Course
Primary Maternity Care and the Institute for Perinatal Quality Improvement (PQI) have partnered to offer a special Step Up Together edition of Intermittent Auscultation Simulation-Based Education—a virtual course designed for nurses, midwives, paramedics, physicians, and other clinical team members committed to providing safe, patient-centered care during labor.
Last updated:
Authored by:
Reviewed by:
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.
Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.
Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.
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.
Full practice/facility team from the community birth setting, plus transport and hospital personnel.
Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.
Download & Print
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.
Drill Kit
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.
This Drill Kit tests the emergency response to a retained placenta occurring in the community birth setting requiring transport of the postpartum individual to a higher level of care for further management.
It is appropriate for:
And may further engage:
To test the process of:
Last updated: May 2025
Authored by:
Alexa Dougherty, MSN, PHN, CNM
Reviewed by:
Debra Bingham, DrPH, FAAN
Emily Bronson, MA, MPH, CD(DONA)
Holly Christensen, MSN, CNM
Timothy Fisher, MD, MS, FACOG
Jennifer Johnson, MS, CNM
Amy Romano, MBA, MSN, CNM, FACNM
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.
Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.
Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.
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.
Full practice/facility team from the community birth setting, plus transport and hospital personnel.
Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.
Retained Placenta with Doula Present
Participants (Minimum of two, up to full practice/facility team):
Assign the following roles:
* Required roles
Setting and supplies:
Instructions:
Retained Placenta with Doula Present
Participants (Full team plus transport and/or hospital personnel):
Assign the following roles:
*Required roles
Setting and supplies:
Instructions:
Download & Print
Clinical Scenario
Nikki is a 37 year-old now G2P1011 who is 27 minutes status-post normal vaginal delivery of a viable infant at 40 weeks 6 days gestation in the community setting. Labor onset was spontaneous, active labor was 4 hours and second stage was 15 minutes. Nikki birthed in the tub and was moved out of the water to the bed after 3 minutes. Minimal bleeding was noted in the tub prior to exit. Newborn Apgars 8/9. With consent, 10 units of IM pitocin was given for active management of the third stage, as she does not have IV access. They are currently 27 minutes post-delivery, lying in the bed, skin-to-skin with the infant, reporting mild intermittent cramping. Placenta remains undelivered. QBL at this time is 50cc. Their partner, Taylor, is present as well as their doula, Sam.
Notable history:
Nikki’s pregnancy was a result of in vitro fertilization (IVF) and was otherwise uncomplicated. They had a normal anatomy scan and routine prenatal blood work; blood type A pos, 36 week Hemoglobin and Hematocrit were 10.1 and 33 respectively, platelets 223k.
Obstetric history notable for an uncomplicated D&C for 11 week spontaneous abortion 2 years ago. No other surgical or relevant medical history.
Clinical Scenario
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 in regards to a transfer for a postpartum patient with a retained placenta. My patient, Nikki, is a 37 year-old now G2P1011 who had an uncomplicated spontaneous vaginal delivery 35 minutes ago at 40 weeks and 6 days gestation. 10 units of IM pitocin was given immediately following the birth for active management of the third stage. Their bladder is empty and despite gentle cord traction and position changes, the placenta remains undelivered. QBL is currently 450cc. Nikki will be coming via EMS and accompanied by her Doula, Sam.”
Notable history:
Nikki’s pregnancy was a result of in vitro fertilization (IVF) and was otherwise uncomplicated. They had a normal anatomy scan and routine prenatal blood work; blood type A pos; anemia noted at 36 weeks with Hgb/Hct of 10.1 and 33 respectively, platelets 223k.
Obstetric history notable for an uncomplicated D&C for 11 week spontaneous abortion 2 years ago. No other surgical or relevant medical history. See transfer form.
