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Minor KC, Bianco K, Mayo JA, Abir G, Judy AE, Lee HC, Leonard SA, Ayotte S, Hedli LC, Schaffer K, Sie L, Daniels K. Virtual simulation training for postpartum hemorrhage in low-to-moderate-volume hospitals in the US. AJOG GLOBAL REPORTS 2024; 4:100357. [PMID: 38975047 PMCID: PMC11227018 DOI: 10.1016/j.xagr.2024.100357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024] Open
Abstract
Background Maternal mortality in the United States is rising and many deaths are preventable. Emergencies, such as postpartum hemorrhage, occur less frequently in non-teaching, rural, and urban low-birth volume hospitals. There is an urgent need for accessible, evidence-based, and sustainable inter-professional education that creates the opportunity for clinical teams to practice their response to rare, but potentially devastating events. Objective To assess the feasibility of virtual simulation training for the management of postpartum hemorrhage in low-to-moderate-volume delivery hospitals. Study design The study occurred between December 2021 and March 2022 within 8 non-academic hospitals in the United States with low-to-moderate-delivery volumes, randomized to one of two models: direct simulation training and train-the-trainer. In the direct simulation training model, simulation faculty conducted a virtual simulation training program with participants. In the train-the-trainer model, simulation faculty conducted virtual lessons with new simulation instructors on how to prepare and conduct a simulation course. Following this training, the instructors led their own simulation training program at their respective hospitals. The direct simulation training participants and students trained by new instructors from the train-the-trainer program were evaluated with a multiple-choice questionnaire on postpartum hemorrhage knowledge and a confidence and attitude survey at 3 timepoints: prior to, immediately after, and at 3 months post-training. Paired t-tests were performed to assess for changes in knowledge and confidence within teaching models across time points. ANOVA was performed to test cross-sectionally for differences in knowledge and confidence between teaching models at each time point. Results Direct simulation training participants (n=22) and students of the train-the-trainer instructors (n=18) included nurses, certified nurse midwives and attending physicians in obstetrics, family practice or anesthesiology. Mean pre-course knowledge and confidence scores were not statistically different between direct simulation participants and the students of the instructors from the train-the-trainer course (79%+/-13 versus 75%+/-14, respectively, P-value=.45). Within the direct simulation group, knowledge and confidence scores significantly improved from pre- to immediately post-training (knowledge score mean difference 9.81 [95% CI 3.23-16.40], P-value<.01; confidence score mean difference 13.64 [95% CI 6.79-20.48], P-value<.01), which were maintained 3-months post-training. Within the train-the-trainer group, knowledge and confidence scores immediate post-intervention were not significantly different compared with pre-course or 3-month post-course scores. Mean knowledge scores were significantly greater for the direct simulation group compared to the train-the-trainer group immediately post-training (89%+/-7 versus 74%+/-8, P-value<.01) and at 3-months (88%+/-7 versus 76%+/-12, P-value<.01). Comparisons between groups showed no difference in confidence and attitude scores at these timepoints. Both direct simulation participants and train-the-trainer instructors preferred virtual education, or a hybrid structure, over in-person education. Conclusion Virtual education for obstetric simulation training is feasible, acceptable, and effective. Utilizing a direct simulation model for postpartum hemorrhage management resulted in enhanced knowledge acquisition and retention compared to a train-the-trainer model.
