital

Coordinator Prompts

Time Scenario (Read Aloud) Values (Share only if assessed)
00:00

Olivia arrives and starts sobbing that she doesn’t want to leave Annie.

Vitals: BP 130/86, HR 90, RR 16
Lochia: minimal
EPDS: 18
C-SSRS: 5 / 0

Debriefing and Action Guide

Reflection Questions

Review the checklist of observed behaviors as a team and discuss subjective assessments such as communication style with team members and family, role clarity, and effectiveness at clinical tasks. 

  • What happened here? Ask 1-2 people to give a brief high-level summary so everyone’s on the same page.
  • What went well? Give everyone a chance to share the good stuff they noticed before critiquing.
  • What needs attention or improvement? Try to focus on processes and systems, not assigning blame.
  • Are there other appropriate ways to manage this emergency or transport? Consider different approaches such as who might accompany the patient, dyad vs. separate transfers, etc.
  • Were we prepared for this emergency? The answer will help clarify the Action Steps.
  • What would be different if this patient presented alone to the visit?
  • What would be different if this patient had other children and had childcare constraints?
  • What would be different if this patient refused to go to the hospital?
  • What would be different if this patient presented with symptoms of psychosis?

Action Steps

  • What changes are needed to processes or procedures? Make sure to assign someone to follow-up on the change.
  • How should this emergency be documented in the medical record? Discuss any documentation standards and tools such as order sets or dot-phrases available to clinicians.
  • What other reporting is required for this emergency transfer? This could include accreditation or licensing bodies, malpractice carriers, and internal organizational reporting.
  • What other follow up would be expected after this emergency? Consider follow-up for patient/family or staff, or other next steps.
  • Has your staff undergone appropriate training to assess for and navigate services for a perinatal mental health crises? Consider looking in to training through state-based mental health consortiums and organizations or Postpartum Support International.

 

Documentation

Document the date, location, clinical scenario(s), time spent in drill, and attendees so you can track participation against your practice’s internal policies and accreditation and/or licensure requirements. You can document your drill using the form at https://bit.ly/4aSAVjk or the QR code to complete and receive a digital copy of your Drill Report.

This will also contribute your drill data to help improve services and identify best practices. Data identifiable to a practice or individual will never be shared without consent.

QR Code

References

AIM Patient Safety Bundle: Perinatal Mental Health Conditions
https://saferbirth.org/psbs/perinatal-mental-health-conditions/

American College of Nurse Midwives. (2020). Mental Health During Childbirth and Across the Lifespan.
https://www.midwife.org/acnm/files/acnmlibrarydata/uploadfilename/000000000324/PS-Mental%20Health%20During%20Childbirth%20and%20Across%20Lifespan.pdf

Screening for perinatal depression. ACOG Committee Opinion Number 757. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;132:208-12.

Guide Icon

Guide

Hospital Guide to Integrating the Freestanding Birth Center Model

Coordinator Information

Drill Description

This guide collates critical tools, information, and resources to help hospitals and health systems integrate the freestanding birth center model, an evidence-based strategy to improve maternal and infant health outcomes and equity. Get step-by-step instructions and specialized tools designed for and with hospitals, birth centers, and community members to accelerate the safe adoption of birth centers.

Learning Objectives:

Last updated:

Authored by:

Reviewed by:

You will be coodinating a...

Partial Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer, but participants are only practicing part of the scenario: either the part that happens in the community before hospitalization, or the arrival at the hospital and post-transfer management.

Who's involved?

Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.

Planning Needs

Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.

Full Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer and participants practice all phases of the transfer: care in the community, emergency transport, and arrival and management at the hospital.

Who's involved?

Full practice/facility team from the community birth setting, plus transport and hospital personnel.

Planning Needs

Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.

Download & Print

Observer Worksheets

Clinical Scenario

Coordinator Prompts

Debriefing and Action Guide

Documentation

Document the date, location, clinical scenario(s), time spent in drill, and attendees so you can track participation against your practice’s internal policies and accreditation and/or licensure requirements. You can document your drill using the form at https://bit.ly/4aSAVjk or the QR code to complete and receive a digital copy of your Drill Report.