Community Setting
| Time | Scenario (Read Aloud) | Values (Share only if assessed) |
|---|---|---|
| 00:00 | Start timer. (27 minutes post-birth) Nikki reports feeling stronger cramping and asks “I hope this is the placenta coming.” Doula, Sam, is helping Nikki and baby to latch. |
Adult Vitals: HR 86, BP 112/68, Temp 98.2F |
| 03:00 | (30 minutes post-birth) Baby now latched and nursing. Nikki asks to have the food she brought warmed up. |
Adult Vitals: HR 80, BP 108/62, Temp 98.0F |
| 07:00 | (35 minutes post-birth) Nikki’s partner, Taylor asks, “is it normal that the placenta takes this long or should we be concerned?” |
Adult Vitals: HR 90, BP 118/70, Temp 98.4F |
|
Placenta remains undelivered. Repeat prompt every 1-2mins until transfer is initiated. Nikki asks Taylor (partner) to stay with the baby if they need to be separated. Increase in QBL by 50cc every 5 minutes until transfer is initiated. |
||
During Transfer
| Time | Scenario (Read Aloud) | Values (Share only if assessed) |
|---|---|---|
| 00:00 | Restart timer. Nikki is visibly upset, asking “what is going to happen at the hospital? I really didn’t want to go there.” Sam is present, explaining what to expect and providing comfort. |
Adult Vitals: HR 92, BP 120/76, Temp 98.2F |
| 02:00 | Nikki states “I just felt more blood come out, is that ok?” |
Adult Vitals: HR 92, BP 120/76, Temp 98.2F |
|
Scenario remains stable until arrival at the hospital. |
||
Receiving Hospital
| Time | Scenario (Read Aloud) | Values (Share only if assessed) |
|---|---|---|
| 00:00 | Restart timer. Nikki visibly anxious and states “I keep feeling these little gushes of blood. Why is the placenta not coming?” |
Adult Vitals: HR 94, BP 112/74, Temp 98.2F |
| 03:00 | Placenta remains undelivered with no additional signs of separation. Nikki states “I need something for the pain if you have to keep touching. There’s no way you’re reaching up there without pain medication! This is terrible.” |
Adult Vitals: HR 94, BP 112/74, Temp 98.2F |
| If/when manual removal is attempted: | Unable to remove placenta manually. Significant clots and blood released after attempt. |
Adult Vitals: HR 96, BP 116/72, Temp 98.2F |
Nikki asks, “I’m terrified, can Sam please stay with me?” Placenta remains undelivered until a decision is made to proceed to D&C. |
Adult Vitals: HR 94, BP 112/64, Temp 98.8F |
|
|
End scenario. |
||
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.
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.
California Maternal Quality Care Collaborative. Hemorrhage. Accessed May 8, 2025. https://www.cmqcc.org/toolkits-quality-improvement/hemorrhage.
Perlman NC, Carusi DA. Retained placenta after vaginal delivery: risk factors and management. Int J Womens Health. 2019;11:527-534. Published 2019 Oct 7. doi:10.2147/IJWH.S218933
Posner, G.D., Black, A.Y., Jones, G.D., & El-Chaar, D. (Eds.). (2023. Oxorn-Foote: Human labor and birth. (7th ed). McGraw-Hill Companies, Inc.
Quantification of blood loss: AWHONN Practice Brief Number 1. J Obstet Gynecol Neonatal Nurs. 2015 Jan-Feb;44(1):158-160. doi: 10.1111/1552-6909.1251
Drill Kit
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.
This Drill Kit tests the emergency response to a breech presentation occurring in a community setting including transport of a laboring patient.
It is appropriate for:
And may further engage:
To test the process of:
Last updated: May 2025
Authored by:
Jennifer Johnson, MS, CNM
Reviewed by:
Debra Bingham, DrPH, FAAN
Emily Bronson, MA, MPH, CD(DONA)
Alexa Dougherty, MSN, PHN, CNM
Amy Romano, MBA, MSN, CNM, FACNM
Sue Gullo, MS
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.
Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.
Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.
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.
Full practice/facility team from the community birth setting, plus transport and hospital personnel.
Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.
Breech Presentation in Labor with Doula Present
Participants (Minimum of two, up to full practice/facility team):
Assign the following roles:
* Required roles
Setting and supplies:
Instructions:
Breech Presentation in Labor with Doula Present
Participants (Full team plus transport and/or hospital personnel):
Assign the following roles:
*Required roles
Setting and supplies:
Instructions:
Download & Print
Clinical Scenario
Grace is a 32 year old G4 P2012 at 39 weeks and 2 days. She has a history of two previous uncomplicated pregnancies with normal vaginal deliveries at term. Her prenatal course includes a normal anatomy scan (2 small fibroids noted <3cm), and normal third trimester labs with the exception of mild anemia. Her blood type is A positive, she is GBS negative, and her 36 week Hgb was 11.2 after taking a daily iron supplement since 28 weeks.