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Affiliation(s)
- Kathleen C. Minor
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine & Obstetrics, Stanford University School of Medicine, Stanford, CA (Dr Minor, Dr Bianco, Mr Mayo, Dr Judy, and Dr Leonard)
| | - Katherine Bianco
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine & Obstetrics, Stanford University School of Medicine, Stanford, CA (Dr Minor, Dr Bianco, Mr Mayo, Dr Judy, and Dr Leonard)
| | - Jonathan A. Mayo
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine & Obstetrics, Stanford University School of Medicine, Stanford, CA (Dr Minor, Dr Bianco, Mr Mayo, Dr Judy, and Dr Leonard)
| | - Gillian Abir
- Department of Anesthesiology, Perioperative and Pain Medicine, Division of Obstetric Anesthesiology, Stanford University School of Medicine, Stanford, CA (Dr Abir)
| | - Amy E. Judy
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine & Obstetrics, Stanford University School of Medicine, Stanford, CA (Dr Minor, Dr Bianco, Mr Mayo, Dr Judy, and Dr Leonard)
| | - Henry C. Lee
- Department of Pediatrics, Division of Neonatology, University of California San Diego, La Jolla, CA (Dr Lee and Ms Schaffer)
| | - Stephanie A. Leonard
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine & Obstetrics, Stanford University School of Medicine, Stanford, CA (Dr Minor, Dr Bianco, Mr Mayo, Dr Judy, and Dr Leonard)
| | - Stephany Ayotte
- Johnson Center for Pregnancy and Newborn Services, Lucile Packard Children's Hospital, Stanford, CA (Ms Ayotte)
| | - Laura C. Hedli
- Department of Pediatrics, Division of Neonatology, Stanford University School of Medicine, Stanford, CA (Ms Hedli and Ms Sie)
| | - Kristen Schaffer
- Department of Pediatrics, Division of Neonatology, University of California San Diego, La Jolla, CA (Dr Lee and Ms Schaffer)
| | - Lillian Sie
- Department of Pediatrics, Division of Neonatology, Stanford University School of Medicine, Stanford, CA (Ms Hedli and Ms Sie)
| | - Kay Daniels
- Department of Obstetrics and Gynecology, Stanford School of Medicine, Stanford, CA (Dr Daniels)
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Lutgendorf MA, Ennen CS, McGlynn A, Spalding CN, Deering S, Delorey DR, Greer JA. Interprofessional obstetric simulation training improves postpartum haemorrhage management and decreases maternal morbidity: a before-and-after study. BJOG 2024; 131:353-361. [PMID: 37580310 DOI: 10.1111/1471-0528.17640] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 07/27/2023] [Accepted: 08/01/2023] [Indexed: 08/16/2023]
Abstract
OBJECTIVE To determine the impact of the Obstetric Simulation Training and Teamwork (OB-STaT) curriculum on postpartum haemorrhage (PPH) rates and outcomes. DESIGN Before-and-after study. SETTING Maternity care hospitals within the USA. POPULATION Patients who delivered between February 2018 and November 2019. METHODS Interprofessional obstetric teamwork training (OB-STaT) conducted at each hospital. Electronic medical records for deliveries were reviewed for 6 months before and after conducting OB-STaT at participating hospitals. MAIN OUTCOME MEASURES The PPH rate (blood loss of ≥1000 ml), uterotonic medications used, tranexamic acid use, blood product transfusion, hysterectomy, length of stay and composite maternal morbidity (postpartum haemorrhage, hysterectomy, transfusion of ≥4 units of blood products and intensive care unit admission for PPH). RESULTS A total of 9980 deliveries were analysed: 5059 before and 4921 after OB-STaT. The PPH rates did not change significantly (5.48% before vs 5.14% after, p = 0.46). Composite maternal morbidity decreased significantly by 1.1% (6.35%-5.28%, p = 0.03), massive transfusions decreased by 57% (0.42%-0.18%, p = 0.04) and the mean postpartum length of stay decreased from 2.05 days (1.05 days SD) to 2.01 days (0.91 days SD) (p = 0.04). Following OB-STaT, haemorrhage medication use increased by 36% (14.8%-51.2%, p = 0.03), the use of tranexamic acid for PPH treatment almost doubled (2.7%-4.8%, p < 0.001) and the rate of hysterectomy significantly increased (0%-0.1%, p = 0.03). CONCLUSIONS Although the PPH rates did not decrease, OB-STaT significantly improved maternal morbidity, decreased massive transfusions, and improved PPH management by increasing the utilization of uterotonic medications, tranexamic acid and hysterectomy.