This will also contribute your drill data to help improve services and identify best practices. Data identifiable to a practice or individual will never be shared without consent.

QR Code

References

Drill Kit Icon

Drill Kit

Severe Range Blood Pressure in Pregnant Patient

Coordinator Information

Drill Description

Introduction

Step Up Together Drill Kits support interdisciplinary clinical teams to run emergency drills involving patient hand-offs and/or transport to a higher level facility.

Each Drill Kit can be used to run a Full Transfer Drill that tests the full, interdisciplinary process of care or a Partial Transfer Drill that involves running just one segment of the scenario (e.g. before transfer or after hospital hand-off). The toolkit includes a standardized high-fidelity case designed to test the process of transferring a birthing person or newborn from one location to another with an interdisciplinary team involved in the care. Observation criteria and a Debriefing and Action Guide are provided to elicit continuous improvement of interdisciplinary care processes and promote respectful care along the continuum.

Drill Description

This Drill Kit tests the emergency response to an antepartum severe range blood pressure occurring in a community setting including emergency transport of a pregnant patient.

It is appropriate for:

  • Outpatient clinics
  • Birth centers
  • Home birth practices
  • Urgent care centers
  • Primary care clinics
  • Critical access hospitals without OB services
  • Other facilities or units requiring patient transport for emergency stabilization (e.g. emergency department)

And may further engage:

  • EMS or other emergency transport partners
  • Labor & Birth unit and other relevant units at the referral hospital

To test the process of:

  • Antepartum Emergency Transfer

Learning Objectives:

  • Identify and respond to a severe-range blood pressure in a pregnant individual in the community setting.
  • Review ways to promote person-focused care during emergencies.
  • Identify and respond to social and clinical risk factors for preeclampsia and eclampsia.
  • Recognize social determinants of health.
  • Identify the need for a higher level of care and initiate appropriate hospital transfer.
  • Practice collaboration that adheres to relevant transfer protocols with warm hand-offs across levels of care.
  • Communicate effectively and with dignity, with the patient, support people, and additional healthcare personnel in the event of an antepartum transfer.
  • Use debriefing skills to ensure integration of individual and collective learning.

Last updated: December 2024

Authored by:

Alexa Dougherty, MSN, PHN, CNM

Reviewed by:

Jennifer Johnson, MS, CNM
Amy Romano, MBA, MSN, CNM, FACNM
Karen A. Scott, MD, MPH, FACOG

You will be coodinating a...

Partial Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer, but participants are only practicing part of the scenario: either the part that happens in the community before hospitalization, or the arrival at the hospital and post-transfer management.

Who's involved?

Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.

Planning Needs

Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.

Full Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer and participants practice all phases of the transfer: care in the community, emergency transport, and arrival and management at the hospital.

Who's involved?

Full practice/facility team from the community birth setting, plus transport and hospital personnel.

Planning Needs

Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.

Setup and Procedure

Severe Range Blood Pressure in Pregnant Patient

Partial Transfer Drill Instructions

Participants (Minimum of two, up to full practice/facility team):

Assign the following roles:

  • *Drill Scenario Roles:
    •  If conducting the drill in the community setting:
      • Assign a lead provider and an assistant if available.
      • Additional learners may be assigned to play the role of a 911 dispatcher and/or a hospital provider receiving the report. 
    • If conducting the drill at the transfer hospital, assign an attending provider and a nurse. Additional learners may be assigned to play the role of the transferring provider and/or the EMS lead.
  • Non-clinical roles: Assign learners to play the roles of: 
    • the patient and partner
    • doula
    • siblings/other family
  • *Drill Coordinator: presents the case scenario, tracks hand-off times,  and leads the debrief; may double as the assistant/nurse if this is a 2-person drill.
  • Observer(s): Unassigned learners are observers, who use Observer Worksheets to track actions and processes during the drill. 