At 34 weeks, her midwife suspected the baby was malpositioned based on their assessment with Leopold’s maneuvers as well as auscultating the clearest fetal heart tones in the right upper quadrant. Grace spent the next 2 weeks doing everything possible to get the baby to turn on her own. At 36 weeks, she had an ultrasound to confirm fetal position, and the baby was breech. She underwent a successful external cephalic version at their local hospital yesterday morning.
Grace calls this morning to report intermittent cramping overnight that has now progressed to contractions every 7-10 minutes. She reports normal fetal movement, without any bleeding or leaking fluid. When the midwife arrives, Grace is supported by her partner Julian and their doula Kira, who reports that contractions are now 4-6 minutes apart.
Clinical Scenario
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 of a patient in labor with a breech presentation. Grace is a 32yo G4 P2012 at 38 weeks and 5 days with an otherwise uncomplicated pregnancy. She is currently contracting every 4-6 minutes with an exam of 5/90/-1 after a spontaneous rupture of membranes for clear fluid a few minutes ago, and I expect she will progress quickly. The fetal heart rate has been normal in the 120-130s, and the amniotic fluid is clear. I will be accompanying her to your facility, along with her partner and their doula.”
Community Setting
| Time | Scenario (Read Aloud) | Values (Share only if assessed) |
|---|---|---|
| 00:00 | Scenario begins. Start timer. Grace breathes through a contraction with Julian giving counter pressure. |
FHTs: 13, 12, 12, 13, 13, 12 best clarity in RUQ |
| 02:00 | Grace paces around the room between contractions, reports feeling “a lot of pressure.” |
FHTs: 13, 12, 12, 13, 13, 12 best clarity in RUQ |
| 04:00 | Grace breathes through a contraction, in the middle of which she startles and says “I think my water just broke!” |
FHTs: 13, 12, 12, 13, 13, 12 best clarity in RUQ |
| 06:00 | Grace paces around the room and says “if this is anything like the last time, things are about to speed up.” |
FHTs: 13, 12, 12, 13, 13, 12 best clarity in RUQ |
|
Repeat prior prompt every 1-2 minutes until transfer process is initiated. |
||
During Transfer
| Time | Scenario (Read Aloud) | Values (Share only if assessed) |
|---|---|---|
| 00:00 | Restart timer. Grace breathes through a contraction and says they feel stronger already. Kira is present, providing comfort and explaining what to expect. |
FHTs: 13, 12, 12, 13, 13, 12 best clarity in RUQ |
| 03:00 | Another contraction begins and Grace is vocalizing quietly. |
FHTs: 13, 12, 12, 13, 13, 12 best clarity in RUQ |
|
Repeat prior prompt every 3-5 minutes until arrival at transfer hospital. |
||
Receiving Hospital
| Time | Scenario (Read Aloud) | Values (Share only if assessed) |
|---|---|---|
| 00:00 | Restart timer. Grace appears sad and uncomfortable. She asks, “Can my doula stay with me?” |
Continuous EFM: 130 bpm |
| 03:00 | Another contraction begins, Grace winces through it, “Do I have to have a c section, can’t I just push her out like this?” |
Continuous EFM: 130 bpm |
|
Repeat prior prompt every 3 minutes until delivery decision is initiated. |
||
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.
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.
American College of Obstetricians and Gynecologists (2018). Mode of Term Singleton Breech Delivery: Committee Opinion 745. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/08/mode-of-term-singleton-breech-delivery
Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet 2000; 356: 1375– 83.
Whyte H, Hannah ME, Saigal S, Hannah WJ, Hewson S, Amankwah K, et al. Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial. Term Breech Trial Collaborative Group. Am J Obstet Gynecol 2004; 191: 864– 71.
