Management of Obstetrical Hemorrhage: Low-cost Uterine Task Trainers Provide Simulation for Residents

Authors

Johanna N Voutyras, MD, Mount Carmel Health System Graduate Medical Education, Grove City, Ohio

Lynn ET Shaffer, PhD, Mount Carmel Research Institute, Grove City, Ohio

Alissa D MacAdam, BS, Mount Carmel Health System Graduate Medical Education, Grove City, Ohio

Dawn M Prall, MD, Mount Carmel Health System Center for Innovative Learning, Columbus, Ohio

The authors have no conflicts of interest to disclose.

Corresponding Author

Johanna N Voutyras, MD, Mount Carmel Health System Graduate Medical Education, Grove City, Ohio (Email: johanna.voutyras@gmail.com)

Abstract

Introduction

Simulation training may improve patient safety and decrease trainer and trainee anxiety. The ability to manage the emergency of obstetrical hemorrhage is a requirement for Obstetrics & Gynecology (OBGYN) physicians. Two operative procedures used to manage obstetrical hemorrhage include uterine artery ligation and uterine compression. Without simulation, resident physicians will initially encounter these procedures during a hemorrhage.

Methods

Didactic sessions on Obstetrical Hemorrhage were held for OBGYN resident physicians including new low-cost, reproducible simulations for uterine artery ligation and uterine compression. The residents were surveyed pre-simulation and post-simulation regarding their confidence in managing obstetrical hemorrhage, including their comfort with these specific surgical skills before and after participating in the simulation sessions.

Results

Twenty-one resident learners completed the paired pre-simulation and post-simulation questionnaires. Upon statistical analysis, the comfort with each procedure significantly improved as did the confidence to independently manage obstetrical hemorrhage (mean confidence level 2.5 + 0.9 vs 3.0 + 1.2, p = .002). The easily constructed low-cost uterine models, one to practice uterine artery ligation and one to practice uterine artery compression, were readily accepted as didactic tools.

Discussion

Obstetrical hemorrhage is a rare and serious complication requiring a timely and effective response, with few opportunities for training on live patients. Our didactic training with simulation using low-cost models improved physician comfort with the techniques of uterine artery ligation and uterine compression, better preparing them for high stakes operating room procedures utilized to treat obstetrical hemorrhage.

Life-threatening emergencies that are low-frequency are ideal for simulation during residency training (Deering & Rowland, 2013). Simulations are now commonly incorporated into graduate medical education didactic curriculums and may improve patient safety in addition to reducing both trainer and trainee anxiety (Gavin & Satin, 2017).

Obstetrical hemorrhage is a life-threatening emergency and can be a preventable cause of maternal mortality (Lu, 2013). High-fidelity obstetric models for simulating obstetric emergencies, including multidisciplinary simulation of obstetric hemorrhage, have been described and determined beneficial for learners (Kerbage et al., 2016). Most high-fidelity postpartum hemorrhage models and simulations focus on teamwork, initial management, and medications for postpartum hemorrhage (American College of Obstetricians and Gynecologists, 2021). One of the published high-fidelity models allows for the specific surgical skills mentioned to be practiced (Pereira & Delvadia, 2013). Planning the logistics to utilize high fidelity trainers can be complex, time consuming and require specific spaces often coordinated by a multidisciplinary team.

Low fidelity, portable task trainers, however, can be regularly incorporated into practice on the Labor and Delivery units. Advantages of low-fidelity task trainers to practice specific obstetrical hemorrhage surgical skills include the ability to hone dexterity by repetition outside of the operating room, simplicity of set up and low cost. Several models for task training these skills exist but most are not yet well studied in regards to effectiveness with confidence (Ramseyer & Lutgendorf, 2019). Additional low fidelity task trainers have been studied that simulate other components of obstetrical hemorrhage management. These include Bakri balloon insertion, uterine packing, pelvic packing and temporary abdominal closure, all of which also showed significantly improved perceived competency (Ramseyer & Lutgendorf, 2019). The combination of standardized patients and task trainers was also evaluated for management of other obstetrical emergencies such as Shoulder Dystocia and Cord Prolapse (Le Lous et al., 2020). In competency-based medical education, simulation training has the potential for standardized evaluation for graduate medical education in addition to increasing perceived competence (Weiss & Rentea, 2021; Hamstra & Philibert, 2012).