* Required roles

Setting and supplies: 

  • Outpatient clinic set up to care for antepartum pregnant patient
  • Supplies to document clinical care of simulated patient (e.g. maternal and neonatal blank transfer forms, blank paper charting templates or fake/simulated patient in the electronic record system)
  • Stopwatch or timer

Instructions: 

  • If conducting a Partial Transfer Drill in the community setting, use Clinical Scenario: Drill Begins in the Community Setting, and conclude the drill with simulated handoff to EMS. If conducting a Partial TransferDrill in the hospital, use Clinical Scenario: Drill Begins at Hospital Handoff, and conclude as directed in the scenario.
  • Drill Coordinator reads Clinical Scenario.
  • When team is ready, start timer and state aloud, “begin drill.”
  • Read additional prompts on the Coordinator Prompts at the appropriate times.
  • Learners in drill scenario roles may ask for clinical values by acting out the assessment (e.g. taking a blood pressure or prepping IV supplies and simulating starting an IV). For visual or subjective assessments, they can ask. If assessments are abnormal or specified, they will be provided in the case. Otherwise, Drill Coordinator may provide any normal value in response.
  • Observers should use the Observer Worksheets to assess performance of clinical tasks as the drill progresses.
  • People assigned to drill scenario roles and the Drill Coordinator should review and complete the Observer Worksheets immediately after the drill, before Debriefing and Action Planning.

Setup and Procedure

Severe Range Blood Pressure in Pregnant Patient

Full Transfer Drill Instructions

Participants (Full team plus transport and/or hospital personnel): 

Assign the following roles:

  • *Drill Scenario Roles: 
    • In the initial community setting: Assign a lead provider and assistant.
    • During patient transport: Assign an EMS lead and other roles as relevant
    • In the referral hospital: Assign an attending provider and a nurse and other roles such as transferring provider and/or the EMS lead as relevant. 
  • Non-clinical roles: Assign learners to play the roles of: 
    • the patient and partner
    • doula
    • siblings/other family
  • *Drill Coordinator(s): Presents the case scenario, tracks hand-off times, and leads the debrief. Consider assigning a coordinator for each segment of the transfer.
  • Observer(s): Unassigned learners are observers, who use Observer Worksheets to track actions and processes during the drill. 

*Required roles

Setting and supplies: 

  • Outpatient clinic set up to care for antepartum patient
  • Supplies to document clinical care of simulated patient (e.g. maternal and neonatal blank transfer forms, blank paper charting templates or fake/simulated patient in the electronic record system)
  • Stopwatch or timer

Instructions: 

  • Use Clinical Scenario: Drill Begins in the Community Setting
  • Drill Coordinator reads Drill Scenario.
  • When team is ready, start timer and state aloud, “begin drill.”
  • Read additional prompts at the appropriate times.
  • Learners in drill scenario roles may ask for clinical values by acting out the assessment (e.g. taking a blood pressure or prepping IV supplies and simulating starting an IV). For visual or subjective assessments, they can ask. If assessments are abnormal or specified, they will be provided in the case. Otherwise, Drill Coordinator may provide any normal value in response.
  • Restart the timer and log the time elapsed after each portion of the Full Transfer Drill: Before Transport, During Transport, and At Hospital.
  • Observers should use the Observer Worksheets to assess performance of clinical tasks as the drill progresses.
  • People assigned to drill scenario roles and the Drill Coordinator should review and complete the Observer Worksheets immediately after the drill, before Debriefing and Action Planning.

Download & Print

Observer Worksheets

Clinical Scenario

Clinical Scenario

Drill begins in community setting

Read the following case aloud. Prior to beginning, participants may ask clarifying questions, but should not discuss their plan of care or move any supplies or equipment.

