Table 3 An iteration of the simulation protocol for a transfer by cesarean section delivery

Preparations

1

Sign-in: Introduction of the entire team, patient, and procedure verification, list of allergies, and anticoagulation.

2

Positioning of the fetus and placenta is determined

3

Instrument check with an extra checklist for and familiarization of the materials.

4

Standard fetal and maternal monitoring modalities are employed such as heart rate and blood pressure monitoring as well as cardiotocography for maternal contraction and fetal monitoring before the procedure.

5

Inform operating personnel to start preparations for the procedure.

6

Other members of the procedural team are also alerted to make their way to the operating theatre.

7

The patient is then transported to the operating theatre.

8

Patient is placed in a 15° left lateral tilt position.

9

Preoxygenation of the patient.

10

The anesthesiologist administers general anesthesia.

• Propofol induction

• Sevoflurane maintenance

• Opiates

• Intubation

11

Administer prophylactic antibiotics

12

Placing body support components (shoulder, hip, gel pads between feet and arms)

13

Inserting catheter

14

The operating field is prepared according to standard protocols (NVDV, Dutch Association for Dermatology and Veneorology)

15

Prepare all the necessary CS transfer materials.

16

Start ultrasound monitoring

Communication moment 1 (transfer team)—start operation

Transfer

17

The surgeon makes a Pfannenstiel incision through to the peritoneum according to standard protocol (Dutch Pediatrics Association), splitting the abdominal muscles (until the abdominal cavity)

18

Blood is tamponed from the incision site to avoid cloudiness of the (artificial) amniotic fluid.

Communication moment 2 (transfer team)—uterus incision

19

The incision in the uterus is made. The width of the incision is based on the diameter of the fetal skull (P29).

20

Amnioinfusion into the native uterus to keep the fetal head submerged.

21

The transferbag is filled with AAF before the perinate is transferred.

22

Increase oxygen percentage (fetal preoxygenation)

23

Mother is manually tilted to her left side.

24

The perinate is delivered while the breathing reflex is prevented and other environmental stimuli are shielded as much as possible.

25

In case of severe uterine contraction, intravenous nitroglycerin can be given at this point for uterine relaxation to facilitate fetal extraction [73]. Dosage is at the discretion of the anesthesiologist

26

The infant is taken from the natural uterus completely into the transferbag.

27

The transferbag is closed from exterior exposure to avoid AAF from leaking or exterior factors to enter.

28

The transferbag is placed in a stable position to allow for cannulation before the perinate is placed in the more permanent APAW system. In the meantime, temperature change of the perinate (and AAF) should be prevented.

29

Mother placed in the supine position.

Cannulation, installation, and suturing

30

Ultrasound monitoring of heart rate via umbilical cord

31

Neonatologist moves to the operation table.

Communication moment 3—decision to proceed with APAW treatment

32

Splitting into two teams: perinatal team and maternal team

Perinatal team

Maternal team

A

Preparing the umbilical cord

A Suction AAF from uterus

B

Cannulation of the umbilical cord

B Wait for placental delivery until cannulation succeeded

C

Clamping of the umbilical cord

C Administer oxytocin

Communication moment 4 (technical support for adjustments to APAW system)

D Uterus massage

D

Administering of medication when necessary

E Placental delivery through controlled cord traction

E

Bring perinate to APAW system

F Blood loss monitoring, additional medication is given if necessary

G Suturing of the uterus and skin

Wrap up

33

Stop anesthesia, extubate the mother

34

Sign-out: count materials, after-care policy

35

Evaluation of procedure and feedback