We developed two low-cost low-fidelity uterine models to function as task trainers. The task trainers were designed for learners to practice specific operative procedures used to manage obstetrical hemorrhage including uterine artery ligation and uterine compression sutures. These obstetrical surgical skills are typically utilized emergently in the operating room for an obstetrical hemorrhage that has been unresponsive to initial management including medications and manual uterine massage. High-fidelity simulation for these surgical maneuvers is available but at greater cost, including equipment and set up time (Pereira & Delvadia, 2013). Additional low-fidelity task trainers are available but also require a greater production time (Ramseyer & Lutgendorf, 2019). 3

The objective of this focused, small group didactic and skills session was to become more efficient and confident with two specific surgical skills required to manage obstetrical hemorrhage in a low-pressure environment. Residents practiced their skills on the task trainer uterine models during didactic sessions on obstetrical hemorrhage. Pre- and post-simulation questionnaires were analyzed to determine a) if comfort with each procedure improved after practicing on the models and b) if confidence regarding independent management of obstetrical hemorrhage improved after practicing the procedures on both models. We report the change in comfort for physicians using low-cost models to simulate the techniques of uterine artery ligation and uterine compression.

Methods

Development

The Mount Carmel Center for Innovative Learning (CIL) is a systemwide education center that includes experiential and simulation-based learning for colleagues and learners within our community-based healthcare system. The CIL develops custom task-training models in addition to developing and supporting simulation-based education throughout the healthcare system. This obstetrical hemorrhage simulation was incorporated into the longitudinal Obstetrics and Gynecology residency simulation curriculum.

Two uterine model task trainers were created (with the acknowledgement of similar albeit different task trainer models (Pereira & Delvadia, 2013; Ramseyer & Lutgendorf, 2019; Chuang et al., 2021) to help residents practice two specific procedures that are utilized in vivo in an immediate, life-saving operative intervention. The didactic sessions included a brief discussion reviewing prevention, etiology, and management of obstetrical hemorrhage directly followed by a practical skills session using these uterine model task trainers. These training sessions were held in a training space dedicated for resident education.

The questionnaire inquired how comfortable the learners were in the two procedures practiced and how confident they were managing obstetrical hemorrhage independently. The comfort and confidence levels were measured on a 4-point Likert scale (1 = least comfortable/confident and 4 = most comfortable/confident). The questionnaire also included knowledge-based questions to assess the retention of the material provided in the brief discussion on the management of obstetrical hemorrhage. The Wilcoxon signed rank test compared pre- vs. post-simulation comfort and confidence levels with aspects of managing obstetric hemorrhage, and whether the residents improved their total number of correct responses to knowledge questions. Test results were considered statistically significant at p<0.05, without adjustment for multiple comparisons. SAS version 9.4 (Cary, NC) was used for statistical analysis.

Equipment

Task Trainer #1 - Uterine Compression Model (Figure 1)

The uterine compression model was created with car wash sponges, glue and scissors, stabilized with a clipboard at the "cervix" during the procedure. Two infinity-shaped car wash sponges were glued together. Adding the second sponge recreates a postpartum uterus with a similar size. After the glue dried, scissors were used to carve the sponge into a uterine shape within minutes. The density of the sponge creates a similar pliability as an atonic uterus. During our simulation session, the B-lynch uterine compression suture was practiced. However, the models were also sufficient to practice other uterine compression sutures, including Hayman compressions and Cho box sutures. The cost of the uterine compression model was approximately $3.40 per model. Reusable surgical instruments and one-time use #1 Chromic suture were utilized during the simulations, which were additional costs. These models are reusable and withstood several simulations. Both sides could be utilized. Some of the models started to tear after four sessions though others lasted up to eight sessions. This sponge model is more three dimensional compared to the described felt model (Chuang et al., 2021).