Hannah ME, Whyte H, Hannah WJ, Hewson S, Amankwah K, Cheng M, et al. Maternal outcomes at 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term: the international randomized Term Breech Trial. Term Breech Trial Collaborative Group. Am J Obstet Gynecol 2004; 191: 917– 27.
External cephalic version. Practice Bulletin No. 161. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016; 127: e54– 61
Hofmeyr GJ, Kulier R, West HM. External cephalic version for breech presentation at term. Cochrane Database of Systematic Reviews 2015, Issue 4. Art. No.: CD000083. DOI: 10.1002/14651858.CD000083.pub3.
Alarab M, Regan C, O’Connell MP, Keane DP, O’Herlihy C, Foley ME. Singleton vaginal breech delivery at term: still a safe option. Obstet Gynecol 2004; 103: 407– 12.
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
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.
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:
And may further engage:
To test the process of:
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
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.
Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.
Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.
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.
Full practice/facility team from the community birth setting, plus transport and hospital personnel.
Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.
Cord Prolapse
Participants (Minimum of two, up to full practice/facility team):
* Required roles
Setting and supplies:
Instructions:
Cord Prolapse
Participants (Full team plus transport and/or hospital personnel):
Assign the following roles:
*Required roles
Setting and supplies:
Instructions:
Download & Print
Clinical Scenario
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
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.”
Community Setting
| 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 |
| 02:00 | Another contraction begins, and Gabriella breathes through it with support from Gloria and Alonso. |
FHTs: 13, 12, 12, 13, 13, 12 |
| 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 |
| 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 |
| 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 |
| 10:00 | Another contraction begins, Gabriella breathes and grunts through it. |
FHTs: 8, 8, 7, 6, 7, 8 |
|
Repeat prior prompt every 1-2 minutes until transfer process is initiated. |
||
During Transfer
| 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 |
| 02:00 | Another contraction with pressure, Gabriella asks what will happen when they get to the hospital |
FHTs: 10, 10, 9, 8, 9, 10 |
|
Scenario remains stable throughout transport |
||
Receiving Hospital
| 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 |
| 02:00 | Next contraction begins, Gabriella continues to feel pressure. |
FHTs (if using continuous monitor): baseline 105 with late decel to 80 |
| 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 |
|
Repeat prior prompt every 1-2 minutes until delivery decision is initiated. |
||
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.
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
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.
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:
And may further engage:
To test the process of:
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
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.
Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.
Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.
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.
Full practice/facility team from the community birth setting, plus transport and hospital personnel.
Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.
Neonatal Respiratory Distress
Participants (Minimum of two, up to full practice/facility team):
* Required roles
Setting and supplies:
Instructions:
Neonatal Respiratory Distress
Participants (Full team plus transport and/or hospital personnel):
Assign the following roles:
*Required roles
Setting and supplies:
Instructions:
Download & Print
Clinical Scenario
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
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.
Community Setting
| Time | Scenario (Read Aloud) | Values (Share only if assessed) |
|---|---|---|
| 00:00 | Scenario begins. Start timer. |
Respiratory Rate: 82, spontaneous |
| 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 |
| 02:00 | Justice continues to have nasal flaring and retractions. Appears fussy. |
Respiratory Rate: 84, spontaneous |
| 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 |
| 06:00 | Justice continues to have nasal flaring and retractions. Appears sleepy. |
Respiratory Rate: 90, spontaneous |
|
Repeat prior prompt every 1-2 minutes until emergency transport process is activated. |
||
During Transfer
| 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 |
| 01:00 | Justice no longer has flaring, but continues to have retractions. |
Respiratory Rate: 75, spontaneous |
| 03:00 | Justice continues to have retractions. |
Respiratory Rate: 86, spontaneous |
|
Repeat prior prompt every 1-2 minutes until patient reaches hospital unit. |
||
Receiving Hospital
| 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 |
| 01:00 | Justice has retractions and minimal response to stimuli. |
Respiratory Rate: 86 |
| 02:00 | Justice has retractions and minimal response to stimuli. |
Respiratory Rate: 88 |
|
Repeat prior prompt every 1-2 minutes until newborn is fully admitted to the unit and care handed off to the neonatal team |
||
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.
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.
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
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.
