ESMOE-EOST Module 3: Sepsis (Puerperal sepsis): Scenario 1 Version 1.

Date: ……………………………. Name of health facility: ………………................................

Name(s) of evaluator(s): Signature(s):

…………………………………………………...… ……………………………………………………

…………………………………………………...… ……………………………………………………

SCORE: BEFORE AFTER

NOTES AND FOLLOW-UP

ATTENDANCE

Name Rank Ward Signature

1.

2.

3.

4.

5.

6.

7.

8.
ESMOE-EOST Module 3: Sepsis (Puerperal sepsis): Scenario 1 Version 1.2

SEPSIS (PUERPERAL SEPSIS)

Scenario 1

MATERIALS TO BE READY AND AVAILABLE BEFORE STARTING THE SESSION:

General Equipment
• Ask a colleague to act as the patient. Give the • Sphygmomanometer
history to her • Stethoscope
• Prompt card with essential information • Pulse oximeter if available
discussed privately with patient actor • A supplemental oxygen source
• Blank clinical notes sheet o If cylinders are used, check that they have
• Clock adequate oxygen
o Flow meter and air oxygen blender
Drugs and supplies o Tubing
• Syringes and needles • Ambu bag and mask
• IV giving sets and IV pole • Spontaneously breathing oxygen mask with
• Test tubes for taking blood samples reservoir
• Ringer’s Lactate • Oxygen tubing
• Oropharyngeal airway
Learning materials • Yankauer sucker
• Flip charts Module 3

CALL FOR • Responsible

HELP! TEAM LEADER for key
DISCOVERER (Most senior appropriate procedures
SBAR person)
approach
• Quick diagnosis
• Basic management LOUD INSTRUCTIONS, role allocations
of patient
and distribution of functions
to …
(Mostly 1 to 3
helpers available) HELPER 1 HELPER 2 HELPER 3

Functions:
Equipment & Medications Care for baby
Interventions Apprise family
documents & monitoring
Comfort patient

For all of the steps, please demonstrate what you would do.
Explain what you are doing as you do it and why you are doing it.
 ESMOE-EOST Module 3: Sepsis (Puerperal sepsis): Scenario 1 Version 1.2

B = Before / A = After B A
Information provided and Key reactions/responses expected from participants
questions asked
Ms Y is a 28 year old P1G1 who presented at the labour ward with the complaint of lower abdominal pain and a foul smelling discharge. She
also stated that she had rigors and fever. She delivered 5 days ago and was discharged on day 3. She is not able to stand up by herself and
says she feels dizzy. (You work in a district hospital that has a functioning theatre)
1. What will you do? Perform a rapid evaluation of the general condition of the woman, including circulation (pulse, BP),
airway, breathing, oxygenation, level of consciousness (AVPU), skin colour, presence of anxiety
and/or confusion, blood loss, and skin temperature.
Ms Y’s pulse is 160 beats/minute, BP100/50mmHg, respirations are 26 breaths per minute but not laboured, the patient feels hot and pulse is
bounding and she is drowsy but is responsive to questions.
Discussion Question 1
2. What will you do? Call for HELP! Mobilise all available personnel!!
Turn the patient onto side
Secure circulation, airway, and breathing (CAB), if needed
Keep the woman warm but do NOT overheat her.
Give oxygen at 4-6L per minute by mask or nasal cannulae, if available
Secure the airway
Put in two large bore IV (16 gauge or largest available) cannulae or needles
Take blood for laboratory tests before infusing IV fluids (type & crossmatch, Hb, platelets and white
cell count, coagulation studies, urea and creatinine, AST) [Do bedside Hb]
Rapidly infuse at the rate of 1 L in 15-20 minutes – give at least 2L of fluid in the first hour
Catheterise the bladder and monitor fluid intake and output
Conduct a targeted history and physical examination to determine the cause of the shock and
feer. Perform a secondary survey (Big 5, Forgotten 4, Core 1)
Ms Y presented at the facility because she had rupture of membranes the previous night. An induction of labour was started. The induction
failed and a caesarean section was performed. She stated that she had strong contractions for a long time before the C/S and that she had
many vaginal examinations. She is currently expressing her breast milk and there is no tenderness or pain over the breasts. She had a fever
since she was discharged. She complained of a watery discharge from her wound for the previous two days. The fever and rigors have been
present for 1 day. She has no headache, neck stiffness, coughing, shortness of breath or leg pain. She passes urine and stool. On abdominal
examination the uterus is at the umbilicus, and the abdomen is tender. The wound is red with pus coming from it... On vaginal examination there
is a foul smelling discharge, the cervix admits two fingers, the parametrium is very tender. She is Rh +, RPR - and HIV negative. Her Hb is 9.2
g/dL.
3. What will you do? Begin IV antibiotics: Cephalosporins (3rd generation IV) / If not available IV Clindamycin or
Ampicillin 2 g IV every 6 hours PLUS Gentamicin 5 mg/kg body weight IV every 24 hours PLUS
Metronidazole 500 g IV every 8 hours
Use a fan or tepid sponge to help decrease temperature
Discussion Questions 2 -5
Ms Y’s BP remains at 100/50mmHg. Use SBAR and refer patient to secondary/tertiary level of care
Give paracetamol as needed to lower temperature
4. What will you do now?
Continue IV infusion
Monitor vital signs (BP, pulse, breathing) and skin temperature every 15 minutes until she has been
transferred to the regional or tertiary hospital
Discussion Question 6
CLINICAL SCORE = TOTAL NUMBER OF TICKS ABOVE
DISCUSSION QUESTIONS
1. Was Ms Y in shock? Yes, Ms Y had severe sepsis or septic shock.
2. What were possible causes of Most likely shock due to sepsis. Differential diagnosis should include: Endometritis, pelvic abscess, peritonitis,
shock in Ms Y’s case? breast engorgement, mastitis, breast abscess, wound abscess, wound cellulitis, cystitis, pyelonephritis, deep vein
thrombosis, pneumonia, atelectasis, uncomplicated malaria, severe/complicated malaria, typhoid, hepatitis,
complications of HIV
3. What would you / did you do to Conduct a targeted history and physical examination to determine the cause of fever plus perform a secondary
make a diagnosis? survey (Big 5, Forgotten 4, Core 1)
4. What is Ms Y’s likely diagnosis? Ms Y has puerperal sepsis due to endometritis