Figure 1: Uterine Compression Model (left) with completed B-Lynch (right)

Instructions for building uterine compression model:

1. Adhere two elliptical shaped car wash sponges using multi-purpose glue.
2. Allow to dry overnight.
3. Carve sponge model into uterine shape with sharp scissors and/or scalpel.

See video: Supplemental Digital Content 1: Uterine Compression Model.mp4

Task Trainer #2 - Uterine Artery Ligation Model (Figure 2)

The uterine artery ligation models were created with tennis balls, large tube socks, water balloons and a Foley catheter simulating a leiomyomatous uterus. This model was also stabilized with a clipboard at the "cervix” during the procedure. The Foley catheter was utilized to represent the uterine artery. The rubber of the catheter provides tactile resilience and moves within the model similarly to a large artery. The water balloons represented the venous plexus within the broad ligament, engorged during pregnancy. The tennis balls were left whole or cut in half to create various shapes and types of leiomyomas. The tennis balls were firm compared to the sock portion of the model creating a density differential similar to a leiomyoma within a uterus. The size of the complete model is a similar size to a postpartum uterus. The cost of the uterine artery ligation model was approximately $8.80 per model. Reusable surgical instruments and one-time use #0 Chromic suture were utilized for the O’Leary ligations during the simulations, which were additional costs. These models withstood multiple sessions well. These models required replacement of new water balloons with each session. These models were required to be semi-disassembled and dried between sessions if the water balloons were punctured during the exercise. This sock model is more three dimensional compared to the described felt model (Chuang et al., 2021).

Figure 2: Uterine artery ligation model:

Inside layer cut open to view core contents, pinned for display

Figure 3: Inside layer with uterine arteries (red rubber catheters) attached bilaterally, coronal view (left)

Outer layer opened to see uterine artery (red rubber catheter), sagittal view (right)

Instructions for building uterine artery ligation model:

1. Cut some tennis balls in half using scalpel.
2. Fill large sock with combination of whole and halved tennis balls into uterine shape.
3. Twist sock, invert and re-cover uterine model creating cervix.
4. Cut red rubber foley catheter in half to create uterine arteries.
5. Attach each half of red rubber catheter along uterus bilaterally with interrupted sutures in 3 locations.
6. Place model into second large sock creating broad ligament.
7. Add semi-filled water balloons along uterine arteries to create venous plexus.
8. Twist sock, invert and re-cover uterine model to again create cervix.

See Supplemental Digital Content 2: Uterine Artery Ligation Model.mp4

Personnel

The Ohio State University Obstetrics and Gynecology (OBGYN) residency program has a total of 44 residents. Mount Carmel Health System is the academic-community partner where this education was conducted. Since there is a small group of residents rotating at this community site at any given time, multiple small group sessions were held with different groups of rotating residents. Two or three Mount Carmel Health System OBGYN faculty members facilitated the activity.

Pre-simulation questionnaires were distributed upon arrival to the small group didactic session and immediately completed without identifiers. After a short discussion regarding management of obstetrical hemorrhage, the residents were split into three or four groups, typically pairing a junior and senior resident. The task trainer models were utilized in successive rotation. Every resident practiced each surgical intervention at least twice, each functioning in the surgeon and assistant surgeon roles. A faculty member provided guidance and instruction for each group throughout the activity. The facilitators observed the paired surgeon and assistant surgeon during their practicing of the surgical procedures and provided contemporary instruction and feedback regarding techniques.

After the second task trainer exercise was complete, the post-simulation questionnaire was distributed and completed again without identifiers. Upon completion of the post-simulation questionnaires, both questionnaires were paired by each resident prior to collection and collected in an anonymous fashion. An informal debriefing was held with the facilitators and learner participants after the questionnaires were collected. The Mount Carmel Institutional Review Board granted exemption for this analysis as simulation activities for obstetrical hemorrhage are an accepted educational practice and no identifiers were collected on the anonymous data.