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:
And may further engage:
To test the process of:
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
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.
Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.
Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.
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.
Full practice/facility team from the community birth setting, plus transport and hospital personnel.
Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.
Delayed Postpartum Hemorrhage with Nurse and Doula Present
Participants (Minimum of two, up to full practice/facility team):
* Required roles
Setting and supplies:
Instructions:
Delayed Postpartum Hemorrhage with Nurse and Doula Present
Participants (Full team plus transport and/or hospital personnel):
Assign the following roles:
*Required roles
Setting and supplies:
Instructions:
Download & Print
Clinical Scenario
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
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.
Community Setting
| 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 |
| 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 |
| 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 |
| 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 |
| 05:00 | Veronica continues to feel dizzy and nauseous. |
Fundus: midline, at umbilicus, firm with massage, small gush of blood with massage |
|
Repeat prior prompt every 1-2 minutes until transfer is initiated. |
||
During Transfer
| 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% |
| 01:00 | Veronica is pale, exhausted, and irritable. |
Vital signs: BP 90/52, HR 115, O2 98% |
| 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 |
Receiving Hospital
| 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 |
| 02:00 | Veronica reports cramping and pain. |
Vital signs: BP 86/48 HR 120, O2 96%, T 99.1 |
|
Repeat prior prompt until manual removal of clots is performed. Bleeding stabilizes after this is performed. |
||
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.
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.
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
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.
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:
And may further engage:
To test the process of:
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
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.
Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.
Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.
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.
Full practice/facility team from the community birth setting, plus transport and hospital personnel.
Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.
Shoulder Dystocia with Neonatal Resuscitation
Participants (Minimum of two, up to full practice/facility team):
Assign the following roles:
* Required roles
Setting and supplies:
If conducting the drill at the transfer hospital print copies of the completed transfer form from the community midwife.
Additional Resource:
Instructions:
Shoulder Dystocia with Neonatal Resuscitation
Participants (Full team plus transport and/or hospital personnel):
Assign the following roles:
Setting and supplies:
Additional Resource:
Instructions:
Download & Print
Clinical Scenario
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:
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
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.
Community Setting
| 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 |
| 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 |
| 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 |
| 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 |
| 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 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 |
| 10:30 | Josie is dried with warm blanket and stimulated by care team. |
Neonatal Tone: poor |
| 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:
(1 min APGAR = 6) Maternal vitals: BP 124/78, Pulse 105, Temp 98.9, uterine bleeding absent |
| 12:00 | Josie coughs and cries, appears more vigorous in both legs and left arm. Right arm with minimal movement. |
Neonatal assessment:
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:
Maternal Vitals: |
| 14:00 | Placenta delivers in another small gush of blood. Josie continues to have some “wet” breathing. |
Neonatal assessment:
Maternal Vitals: |
| 15:00 | 5 minutes since birth. Allison asks about Josie’s right arm and breathing “weird”. Repeat prompt until transfer initiated. |
Neonatal assessment:
(5 min apgar = 8) Maternal Vitals: |
|
Repeat prior prompt every 1-2 minutes until transfer initiated. |
||
During Transfer
| 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% |
|
Scenario remains stable throughout transport to hospital. |
||
Receiving Hospital
| 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% |
| 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%. |
| 02:00 | Repeat prompt until neonate taken for imaging then moved to observation |
|
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.
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
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.
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:
And may further engage:
To test the process of:
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
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.
Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.
Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.
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.
Full practice/facility team from the community birth setting, plus transport and hospital personnel.
Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.
Birth with Postpartum Hemorrhage
Participants (Minimum of two, up to full practice/facility team):
* Required roles
Setting and supplies:
Additional Resource:
Instructions:
Birth with Postpartum Hemorrhage
Participants (Full team plus transport and/or hospital personnel):
Assign the following roles:
*Required roles
Setting and supplies:
Additional Resource:
Instructions:
Download & Print
Clinical Scenario
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
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.