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Affiliation(s)
- Monica A Lutgendorf
- Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
- Division of Maternal-Fetal Medicine, Department of Gynecologic Surgery and Obstetrics, Naval Medical Center, San Diego, California, USA
| | - Christopher S Ennen
- Department of Gynecologic Surgery and Obstetrics, Naval Medical Center, Portsmouth, Virginia, USA
| | - Andrea McGlynn
- Clinical Investigations Department, Naval Medical Center, Portsmouth, Virginia, USA
| | - Carmen N Spalding
- Bioskills and Simulation Training Center, Naval Medical Center, San Diego, California, USA
| | - Shad Deering
- Department of Obstetrics and Gynecology, Baylor College of Medicine, San Antonio, Texas, USA
| | - Donald R Delorey
- Healthcare Simulation and Bioskills Training Center, Naval Medical Center, Portsmouth, Virginia, USA
| | - Joy A Greer
- Department of Gynecologic Surgery and Obstetrics, Naval Medical Center, Portsmouth, Virginia, USA
- Healthcare Simulation and Bioskills Training Center, Naval Medical Center, Portsmouth, Virginia, USA
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Araújo NM, da Costa Silveira de Camargo J, Ochiai AM, Ferreira FM, Riesco MLG. Instructional and didactic support tool for teaching-learning Post-Partum Haemorrhage care in simulated settings: Creation and validation. Nurse Educ Pract 2024; 74:103867. [PMID: 38101091 DOI: 10.1016/j.nepr.2023.103867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/16/2023] [Accepted: 11/26/2023] [Indexed: 12/17/2023]
Abstract
OBJECTIVE To describe the creation and validation process of an instructional, didactic and self-applied support tool for teaching-learning Post-Partum Haemorrhage care in simulated settings. BACKGROUND Students frequently face difficulties performing the actions in the proper sequence in Post-Partum Haemorrhage simulated cases. Even in a controlled environment, anxiety, nervousness and fear of making mistakes are evident, which render the simulated experience highly stressful. Having a tool with a guideline can help students perform these actions more assertively. DESIGN A methodological study to develop a didactic tool. METHODS The creation process of the didactic tool, called Instructional Disk for the Management of Post-Partum Haemorrhage, was divided into five phases: Analysis, Design, Development, Implementation and Evaluation. Nine experts specialised in Obstetrics and Midwifery validated the tool by answering a questionnaire with nine items; in turn, 32 undergraduate Midwifery program students carried out the evaluation using a questionnaire on applicability, functionality, clarity, coherence and usability of the tool in Post-Partum Haemorrhage simulated stations. The data were analysed descriptively, considering absolute agreement when the answers to all questions in the five-point Likert scale corresponded to 5 (I totally agree). The Content Validity Index was calculated for the experts' questionnaires. RESULTS In the validation stage, the experts agreed or totally agreed with all nine items, reaching a Content Validity Index = 1. In the total scores assigned by the experts, there was a variation between 80.0% and 100% absolute agreement, with a mean of 95.6%. In the students' assessment, the variation was between 87.5% and 100% absolute agreement, with a mean of 97.7%, in the eight items evaluated. The agreement level above 90% among experts and students was considered high. CONCLUSIONS The Instructional Disk for the Management of Post-Partum Haemorrhage was validated by experts with extensive experience in Obstetrics and Midwifery care and teaching, ensuring that the content included in the guidelines for the management of Post-Partum Haemorrhage adopted in Brazil is covered. The students positively evaluated this support tool for learning the care to be provided in Post-Partum Haemorrhage cases in the simulated stations.
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Affiliation(s)
- Natalucia Matos Araújo
- Faculty of Midwifery Course School of Arts, Sciences and Humanities, Street Arlindo Bettio, 1000, ZIP 03828-000, Sao Paulo, SP, Brazil.
| | | | - Angela Megumi Ochiai
- Faculty of Midwifery Course School of Arts, Sciences and Humanities, Street Arlindo Bettio, 1000, ZIP 03828-000, Sao Paulo, SP, Brazil
| | - Fernanda Marçal Ferreira
- Faculty University of Sao Paulo School of Nurse, Avenue Dr. Enéas Carvalho de Aguiar, 419 - Cerqueira César, ZIP 05403-000, Sao Paulo, SP, Brazil
| | - Maria Luiza Gonzalez Riesco
- University of Sao Paulo School of Nurse, Avenue Dr. Enéas Carvalho de Aguiar, 419 - Cerqueira César, ZIP 05403-000, Sao Paulo, SP, Brazil
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Lord MG, Esposito MA, Gimovsky AC, Carr SR, Russo ML. A Low-Cost, High-Fidelity Simulator for Transabdominal Chorionic Villus Sampling. Fetal Diagn Ther 2023; 51:101-111. [PMID: 38081148 DOI: 10.1159/000534485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 09/26/2023] [Indexed: 04/04/2024]
Abstract
INTRODUCTION Chorionic villus sampling (CVS) remains essential for first-trimester genetic diagnosis, yet clinical volume may be insufficient to train new clinicians in the technique. Available simulation models are expensive, require animal parts or specialized resins, and cannot be stored for repeated use. METHODS We present a model for trans-abdominal CVS (TA-CVS) which is constructed from readily available materials costing less than $10 and can be refrigerated and re-used to train maternal-fetal medicine fellows in CVS. RESULTS All three attending physicians performing TA-CVS at our institution described the model as an accurate visual and tactile simulation, prompting its integration into our fellowship curriculum. To date, two senior fellows have achieved competency on the simulator and begun to perform clinical CVS under supervision, one of whom is an author on this paper. Both fellows and attendings indicated that the simulator provided a valuable tool for repeated practice prior to clinical CVS. Simulators are now maintained on the unit and have been re-used for 3 months and dozens of simulated procedures each without any apparent qualitative degradation in performance. DISCUSSION/CONCLUSION We describe a low-cost easily constructed, durable, high-fidelity simulator for TA-CVS.