Nicole is a 21yo black cisgender female, G1P0000 at 37 weeks and 1 day gestation who presents to your clinic “feeling off.” She reports a persistent headache that began yesterday, explaining that last night it was mild, and today has worsened and feels like it’s throbbing across her head. She took 1000mg Tylenol 3 hours ago with no relief. Her intake today includes a piece of toast, a half cup of coffee, and 60oz of water so far.  She is studying pre-med in school and gearing up for finals so endorses increased stress recently. She reports no right upper quadrant pain,  vision changes, or swelling. She does not feel dizzy or lightheaded. She reports no fever or chills.  She denies leaking of fluid, vaginal bleeding, or contractions. She reports the baby’s movements are “a little slower today” and hasn’t felt any movements over the last hour.  She presents with her boyfriend Alex, and her mother Silvia who is a retired attorney. She has had routine prenatal care and an uncomplicated pregnancy to date. She has had all routine prenatal lab work which has been normal as well as a normal fetal anatomy scan at 20 weeks. She is GBS negative and Rh negative. She has a history of asthma, for which she has an albuterol inhaler and has used it once during pregnancy. She also has anxiety, diagnosed 2 years ago, for which she sees a therapist occasionally and does not take any medication. She takes prenatal vitamins and no additional prescription or supplemental medications. Her baseline blood pressure has been 110s/70s and heart rate 70s-80s throughout her pregnancy.

Clinical Scenario

Drill begins at hospital handoff

Read the following case aloud. Prior to beginning, participants may ask clarifying questions, but should not discuss their plan of care or move any supplies or equipment.

Print copies of the completed transfer form from the community provider.

You receive the following report by phone from a local provider in the community. They introduce themself and state: 

“I’m calling to initiate an emergent antepartum transfer for my patient with elevated blood pressures and new onset headache. Nicole is a 21yo black cisgender female, G1P0000 at 37 weeks and 1 day gestation with an uncomplicated pregnancy and routine prenatal care. She presented to my clinic feeling unwell with a new onset headache that she currently rates 7/10, unresolved by 1000mg Tylenol that she took 3 hours ago. She denies right upper quadrant pain or vision changes. She initially reported decreased fetal movement on arrival, but since presenting she has been feeling the baby move and the fetal heart rate is 130. She reports increased stress due to school finals right now. She is studying pre-med. On arrival today, her blood pressure was 168/104, repeated 3 minutes later it was 160/98. Her blood pressure was repeated after 15 minutes and is now mild-range at 156/94. Her heart rate is 58, pulse oximetry 98%, respiratory rate 18, and she has a normal physical exam. She has not received any anti-hypertensives or additional medications for her headache. 

Nicole takes prenatal vitamins, has an albuterol inhaler for history of asthma and does not take any additional prescription medications or supplements. She has no known allergies. We will be arriving via EMS and Nicole will be accompanied by myself and her boyfriend, Alex. Her mother, a retired attorney, will be meeting us at the hospital.”

Coordinator Prompts

Community Setting

Coordinator Prompts

Time Scenario (Read Aloud) Values (Share only if assessed)
00:00

Nicole continues to feel “off.” Out of breath as she arrives in the exam room.

Blood pressure: 168/104
Heart rate: 68
Sp02: 97%
Respiratory Rate: 28
Pain: 7/10 headache
FHTs: 130s by doppler
Physical exam: WNL
03:00

Nicole starts to feel the baby moving again. She is holding her head complaining of headache.

Blood pressure: 160/98
Heart rate: 62
Sp02: 98%
Respiratory Rate: 20
Pain: 7/10 headache
FHTs: 130s by doppler
NST (if performed): 130 baseline, minimal variability, no accels, no decels
Physical exam: WNL
00:00

Coordinator may “fast forward” time stating “12 minutes have passed” and continue to the next prompt if transfer has not been initiated.
15:00

Nicole is feeling the same. Her boyfriend is asking when he can take her home.

Blood pressure: 156/94
Heart rate: 58
Sp02: 98%
Respiratory Rate: 18
Pain: 7/10 headache
FHTs: 130s by doppler
NST (if available): 130 baseline, minimal variability, no accels, no decels
Physical exam: WNL

Repeat prior prompt every 1-2 minutes until transfer process is initiated.

During Transfer

Coordinator Prompts

Time Scenario (Read Aloud) Values (Share only if assessed)
00:00

Restart timer.

Nicole reports feeling anxious about transferring to the hospital. Reports she is starting to feel nauseous. Still feeling the baby moving. Headache persists.