5. How should you / did you determine If the blood pressure did not rise with the IV fluids (20 ml per kg) then Ms Y is in septic shock Ms Y has septic
if Ms Y has septic shock? shock and requiresa laparotomy and probably a hysterectomy She needs referral to a regional or tertiary hospital
where a hysterectomy could be performed.
 ESMOE-EOST Module 3: Sepsis (Puerperal sepsis): Scenario 1 Version 1.2

BEFORE AFTER
CLINICAL SCORE: Assessment, diagnosis, monitoring and emergency management 18 18
CLINICAL SCORE: Total number of boxes ticked above
EXECUTION OF DRILL SCORE:
A. Activation/Communication skills
1. Appropriate equipment brought (emergency trolley)
2. Discoverer exchanges information with team leader and helpers using SBAR approach
3. Team leader assigns essential roles to helpers (care for the woman, calling a doctor, etc.)
4. Team leader addresses team members by name
5. All observations are communicated clearly and loudly
6. Communication done correctly: instruction
repeat instruction
inform team when instruction is completed
7. The delegated helper informs the patient and family of what is happening and what will be done for the woman
B. Response/Team work
8. Team responds appropriately to team leaders’ instructions
9. Team members cooperate with each other
10. The team determines the disposition of the patient (transfer, plan for further management)
C. Sign out/Documentation
11. Person allocated to do documentation
12. Care (actions) completely documented (timing of intervention and administration of drugs)
D. Sequence of activities
13. Activities performed in the correct order of priority
EXECUTION OF DRILL SCORE (A-D above) 13 13
EXECUTION OF DRILL SCORE (A-D above): Number of boxes ticked
TOTAL SCORE (CLINICAL SCORE + EXECUTION OF DRILL SCORE)
Out of a possible score of 31 31
DISCUSSION POINTS
1. Remember to replace drugs etc (on emergency trolley) 4. The environment should be quiet. Only instructions and
2. Equipment to be cleaned and sterilised appropriately feedback allowed
3. During drill there are no arguments or in-between discussions of opinions on 5. Observations are given clearly and loudly
how something should be done. Only the necessary actions are performed 6. Importance of the correct sequence of events
as swiftly and efficiently as possible 7. Documentation