Results

Twenty-seven learners participated in the simulations between July 2019 to September 2020. Of those twenty-seven, twenty-one learners participated in the brief didactic session, both task trainer simulations, and completed both the pre-simulation and post-simulation questionnaires. Three pre-simulation and three post-simulation questionnaires each were unpaired and therefore excluded. These excluded learners participated in only a portion of the activity either arriving late or leaving early likely due to patient care needs. Therefore, the unpaired residents’ change in knowledge and comfort could not be assessed. With respect to postgraduate year level among the paired surveys, 9 were first-year residents, 3 were second-year residents, 4 were third-year residents and 5 were fourth-year residents (Figure 3). The questionnaire was developed by the lead author as there was no suitable validated instrument at the time the sessions were performed (Supplemental Digital Content 3: Questionnaires.doc).

Figure 4: Flowchart of Included and Excluded Participants

The change in comfort with each task trainer and the change in confidence with overall management of obstetrical hemorrhage were significantly improved after the exercises (Table 1). Subdividing the results among each post-graduate level revealed improvement in comfort with both uterine compression and uterine artery ligation at all four skill levels (Figure 3). For the first-year, second-year and third-year residents, comfort managing an obstetrical hemorrhage independently improved after the didactic session and simulation (Figure 4). The fourth-year residents' comfort managing an obstetrical hemorrhage independently did not change because all five fourth-year residents reported maximum comfort on both their pre-simulation questionnaires and maximum on their post-simulation questionnaires. While the mean comfort levels increased significantly for the entire cohort (Table 1), the increase amongst each class of resident was not significant, likely due to the small sample size once subdivided by year of residency.

Figure 5: Graphs display resident comfort as rated on Likert scale (1-4) before and after using task trainers for uterine compression (left) and uterine artery ligation (right) by year of resident training.

Figure 6: Graph displays resident confidence as rated on Likert scale (1-4) before and after using hemorrhage simulation by year of resident training.

The questionnaires also included knowledge-based questions to assess the retention of the material provided in the brief discussion on the management of obstetrical hemorrhage. As anticipated the percentage of correct answers to the knowledge-based questions significantly improved after the didactic session (number of correctly answered questions 2.5 + 1.2 vs. 4.7 + 1.0, p<0.0001).

Discussion

The overall confidence in managing life-threatening obstetrical hemorrhage improved through the task trainer simulation. Simulating these surgical maneuvers has the potential to improve the efficiency of the residents in the operating room, though this was not evaluated in this study. The uterine model task trainers described are easily constructed, inexpensive and reusable. Low-fidelity task trainers focusing on specific obstetrical surgical skills are ideally utilized in workshop settings with multiple stations where the residents can practice the skill with repetition, allowing for improved comfort and confidence. Repetition of the specific surgical skill has the potential to improve dexterity and efficiency although those aspects were not studied at this time.

Although simulation has become an accepted component of OBGYN residency didactics, little is known regarding how these training exercises correlate with patient outcomes (Satin, 2012). While this study does not correlate directly to patient outcomes, it is a good foundation for future studies evaluating a direct link from simulation to patient outcomes. As of July 1, 2020 the Joint Commission has required annual multidisciplinary drills on obstetric units in effort to reduce the incidence of postpartum hemorrhage (The Joint Commission, 2019; Gavigan et al., 2019). Multidisciplinary drills on Labor and Delivery units with nursing and provider staff will ideally prevent postpartum hemorrhage and/or improve timeliness and effectiveness of treatment. Determining correlation between simulation exercises for obstetrical hemorrhage and patient outcomes is worthy of future investigation.