Community Setting
| Time | Scenario (Read Aloud) | Values (Share only if assessed) |
|---|---|---|
| 00:00 | Scenario begins. Start timer. |
Adult Vitals: HR 95, BP unable to auscultate |
| 01:00 | Patient has another contraction after SROM and feels the need to push. |
Adult Vitals: HR 95, BP unable to auscultate |
| 02:00 | After 2 pushes, she delivers the baby who is vigorous with spontaneous cry. |
Adult Vitals: HR 95, BP unable to auscultate |
| 03:00 | Baby is vigorous, appears LGA, baby is placed skin-to-skin. |
Adult Vitals: HR 94, BP 104/68, Temp 98.0F |
| 04:00 | You begin to see cord lengthening. Patient reports strong cramping. |
Adult Vitals: HR 94, BP 104/68, Temp 98.0F |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
|
Repeat prior prompt every 1-2 minutes until transfer process is initiated |
||
During Transfer
| 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 |
| 02:00 | Amara reports significant cramping. |
Adult Vitals: HR 115, BP 95/52, SpO2 97%, fundus firm 1fb below umbilicus |
| 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% |
|
Repeat prior prompt every 1-2 minutes until patient reaches hospital unit. |
||
Receiving Hospital
| 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% |
| 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% |
| 03:00 | Amara again reports feeling slightly dizzy. |
Adult Vitals: HR 120, BP 92/52, SpO2 97% |
| 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 |
| 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% |
|
End scenario. Document time elapsed. |
||
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.
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
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.
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:
And may further engage:
To test the process of:
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
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.
Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.
Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.
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.
Full practice/facility team from the community birth setting, plus transport and hospital personnel.
Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.
First Stage Fetal Bradycardia
Participants (Minimum of two, up to full practice/facility team):
* Required roles
Setting and supplies:
Additional Resource:
Instructions:
First Stage Fetal Bradycardia
Participants (Full team plus transport and/or hospital personnel):
Assign the following roles:
*Required roles
Setting and supplies:
Additional Resource:
Instructions:
Download & Print
Clinical Scenario
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
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.
Community Setting
| Time | Scenario (Read Aloud) | Values (Share only if assessed) |
|---|---|---|
| 00:00 | Scenario begins. Start timer. |
Pulse: 88 |
| 01:00 | Deidra coping well with contractions but reports feeling them much more intensely |
Pulse: 96 |
| 02:30 | Another contraction has started. |
Pulse: 98 |
| 03:30 | Deidra complains of being lightheaded. |
Pulse: 96 |
| 04:30 | Another contraction begins. |
Pulse: 100 |
|
Repeat prior prompt every 1-2 minutes until emergency transport process is activated. |
||
During Transfer
| 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 |
| 02:00 | Another contraction begins. Deidra is asking if her baby is going to be OK. |
Pulse: 100 |
| 04:00 | Another contraction begins. Deidra is asking what is going to happen to her when she gets to the hospital. |
Pulse: 94 |
|
Repeat prior prompt every 1-2 minutes until patient reaches hospital unit. |
||
Receiving Hospital
| 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 |
| 02:00 | Deidra begins having a contraction. On EFM, FHT baseline is 94 with minimal variability. |
Pulse: 90 |
| 03:00 | The contraction is over. FHT deceleration noted to 68. |
Pulse: 90 |
| 04:00 | Another contraction begins. Yellow-tinged fluid is noted on the pad under Deidra. |
Pulse: 90 |
|
Repeat prior 2 prompts every 1-2 minutes until patient is fully admitted to the unit and stat-cesarean is initiated. |
||
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.
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
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.
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:
And may further engage:
To test the process of:
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
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.
Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.
Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.
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.
Full practice/facility team from the community birth setting, plus transport and hospital personnel.
Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.
Second Stage Fetal Bradycardia
Participants (Minimum of two, up to full practice/facility team):
* Required roles
Setting and supplies:
Additional Resource:
Instructions:
Second Stage Fetal Bradycardia
Participants (Full team plus transport and/or hospital personnel):
Assign the following roles:
*Required roles
Setting and supplies:
Additional Resource:
Instructions:
Download & Print
Clinical Scenario
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
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.
