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This is a case report of a 39-year-old multigravida woman without allopathic prenatal care who, after three previous caesarean sections, attempted to deliver her fourth child at home with the help of a direct entry midwife. During labour, fetal movement and fetal heart tones became undetectable, at which time the patient was referred by the midwife to the hospital. The patient was diagnosed with uterine rupture, bladder rupture and fetal demise; she was rushed to emergency surgery. The patient's lack of allopathic prenatal care, attempt of vaginal birth after three previous caesarean sections, coupled with her desire for delivery at home, led to her complicated course. The patient related that she was never made aware that attempting a home birth after three prior caesarean sections put her at increased risk for complications, and she was also unaware that midwives could have varying levels of training.

Introduction: Delayed emergence is failure to regain consciousness following general anesthesia. It commonly involves altered mental status and respiratory compromise leading to increased morbidity, operating room delays, and increased cost. Causes include residual anesthetics, pharmacologic actions, surgical complications, neurologic events, endocrine disturbances, and patient-related factors. Pseudocholinesterase deficiency is an important consideration in delayed emergence. These patients are unable to effectively metabolize the muscle relaxants succinylcholine and mivacurium, leading to prolonged paralysis following administration. Methods: This simulation exercise is designed for medical students, student nurse anesthetists, and resident physicians. It is a 1-hour small-group learning activity centered upon a single patient encounter. We employ this exercise using an anesthesiology resident physician to proctor, a simulation technician to program and run, and a faculty anesthesiologist to mentor each session. It is intended to reinforce required reading assignments and improve the approach to delayed emergence from anesthesia. The debriefing includes discussion of risk-reduction strategies for incorporation in clinical practice. This exercise is easily reproduced using modern simulation mannequins without specialized programming. Results: Learners provided evaluations of their experience participating in the exercise, and resident physicians evaluated their experience proctoring the sessions. Responses were positive, and constructive criticism led to modifications to the exercise after development. Discussion: We use this exercise as an educational opportunity for medical students rotating clinically in our department. Medical students are paired with resident physicians for scenario development and work with faculty to produce valuable educational activities that benefit the entire department.

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