Blood pressure: 158/96
Heart rate: 58
Sp02: 98%
Respiratory Rate: 18
Pain: 7/10 headache
FHTs: 130s by doppler
Physical exam: WNL
02:00

Alex is asking if transfer is really necessary, states Nicole will feel better at home.

Blood pressure: 158/96
Heart rate: 58
Sp02: 98%
Respiratory Rate: 18
Pain: 7/10 headache
FHTs: 130s by doppler
Physical exam: WNL

Scenario remains stable throughout transport.

Receiving Hospital

Coordinator Prompts

Time Scenario (Read Aloud) Values (Share only if assessed)
00:00

Restart timer.

Nicole is visibly uncomfortable and anxious, holding her head. Asking if she and the baby will be OK.

Blood pressure: 164/102
Heart rate: 62
Sp02: 98%
Respiratory Rate: 20
Pain: 8/10 headache
FHTs: 130s by doppler
Physical exam: WNL
04:00

Nicole is feeling the same. Her boyfriend is requesting that Nicole return home where she will feel better and stating, “her blood pressure is high because she is stressed here!”

Blood pressure: 162/100
Heart rate: 64
Sp02: 99%
Respiratory Rate: 20
Pain: 7/10 headache
FHTs: 130s by doppler
Continuous EFM (if available): 135 baseline, moderate variability, no accels, no decels
Physical exam: WNL
00:00

Coordinator may “fast forward” time stating “11 minutes have passed” and continue to the next prompt if preeclampsia interventions have not been initiated.

15:00

Nicole continues to feel the same. Asking what is going on and if there’s anything to make her feel better.

Blood pressure: 168/104
Heart rate: 64
Sp02: 98%
Respiratory Rate:
Pain: 7/10 headache
FHTs: 130s by doppler
Continuous EFM (if available): 135 baseline, moderate variability, no accels, no decels
Physical exam: WNL

End scenario.

Debriefing and Action Guide

Reflection Questions

Review the checklist of observed behaviors as a team and discuss subjective assessments such as communication style with team members and family, role clarity, and effectiveness at clinical tasks. 

  • What happened here? Ask 1-2 people to give a brief high-level summary so everyone’s on the same page.
  • What went well? Give everyone a chance to share the good stuff they noticed before critiquing.
  • What needs attention or improvement? Try to focus on processes and systems, not assigning blame.
  • Are there other appropriate ways to manage this emergency or transport? Consider different approaches such as who might accompany the patient, dyad vs. separate transfers, etc.
  • Were we prepared for this emergency? The answer will help clarify the Action Steps.

 

Action Steps

  • What changes are needed to processes or procedures? Make sure to assign someone to follow-up on the change.
  • How should this emergency be documented in the medical record? Discuss any documentation standards and tools such as order sets or dot-phrases available to clinicians.
  • What other reporting is required for this emergency transfer? This could include accreditation or licensing bodies, malpractice carriers, and internal organizational reporting.
  • What other follow up would be expected after this emergency? Consider follow-up for patient/family or staff, or other next steps.

Documentation

Document the date, location, clinical scenario(s), time spent in drill, and attendees so you can track participation against your practice’s internal policies and accreditation and/or licensure requirements. You can document your drill using the form at https://bit.ly/4aSAVjk or the QR code to complete and receive a digital copy of your Drill Report.

This will also contribute your drill data to help improve services and identify best practices. Data identifiable to a practice or individual will never be shared without consent.

QR Code

References

The American College of Obstetricians and Gynecologists. Hypertensive Emergency Checklist. Safe Motherhood Initiative. Updated January 2019.  https://www.acog.org/-/media/project/acog/acogorg/files/forms/districts/smi-hypertension-bundle-emergency-checklist.pdf

The American College of Obstetricians and Gynecologists. Maternal Safety Bundle for Severe Hypertension in Pregnancy. Safe Motherhood Initiative. Updated August 2020. https://www.acog.org/-/media/project/acog/acogorg/files/forms/districts/smi-hypertension-bundle-slides.pdf 