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Affiliation(s)
- Megan G Lord
- Division of Maternal Fetal Medicine, Women & Infants Hospital of Rhode Island, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Matthew A Esposito
- Division of Maternal Fetal Medicine, Women & Infants Hospital of Rhode Island, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Alexis C Gimovsky
- Division of Maternal Fetal Medicine, Women & Infants Hospital of Rhode Island, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Stephen R Carr
- Division of Maternal Fetal Medicine, Women & Infants Hospital of Rhode Island, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Melissa L Russo
- Division of Maternal Fetal Medicine, Women & Infants Hospital of Rhode Island, Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Ruiz MT, Azevedo NF, Resende CVD, Rodrigues WF, Meneguci J, Contim D, Wernet M, Oliveira CJFD. Quantification of blood loss for the diagnosis of postpartum hemorrhage: a systematic review and meta-analysis. Rev Bras Enferm 2023; 76:e20230070. [PMID: 38055493 DOI: 10.1590/0034-7167-2023-0070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/21/2023] [Indexed: 12/08/2023] Open
Abstract
OBJECTIVE to compare the effectiveness of different diagnostic methods to estimate postpartum blood volume loss. METHODS a systematic review of effectiveness according to PRISMA and JBI Protocol. Searches in PubMed/MEDLINE, LILACS, Scopus, Embase, Web of Science and CINAHL, with descriptor "Postpartum Hemorrhage" associated with keyword "Quantification of Blood Loss". Tabulated extracted data, presented in metasynthesis and meta-analysis was applied to quantitative data. To assess risk of bias, JBI Appraisal Tools were applied. RESULTS fourteen studies were included, published between 2006 and 2021. Quantification of loss by any method was superior to visual estimation and is highly recommended, however the studies' high heterogeneity did not allow estimating this association. CONCLUSION the studies' high heterogeneity, with a probable margin of error given the uncontrolled factors, indicates the need for further studies, however quantification proved to be effective in relation to visual estimate. PROSPERO registration CRD 42021234486.
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Affiliation(s)
| | | | | | | | - Joilson Meneguci
- Universidade Federal do Triângulo Mineiro, Hospital de Clínicas. Uberaba, Minas Gerais, Brazil
| | - Divanice Contim
- Universidade Federal do Triângulo Mineiro. Uberaba, Minas Gerais, Brazil
| | - Monika Wernet
- Universidade Federal de São Carlos. São Carlos, São Paulo, Brazil
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Lee JS, Day G, Valentino D, Hedges C, Decker C, Booth J, Lockey R, Schroeppel TJ. Help a mother out: The impact of acute care surgeon response in postpartum hemorrhage. Am J Surg 2023; 226:882-885. [PMID: 37532591 DOI: 10.1016/j.amjsurg.2023.07.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 07/03/2023] [Accepted: 07/22/2023] [Indexed: 08/04/2023]
Abstract
INTRODUCTION A Code White (CW) activation is a hospital-wide alert for postpartum hemorrhage (PPH) and acute care surgeons (ACS) were added to the response team to assist in resuscitation. A multidisciplinary training program was also implemented. This study aimed to evaluate the impact of ACS involvement and training on maternal outcomes. METHODS A retrospective review was performed on all CW activations from 1/1/2015-8/31/2022. Three groups-pre-ACS response, ACS response, and ACS response + training (R&T)-were compared. RESULTS 218 patients had CW activations. ACS response increased MTP activations (50.0%vs76.5%vs76.2%, p = 0.014) and TXA administration (50.0%vs96.5%vs93.3%, p < 0.0001). The ACS R&T had the highest ACS presence (53.6%vs72.9%vs96.2%, p < 0.0001), shortest operation (99 vs 67 vs 53min, p = 0.002), lowest crystalloid use (2000 vs 1110 vs 800 ml, p = 0.003), and lowest transfusion requirements. Mortality decreased from 17.9% in pre-ACS to 2.4% in ACS response and 0% in ACS R&T (p < 0.0001). CONCLUSION ACS assistance in CW activations and multidisciplinary PPH education led to the prevention of maternal mortality. ACS are a valuable resource in this unique population.