Community Setting
| Time | Scenario (Read Aloud) | Values (Share only if assessed) |
|---|---|---|
| 00:00 | Scenario begins. Start timer. |
Maternal Pulse: 92 |
| 01:00 | Another contraction begins. Avery asking to change position, vocalizing and bearing down at a high pitch. |
Maternal Pulse: 94 |
| 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 |
| 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 |
| 06:00 | Another contraction begins. Avery shouting “I can’t!” and not pushing effectively. |
Maternal Pulse: 98 |
| 07:30 | Another contraction begins, Avery vocalizing at high pitch. Partner encouraging her. |
Maternal Pulse: 94 |
|
Repeat prior prompt every 1-2 minutes until emergency transport process is activated. |
||
During Transfer
| 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 |
| 02:00 | Another contraction begins, Avery bearing down occasionally but encouraged to breathe through the contractions as best as possible. |
Maternal Pulse: 94 |
|
Repeat prior prompt every 1-2 minutes until patient reaches hospital unit. |
||
Receiving Hospital
| 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 |
| 02:00 | Another contraction begins. Avery has a much stronger, uncontrollable urge to bear down. Reports feeling much more pressure. |
Maternal Pulse: 96 |
| 03:00 | Fetal head becomes visible at introitus with pushing. |
Maternal Pulse: 94 |
|
Repeat prior prompt every 1-2 minutes until patient is fully admitted and operative vaginal delivery is initiated. |
||
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.
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.
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.
Download
A tool to systematically assess different community birth center stakeholders and identify approaches to address their concerns and/or interests.
Last updated:
Authored by:
Reviewed by:
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.
Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.
Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.
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.
Full practice/facility team from the community birth setting, plus transport and hospital personnel.
Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.
Download & Print
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.
Download
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.
Last updated:
Authored by:
Reviewed by:
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.
Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.
Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.
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.
Full practice/facility team from the community birth setting, plus transport and hospital personnel.
Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.
Download & Print
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.
Download
Last updated:
Authored by:
Reviewed by:
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.
Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.
Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.
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.
Full practice/facility team from the community birth setting, plus transport and hospital personnel.
Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.
Download & Print
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.
Download
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.
Last updated:
Authored by:
Reviewed by:
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.
Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.
Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.
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.
Full practice/facility team from the community birth setting, plus transport and hospital personnel.
Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.
Download & Print
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.
Download
An editable modeling tool to help you identify birth center staffing needs based on information specific to your practice.
Last updated:
Authored by:
Reviewed by:
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.
Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.
Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.
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.
Full practice/facility team from the community birth setting, plus transport and hospital personnel.
Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.
Download & Print
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.
Download
A sample, and editable template, of birth center job descriptions. Adapt and change to fit your birth center and state regulatory environment.
Last updated:
Authored by:
Reviewed by:
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.
Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.
Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.
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.
Full practice/facility team from the community birth setting, plus transport and hospital personnel.
Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.
Download & Print
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.
Download
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.
Last updated:
Authored by:
Reviewed by:
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.
Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.
Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.
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.
Full practice/facility team from the community birth setting, plus transport and hospital personnel.
Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.
Download & Print
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.
Download
Use this fun and engaging activity to ensure your team is prepared for emergencies.
Last updated:
Authored by:
Reviewed by:
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.
Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.
Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.
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.
Full practice/facility team from the community birth setting, plus transport and hospital personnel.
Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.
Download & Print
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.
Drill Kit
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.
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:
And may further engage:
To test the process of:
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
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.
Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.
Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.
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.
Full practice/facility team from the community birth setting, plus transport and hospital personnel.
Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.
Postpartum Mental Health Crisis
Participants (Minimum of two, up to full practice/facility team):
* Required roles
Setting and supplies:
Instructions:
Postpartum Mental Health Crisis
Participants (Full team plus transport and/or hospital personnel):
Assign the following roles:
*Required roles
Setting and supplies:
Instructions:
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Clinical Scenario
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
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.”
Community Setting
| 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: 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: 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 |
| 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
| 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
| 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 |
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.
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.
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.
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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.
Minimum of two individuals from a practice, up to the full practice/facility, with or without collaborating partners present.
Can be impromptu with a small group or scheduled in advance at regular times, for which participation should be compensated.
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.
Full practice/facility team from the community birth setting, plus transport and hospital personnel.
Requires coordination and advanced planning with community practice, EMS, and hospital teams. Compensate for time to participate.
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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.