Obstetric Comorbidity Scoring System | California Maternal Quality Care Collaborative. www.cmqcc.org. https://www.cmqcc.org/research/severe-maternal-morbidity/obstetric-comorbidity-scoring-system

SCOTT KA, DAVIS DA. Destigmatizing and Democratizing Postpartum Care: A “Black Woman-Person First” Approach. Clinical Obstetrics & Gynecology. 2022;65(3):663-675. doi:https://doi.org/10.1097/grf.0000000000000729. https://journals.lww.com/clinicalobgyn/fulltext/2022/09000/Destigmatizing_and_Democratizing_Postpartum_Care_.20.aspx

Drill Kit Icon

Drill Kit

Birth In Place: Girl Scouts / Good Samaritan

Coordinator Information

Drill Description

Introduction

Step Up Together Drill Kits support interdisciplinary clinical teams to run emergency drills involving patient hand-offs and transport to a higher level facility. However, sometimes a birth occurs in a community setting without the presence of any trained medical professionals.

Our “Birth in Place” Series is tailored for various community organizations to train for the support of a person who goes into labor in the community, without a healthcare professional nearby. It is intended for lay people and community members without any medical training, such as scouting organizations or youth groups, retail employees, or others who interact with the general public. The Toolkit is intended to be used after reviewing the Birth In Place Educational Materials.

This Drill Kit includes a standardized high-fidelity case designed to test the process of caring for a birthing person and newborn outside of a medical setting until professional help arrives. Observation criteria and a Debriefing and Action Guide are provided to elicit continuous improvement of care processes and promote respectful care along the continuum.

 

Drill Description

This Drill Kit tests the community response to a birth occurring unexpectedly in a non-clinical community setting. The scenario includes prompts and guidance for an uncomplicated, precipitous vaginal birth of a healthy newborn. 

It is appropriate for:

  • Student groups, scouting groups, and other community organizations
  • Non-clinical personnel who interact frequently with pregnant individuals (e.g. doulas, childbirth educators, administrators)

And may further engage:

  • EMS or other emergency transport partners
  • Labor & Birth unit and other relevant units at the referral hospital

To test the process of:

  • Facilitating “birth in place” and arranging postpartum transport of the parent(s) and baby
  • Initial care and stabilization without direct clinical care

Learning Objectives:

  • Know steps to calmly call for help if the baby is coming
  • Practice techniques for supporting someone in labor
  • Give practical help when the baby is born and just after
  • Help maintain warmth and safety after the baby is born
  • Review ways to promote dignity, equity, and person-focused care during emergencies

Last updated: December 2024

Authored by:

Amy Romano, MBA, MSN, CNM, FACNM and Jennifer Johnson, MS, CNM

Reviewed by:

Alexa Dougherty, MSN, PHN, CNM
Cecilia Jevitt, PhD, CNM, MSN, APRN, FACNM

You will be coodinating a...

Partial Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer, but participants are only practicing part of the scenario: either the part that happens in the community before hospitalization, or the arrival at the hospital and post-transfer management.

Who's involved?

Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.

Planning Needs

Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.

Full Transfer Drill

What is it?

An emergency drill of a clinical scenario that requires transfer and participants practice all phases of the transfer: care in the community, emergency transport, and arrival and management at the hospital.

Who's involved?

Full practice/facility team from the community birth setting, plus transport and hospital personnel.

Planning Needs

Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.

Setup and Procedure

Birth In Place: Girl Scouts / Good Samaritan

Partial Transfer Drill Instructions

Participants (Minimum of two, up to full group/troupe):

  • *Drill Scenario Roles:
    • Assign a lead responder to the scenario
    • Assign a patient and (possibly) children
    • Additional learners or adult volunteers may be assigned to play the role of a 911 dispatcher or EMS lead. 
  • *Drill Coordinator presents the case scenario, and leads the debrief; may double as one of the participants if it is a smaller group.
  • Observer(s): Unassigned learners are observers, who use Observer Worksheets to track actions and processes during the drill. 