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Affiliation(s)
- Janet S Lee
- Department of Trauma and Acute Care Surgery, University of Colorado Health Memorial Hospital, Colorado Springs, CO, USA; Department of Surgery, University of Colorado, Aurora, CO, USA.
| | - Gregory Day
- Department of Trauma and Acute Care Surgery, University of Colorado Health Memorial Hospital, Colorado Springs, CO, USA.
| | - Daniel Valentino
- Department of Trauma and Acute Care Surgery, University of Colorado Health Memorial Hospital, Colorado Springs, CO, USA.
| | - Caroline Hedges
- Department of Obstetrics and Gynecology, University of Colorado Health Memorial Hospital, Colorado Springs, CO, USA.
| | - Cassie Decker
- Department of Trauma Research, University of Colorado Health Memorial Hospital, Colorado Springs, CO, USA.
| | - Jessica Booth
- Department of Anesthesiology, University of Colorado Health Memorial Hospital, Colorado Springs, CO, USA.
| | - Renee Lockey
- Department of Obstetrics and Gynecology, University of Colorado Health Memorial Hospital, Colorado Springs, CO, USA.
| | - Thomas J Schroeppel
- Department of Trauma and Acute Care Surgery, University of Colorado Health Memorial Hospital, Colorado Springs, CO, USA.
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Ghose I, Wiley RL, Ciomperlik HN, Chen HY, Sibai BM, Chauhan SP, Mendez-Figueroa H. Association of adverse outcomes with three-tiered risk assessment tool for obstetrical hemorrhage. Am J Obstet Gynecol MFM 2023; 5:101106. [PMID: 37524259 DOI: 10.1016/j.ajogmf.2023.101106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 06/23/2023] [Accepted: 07/14/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Guidelines promote stratification for the risk for postpartum hemorrhage among parturients, although the evidence for the associated differential morbidity among the groups remains inconsistent among published reports. OBJECTIVE Using the California Maternal Quality Care Collaborative schema modified by the American College of Obstetrics and Gynecology, we compared the composite maternal hemorrhagic outcome and the composite neonatal adverse outcome among singletons who were categorized after delivery by the researchers as low-, medium-, or high-risk for postpartum hemorrhage. We hypothesized that the composite outcomes would be significantly different among the individuals in the different 3-tiered categories. STUDY DESIGN This was a retrospective cohort study of all singleton parturients with a gestational age of at least 14 weeks who delivered at a single site within 1 year. The composite maternal hemorrhagic outcome included any of the following: estimated blood loss ≥1000 mL, use of uterotonics (excluding prophylactic oxytocin) or Bakri balloon, surgical management of postpartum hemorrhage, blood transfusion, hysterectomy, thromboembolism, admission to the intensive care unit, or maternal death. The composite neonatal adverse outcome included Apgar score <7 at 5 minutes, birth injury, bronchopulmonary dysplasia, intraventricular hemorrhage, neonatal seizure, sepsis, ventilation > 6 hrs., brachial plexus palsy, hypoxic-ischemic encephalopathy, or neonatal death. Multivariable Poisson regression models with robust error variance were used to estimate the adjusted relative risks with 95% confidence intervals. RESULTS Of the 4544 deliveries in the study period, 4404 (96.7%) met the inclusion criteria, and among them, 1745 (39.6%) were categorized as low, 1376 (31.2%) as medium, and 1283 (29.1%) as high risk. Overall, 941 (21.4%) participants experienced the composite maternal hemorrhagic outcome with 285 (16.4%) of those being in the low-risk group, 319 (23.2%) in the medium-risk group, and 337 (26.3%) in the high-risk group. Among all parturients, 95.7% in the low-, 89.4% in the medium-, and 85.3% in the high-risk group neither had an estimated blood loss or a quantified blood loss ≥1000 mL nor were transfused. After multivariable adjustment and when compared with the low-risk group, there was a significantly higher risk for the composite maternal hemorrhagic outcome in the medium-risk group (adjusted relative risk, 1.23; 95% confidence interval, 1.05-1.43) and in the high-risk group (adjusted relative risk, 1.51; 95% confidence interval, 1.31-1.75). Overall, 366 newborns (8.4%) developed the composite neonatal adverse outcome with 76 (4.2%) in of those being in the low-risk group, 153 (11.3%) in the medium-risk group, and 140 (11.1%) in the high-risk group. After multivariable adjustment and when compared with the low-risk group, there were no significant differences in the composite neonatal adverse outcome in the medium- (adjusted relative risk, 1.27; 95% confidence interval, 0.97-1.68) or the high-risk group (adjusted relative risk, 1.29; 95% confidence interval, 0.98-1.68). CONCLUSION Although 8 of 10 parturients categorized as high risk neither had blood loss ≥1000 mL nor underwent transfusion, the risk stratification provides information regarding the composite maternal hemorrhagic outcome.
