OB Hemorrhage - Drills/Simulations Resources

Multidisciplinary training for obstetric emergencies is an issue of current interest and debate in the UK. This paper presents a survey of current practice in obstetric emergency drill training in England and Wales. A wide range of training methods and opinions about these methods are demonstrated in this survey. There is much interest in improving the management of obstetric emergencies and this is to be encouraged. However, reliable methods to assess and thereby optimise methods are urgently required in order that women and their babies can realise the maximum benefit from these complex interventions.

OBJECTIVE: To determine the most effective method of delivering training to staff on the management of an obstetric emergency.
SUBJECTS: The research was conducted in a District General Hospital in the UK, delivering approximately 3500 women per year. Thirty-six staff, comprising of junior and senior medical and midwifery staff were included as research subjects. Each of the staff members were put into one of six multi-professional teams. Effectively, this gave six teams, each comprising of six members.
METHOD: Three teaching methods were employed. Lecture based teaching (LBT), simulation based teaching (SBT) or a combination of these two (LAS). Each team of staff were randomly allocated to undertake a full day of training in the management of Post Partum Haemorrhage utilising one of these three teaching methods. Team knowledge and performance were assessed pre-training, post training and at three months later. In addition to this assessment of knowledge and performance, qualitative semi-structured interviews were carried out with 50% of the original cohort one year after the training, to explore anxiety, confidence, communication, knowledge retention, enjoyment and transferable skills.
RESULTS: All teams improved in their performance and knowledge. The teams taught using simulation only (SBT) were the only group to demonstrate sustained improvement in clinical management of the case, confidence, communication skills and knowledge. However, the study did not have enough power to reach statistical significance. The SBT group reported transferable skills and less anxiety in subsequent emergencies. SBT and LAS reported improved multidisciplinary communication. Although tiring, the SBT was enjoyed the most.
CONCLUSION: Obstetrics is a high risk speciality, in which emergencies are to some extent, inevitable. Training staff to manage these emergencies is a fundamental principal of risk management. Traditional risk management strategies based on incident reporting and event analysis are reactive and not always effective. Simulation based training is an appropriate proactive approach to reducing errors and risk in obstetrics, improving teamwork and communication, whilst giving the student a multiplicity of transferable skills to improve their performance.

OBJECTIVE: To describe models used for the training of labour ward personnel in acute obstetric emergencies and to describe how these models have been evaluated and compared.
DESIGN: A systematic review of the following databases: Medline, the Cumulative Index of Nursing and Allied Health Literature, Embase, PsycLit, Allied and Alternative Medicine, Education Resources Information Center and the Cochrane Library using a structured search strategy.
SETTING: Labour ward.
POPULATION OR SAMPLE: Labour ward personnel.
INCLUSION CRITERIA: All papers that described or evaluated any form of drill or training in acute obstetric emergencies involving any personnel in a labour ward environment were included. Descriptions of training in developing countries were excluded.
METHODS: Papers were classified as editorials or commentaries, papers describing a training programme or papers evaluating a training method. A data collection form was used to extract relevant information by two investigators independently.
MAIN OUTCOME MEASURE: Description of training models.
RESULTS: Of 44 relevant papers, 22 were classed as editorials or commentaries. Six descriptions of training programmes were found and four papers involved an evaluation of such programmes. All evaluations involved the use of questionnaires to course participants. No studies comparing one form of training with another were found.
CONCLUSIONS: With regard to training in acute obstetric emergencies, few training programmes have been described, and even fewer have been evaluated. Training methods need to be developed, described and evaluated; further well-conducted research for this important intervention is urgently required.

OBJECTIVES: To explore the effect of obstetric emergency training on knowledge. Furthermore, to assess if acquisition of knowledge is influenced by the training setting or teamwork training.
DESIGN: A prospective randomised controlled trial.
SETTING: Training was completed in six hospitals in the South West of England, UK and at the Bristol Medical Simulation Centre, UK.
POPULATION: Midwives and obstetric doctors working for the participating hospitals were eligible for inclusion in the study. A total of 140 participants (22 junior and 23 senior doctors, 47 junior and 48 senior midwives) were studied.
METHODS: Participants were randomised to one of four obstetric emergency training interventions: (1) 1-day course at local hospital, (2) 1-day course at simulation centre, (3) 2-day course with teamwork training at local hospital and (4) 2-day course with teamwork training at simulation centre.
MAIN OUTCOME MEASURES: Change in knowledge was assessed by a 185 question Multiple-Choice Questionnaire (MCQ) completed up to 3 weeks before and 3 weeks after the training intervention.
RESULTS: There was a significant increase in knowledge following training; mean MCQ score increased by 20.6 points (95% CI 18.1-23.1, P < 0.001). Overall, 123/133 (92.5%) participants increased their MCQ score. There was no significant effect on the MCQ score of either the location of training (two-way analysis of variants P = 0.785) or the inclusion of teamwork training (P = 0.965).
CONCLUSIONS: Practical, multiprofessional, obstetric emergency training increased midwives' and doctors' knowledge of obstetric emergency management. Furthermore, neither the location of training, in a simulation centre or in local hospitals, nor the inclusion of teamwork training made any significant difference to the acquisition of knowledge in obstetric emergencies.