* Required roles

Setting and supplies: 

  • Room is set up to be a mock community setting (e.g. grocery store or restaurant)
  • Basic baby doll
  • Supplies that might be useful during the birth and that would be available in the simulated community environment (e.g. towels, cloths, clothing, pots/bowls, garbage bags, beverages and snacks, etc.)
  • Stopwatch or timer

Instructions: 

  • Drill Coordinator reads Clinical Scenario.
  • When team is ready, start timer and state aloud, “begin drill.”
  • Read additional prompts on the Coordinator Prompts at the appropriate times.
  • Observers should use the Observer Worksheets to assess performance of clinical tasks as the drill progresses. 
  • People assigned to drill scenario roles and the Drill Coordinator should review and complete the Observer Worksheets immediately after the drill, before Debriefing and Action Planning.

Download & Print

Observer Worksheets

Clinical Scenario

Clinical Scenario

Drill Begins in Community Setting

Read the following case aloud. Prior to beginning, participants may ask clarifying questions, but should not discuss their plan of care or move any supplies or equipment.

You go into the bathroom while at the grocery store and hear someone in the stall next to you say “Excuse me, can you help me? My water just broke and I think the baby will come soon.” 

You introduce yourself to the woman, Amy, and her two children, ages 6 and 4, who are with her at the store. She tells you that her due date was 3 days ago, and that she is out shopping with her children today while her husband is at work. She has had an uncomplicated pregnancy, and gets prenatal care at a nearby hospital. She says her last labor went very fast, “she was almost born in the car!”

Amy wants to call her husband to tell him to come to the store, and she asks you to call for help. As she looks for her phone in her purse, you can see her close her eyes, take long breaths, and grab onto the tops of her thighs.

Coordinator Prompts

Community Setting

Coordinator Prompts

Time Scenario (Read Aloud) Values (Share only if assessed)
00:00

Amy reports leaking fluid and strong cramping. Has to breathe through the contractions, but can talk and move in between.

02:00

Another contraction comes, and Amy has to stop to breathe through it. She groans and says “I’m feeling so much pressure!”

If learner calls 911, have someone read the dispatcher questions.

911 what is your emergency?
What’s the address?
Where are you in the building?
How old is the patient?
Is this her first baby?
Is Amy conscious? Is she breathing?
04:00

Another contraction comes, and Amy says “I have to push!” as she visibly bears down.
06:00

Amy winces and bears down again, as the baby’s head emerges. She reaches down, and with another big grunt, the rest of the baby comes out. A strong cry is heard from the baby as Amy brings her up to her chest.

911 dispatcher may walk bystander through the delivery as follows: 

You see the baby’s head, now you can gently support the head as Amy pushes the rest of the baby out. Help Amy lift the baby up to her chest, making sure not to pull too tightly on the umbilical cord.
Is the baby crying?
Put a dry towel or piece of clothing over the baby to keep it warm. The ambulance is on the way.

10:00

Amy and baby Rose lay together skin to skin. Amy reports some mild cramping and a small amount of fluid coming out, but no pain. Rose cries heartily on Amy, her skin is pink with her arms and legs bent.

Amy and Rose remain stable until First Responders arrive.

Debriefing and Action Guide

Reflection Questions:

  • What happened here? Ask 1-2 people to give a brief high-level summary so everyone’s on the same page.
  • What went well? Give everyone a chance to share the good stuff they noticed before critiquing.
  • What needs attention or improvement? Try to focus on processes and systems, not assigning blame.
  • Were we prepared for this emergency? The answer will help clarify the Action Steps.
  • What could you do if you spoke a different language than Amy?
  • What could you do if Amy couldn’t reach her husband to come take her children?

For additional resource download the Birth In Place Patch Activity Book

Documentation

Document the date, location, clinical scenario(s), time spent in drill, and attendees so you can track participation against your practice’s internal policies and accreditation and/or licensure requirements. You can document your drill using the form at https://bit.ly/4aSAVjk or the QR code to complete and receive a digital copy of your Drill Report.

This will also contribute your drill data to help improve services and identify best practices. Data identifiable to a practice or individual will never be shared without consent.

QR Code

References