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Affiliation(s)
- Ipsita Ghose
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Rachel L Wiley
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Hailie N Ciomperlik
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Han-Yang Chen
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Baha M Sibai
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Suneet P Chauhan
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX.
| | - Hector Mendez-Figueroa
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
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Angarita AM, Cochrane E, Bianco A, Berghella V. Prevention of postpartum hemorrhage in vaginal deliveries. Eur J Obstet Gynecol Reprod Biol 2023; 280:112-119. [PMID: 36455391 DOI: 10.1016/j.ejogrb.2022.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/07/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
Abstract
Identification of patients at risk for postpartum hemorrhage (PPH) may allow for prompt diagnosis and intervention. Individual risk factors, risk assessment tools and prediction models have been used for determining a patient's risk of PPH. Measures for the prevention of PPH include identification and management of iron deficiency anemia, unit readiness and preparedness through performing regular simulations and having a PPH cart or medication kit readily available, prophylactic uterotonic - carbetocin alone or dual agents such as oxytocin and misoprostol or oxytocin and methylergometrine or antifibrinolytic (oxytocin and tranexamic acid) use in the third stage of labor immediately after fetal head delivery, and controlled cord traction.
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Affiliation(s)
- Ana M Angarita
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, United States
| | - Elizabeth Cochrane
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Angela Bianco
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, United States.
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Mendez-Figueroa H, Bell CS, Wagner SM, Pedroza C, Gupta M, Mulder I, Lee K, Blackwell SC, Bartal MF, Chauhan SP. Postpartum hemorrhage drills or simulations and adverse outcomes: a systematic review and Bayesian meta-analysis. J Matern Fetal Neonatal Med 2022; 35:10416-10427. [PMID: 36220264 DOI: 10.1080/14767058.2022.2128659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To compare the rates of adverse outcomes with postpartum hemorrhage (PPH) before and after implementation of drills or simulation exercises. STUDY ELIGIBILITY CRITERIA We included all English studies that reported on rates of PPH and associated complications during the pre- and post-implementation of interventional exercises. STUDY APPRASIAL AND SYNTHESIS METHODS Two investigators independently reviewed the abstracts, and full articles for eligibility of all studies. Inconsistencies related to study evaluation or data extraction were resolved by a third author. The co-primary outcomes were the rate of PPH and of any transfusion; the secondary outcomes included admission to the intensive care unit (ICU), transfusion ≥ 4 units of packed red blood cells, hysterectomy, or maternal death. Study effects were combined by Bayesian meta-analysis and reported as risk ratios (RR) and 95% credible intervals (Cr). RESULTS We reviewed 142 full length articles. Of these, 18 publications, with 355,060 deliveries-150,562 (42%) deliveries during the pre-intervention and 204,498 (57.6%) deliveries in the post-interventional period-were included in the meta-analysis. Using the Newcastle-Ottawa Scale, only three studies were considered good quality, and none of them were done in the US. The rate of PPH prior to intervention was 5.06% and 5.46% afterwards (RR 1.09, 95% CI 0.87-1.36; probability of reduction in the diagnosis being 21%). The likelihood of transfusion decreased from 1.68% in the pre-intervention to 1.27% in the post-intervention period (RR 0.80, 95% Cr 0.57-1.09). The overall probability of reduction in transfusion was 93%, albeit it varied among studies done in non-US countries (96%) versus in the US (23%). Transfusion of 4 units or more of blood occurred in 0.44% of deliveries before intervention and 0.37% afterwards (RR of 0.85, 95% CI 0.50-1.52), with the overall probability of reduction being 72% (76% probability of