Introduction: The leading causes of pregnancy-related death are embolism (20%), hemorrhage (17%), and pregnancy-induced hypertension (16%).The Obstetric and Mechanical Engineering Departments at Stanford University worked together to create inexpensive devices that were used in high fidelity simulations to replicate 2 of the leading causes of maternal mortality: hemorrhage and eclampsia (seizure). Methods: The mechanisms were designed to behave as similarly as possible to a human patient. The engineering team designed the eclampsia mechanism to jostle the mannequin's head at a frequency and randomness that matched those observed in human generalized seizures. The hemorrhage mechanism was designed to give visual and tactile cues similar to the actual physiology of a pregnant uterus. Both devices were remote controlled. Results: The hemorrhage mechanism was used in a scenario of an amniotic fluid embolism with severe postpartum hemorrhage. The final flow rate was adjustable between 525 and 600 mL/min. The trainees' rapid response and control of the postpartum hemorrhage was deemed to be a vital part of a successful maternal resuscitation. The seizure mechanism was used in a simulation of a pregnant woman in labor with evidence of severe preeclampsia. If the trainees did not recognize the need for treatment of the preeclampsia, the patient simulator had a 45- to 60-second seizure. If corrective actions were not taken, another seizure occurred. Conclusions: The use of remote controlled mechanical devices designed to accurately replicate the visual, auditory, and tactile cues of hemorrhage and eclampsia enhanced high fidelity simulation training in obstetrical emergencies.

OBJECTIVE: To develop a simulation-based curricular unit for labor and delivery teams involved in obstetric emergencies to detect and address common mistakes.
METHODS: A simulation-based curricular unit for hands-on training of four obstetric emergency scenarios was developed using high-tech mannequins and low-tech simulators. The scenarios were eclamptic seizure, postpartum hemorrhage, shoulder dystocia, and breech extraction. The obstetric teams consisted of at least one resident and two midwives. Checklists of actions expected from the teams were handed out to the course's tutors who observed the "event." All sessions were videotaped and then reviewed and analyzed by the trainees themselves, who were guided by two experienced tutors. We identified the most commonly occurring mistakes by summing up checklists and by watching the recorded sessions.
RESULTS: Between February 2004 and April 2006, 60 residents in obstetrics and gynecology and 88 midwives underwent the simulation-based course. Forty-two labor and delivery teams completed all four sessions. The most common management errors were delay in transporting the bleeding patient to the operating room (82%), unfamiliarity with prostaglandin administration to reverse uterine atony (82%), poor cardiopulmonary resuscitation techniques (80%), inadequate documentation of shoulder dystocia (80%), delayed administration of blood products to reverse consumption coagulopathy (66%), and inappropriate avoidance of episiotomy in shoulder dystocia and breech extraction (32%). Eighteen trainees were invited for repeated sessions at least 6 months after the first training day, and their scores were significantly higher in the latter sessions (79.4+/-4.3 versus 70+/-5.3 for the second and first simulated eclampsia sessions).
CONCLUSION: A curricular unit based on simulation of obstetric emergencies can identify pitfalls of management in labor and delivery rooms that need to be addressed.

OBJECTIVE: To evaluate the effect of teamwork training on the occurrence of adverse outcomes and process of care in labor and delivery.
METHODS: A cluster-randomized controlled trial was conducted at seven intervention and eight control hospitals. The intervention was a standardized teamwork training curriculum based on crew resource management that emphasized communication and team structure. The primary outcome was the proportion of deliveries at 20 weeks or more of gestation in which one or more adverse maternal or neonatal outcomes or both occurred (Adverse Outcome Index). Additional outcomes included 11 clinical process measures.
RESULTS: A total of 1,307 personnel were trained and 28,536 deliveries analyzed. At baseline, there were no differences in demographic or delivery characteristics between the groups. The mean Adverse Outcome Index prevalence was similar in the control and intervention groups, both at baseline and after implementation of teamwork training (9.4% versus 9.0% and 7.2% versus 8.3%, respectively). The intracluster correlation coefficient was 0.015, with a resultant wide confidence interval for the difference in mean Adverse Outcome Index between groups (-5.6% to 3.2%). One process measure, the time from the decision to perform an immediate cesarean delivery to the incision, differed significantly after team training (33.3 minutes versus 21.2 minutes, P=.03).
CONCLUSION: Training, as was conducted and implemented, did not transfer to a detectable impact in this study. The Adverse Outcome Index could be an important tool for comparing obstetric outcomes within and between institutions to help guide quality improvement.
CLINICAL TRIAL REGISTRATION: (www.ClinicalTrials.gov), NCT00381056
LEVEL OF EVIDENCE: I.

We reviewed all cases of massive primary postpartum haemorrhage greater than 1000 mL over a six month period in 1999 to establish the incidence, identify aetiological factors and implement change. Fifty-four cases (1.7%) were identified. We classified four as 'near-miss' maternal mortality. Over 60% were delivered by caesarean section. Seventy-six percent were due to uterine atony, 9% due to genital tract trauma and 15% were associated with significant antepartum haemorrhage from placenta praevia or abruption. No obvious labour or delivery risk factors were identified but deviation from hospital guidelines was common. Following revision of the guidelines, dissemination to staff and use of practice drills, we repeated the study on a prospective basis over the same time period in 2002. There was a significant reduction in the incidence of massive postpartum haemorrhage to 0.45%, and 100% adherence to the guidelines which resulted in a significant reduction in maternal morbidity. We believe that this approach can be replicated in other units.

This article describes the need for mock emergency drills in perinatal emergencies such as shoulder dystocia, maternal hemorrhage, and emergency cesarean section. Effective drills are a patient safety initiative to reduce medical errors and adverse events during the antepartum, intrapartum, and postpartum periods. Successful strategies are identified from other fields of practice to improve patient outcomes. Realistic, institutional specific scenarios for mock emergency drills result in improved team behaviors leading to better outcomes for mothers and infants.

This is the website for the Wisconsin Association for Perinatal Care and the Perinatal Foundation, and is an information source for perinatal health care professionals and consumers alike. The specific link provides resources related to protocols and management of postpartum hemorrhage, including case studies, case-scenario drills, drill checklists, B-Lynch suture diagrams and more.