Our study has limitations including the small sample size from one residency program. External validity needs to be established. The increased confidence in overall independent management of hemorrhage may be attributed to the brief didactic discussion and not solely practicing with task trainers. A follow up study could involve the lecture with a knowledge-based pre-test and post-test questionnaire followed by the skill session with a separate pre-test and post-test questionnaire isolating comfort and confidence to the practical activities. Further investigation of emergent obstetrical skills training effectiveness and impact on patient care is warranted. Additionally, this simulation focuses on specific aspects of managing obstetric hemorrhage and is merely one component of a comprehensive approach to improve and review management of obstetric hemorrhage.

Task trainer activities to manage obstetrical hemorrhage have been incorporated into our simulation curriculum with annual participation. This study found that practicing these obstetrical surgical maneuvers on simple task trainers improves OBGYN resident comfort with each maneuver and their overall confidence managing obstetrical hemorrhage. PGY-1 and 2 residents appear to show the largest increase in these outcomes; however, this would need to be confirmed with additional research. Additional research could also evaluate the value to senior residents to practice teaching these surgical maneuvers in a non-emergent situation. Given their low cost and ease of construction, the task trainers developed for this curriculum can be adopted by most OBGYN training programs across the country.

Supplemental Digital Content (SDC) Legend

SDC 1: mp4. Uterine Compression Model

SDC 2: mp4. Uterine Artery Ligation Model

SDC 3: doc. Questionnaires

References

American College of Obstetricians and Gynecologists. Simulation: Uterine Atony, Obstetrical Surgical Skills Series, (https://www.acog.org/education-and-events/simulations/uterine-atony), Accessed July 14, 2021.

Chuang M, Purswani H, Fazzari MJ, Kaplan J, Pardanani S, Banks EH. A Low-Cost Trainer for the Surgical Management of Postpartum Hemorrhage. Simul Healthc. 2020;15(4):289-294.

Deering S, Rowland J. Obstetric emergency simulation. Semin Perinatol. 2013;37(3):179-188.

Gavigan S, Rosenberg N, Hulbert J. Proactively Preventing Maternal Hemorrhage-Related Deaths (https://www.jointcommission.org/resources/news-and-multimedia/blogs/leading-hospital-improvement/2019/11/proactively-preventing-maternal-hemorrhagerelated-deaths/) Written 11/06/2019, Accessed 1/25/21.

Gavin NR, Satin AJ. Simulation Training in Obstetrics. Clin Obstet Gynecol. 2017;60(4):802-810.

Hamstra S, Philibert I. Simulation in graduate medical education: understanding uses and maximizing benefits. J Grad Med Educ. 2012;4(4):539-540.

Kerbage Y, Debarge V, Lucot JP, Clouqueur E, Rubod C. Simulation training to teach postpartum hemorrhage surgery to residents. Eur J Obstet Gynecol Reprod Biol. 2016;201:27-30.

Le Lous, M., Simon, O., Lassel, L., Lavoue, V., & Jannin, P. (2020). Hybrid simulation for obstetrics training: A systematic review. European journal of obstetrics, gynecology, and reproductive biology, 246, 23–28.

Lu MC. Reducing Maternal Mortality in the United States. JAMA. 2018;320(12):1237-1238.

Pereira N, Delvadia D. A tool for teaching the B-Lynch brace suture method: an inexpensive new simulator allows obstetricians to polish an essential technique. Am J Obstet Gynecol. 2013;209(6):591.e1.

Ramseyer, A. M., & Lutgendorf, M. A. (2019). Implementation of Low-Cost Obstetric Hemorrhage Simulation Training Models for Resident Education. Military medicine, 184(11-12), e637–e641.

Satin AJ. Simulation in Obstetrics. Obstet Gynecol. 2018;132(1):199-209.

The Joint Commission Division of Healthcare Improvement. Proactive prevention of maternal death from maternal hemorrhage. Quick Safety. 2019; (51): 1-3.

Weiss, T. G., & Rentea, R. M. (2021). Simulation Training and Skill Assessment in Obstetrics and Gynecology. In StatPearls. StatPearls Publishing.