reduction in studies from non-US countries and 49% reduction with reports from the US). Surgical interventions to manage PPH, which was not reported in any US studies, occurred in 0.14% before intervention and 0.28% afterwards (RR 1.29; 95% CI 0.56-3.06; probability of reduction 27%). Admission to the ICU occurred in 0.10% before intervention and 0.08% subsequently (RR 0.92, 95% CI 0.58-1.43), with the overall probability of reduction being 65% (81% in studies from non-US countries and 27% from the study done in the US). Maternal death occurred in 0.17% in the pre-intervention period and 0.09% during the post-intervention (RR 0.62, 95% CI 0.33-1.05; probability of reduction 93% in studies from non-US countries and 82% in one study from the US). CONCLUSIONS Interventions to reduce the sequelae of PPH are associated with decrease in adverse outcomes. The conclusion, however, ought not to be accepted reflexively for the US population. All of the studies on the topic done in the US are of poor quality and the associated probability of reduction in sequelae are consistently lower than those done in other countries. SYNOPSIS Since the putative benefits of PPH drills or simulation exercises are based on poor quality pre- and post-intervention trials, policies recommending them ought to be revisited.
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Affiliation(s)
- Hector Mendez-Figueroa
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Cynthia S Bell
- Department of Center for Clinical Research & Evidence-Based Medicine in the Department of Pediatrics, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Steve M Wagner
- Department of Obstetrics and Gynecology, Alpert Medical School, Brown University, Providence, RI, USA
| | - Claudia Pedroza
- Department of Center for Clinical Research & Evidence-Based Medicine in the Department of Pediatrics, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Megha Gupta
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Isabelle Mulder
- Department of Obstetrics and Gynecology, University of Texas Southwestern, Dallas, TX, USA
| | - Keya Lee
- The Texas Medical Center Library, Houston, TX, USA
| | - Sean C Blackwell
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Michal F Bartal
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Suneet P Chauhan
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
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Postpartum hemorrhage: The role of simulation. Best Pract Res Clin Anaesthesiol 2022; 36:433-439. [PMID: 36513437 DOI: 10.1016/j.bpa.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 11/10/2022] [Indexed: 11/17/2022]
Abstract
Postpartum hemorrhage (PPH) persists as a leading cause of maternal death worldwide, and in the United States, most maternal deaths due to hemorrhage are deemed preventable. While essential preparations for hemorrhage include protocols and checklists, implementation science has revealed that it is not enough to merely introduce these tools into units. Simulation affords safe opportunities for practice and produces reliable behavior change, and it does not always need to be highly expensive and resource consuming. We review how simulation can be applied to address a unit's vulnerabilities in identifying, managing, and resolving PPH, as well as considerations for crafting a comprehensive simulation program for your unit.
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11
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Zehler A, Severi E. Enhancing Clinical Judgment in Managing Postpartum Hemorrhage: A Replication Study. J Contin Educ Nurs 2022; 53:500-504. [DOI: 10.3928/00220124-20221006-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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12
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The Influence of Nursing Simulation on Patient Outcomes and Patient Safety: A Scoping Review. Clin Simul Nurs 2022. [DOI: 10.1016/j.ecns.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Abstract
Simulation is a critical part of training for obstetric emergencies. Incorporation of this training modality has been shown to improve outcomes for patients and is now required by national accrediting organizations.
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Detlefs SE, Goffman D, Buttle RA, Crump CM, Thornburg LL, Foley MR, Deering S. Correlation between medical management and teamwork in multidisciplinary high-fidelity obstetrics simulations. Am J Obstet Gynecol MFM 2022; 4:100626. [PMID: 35351671 DOI: 10.1016/j.ajogmf.2022.100626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 03/23/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Teamwork and communication gaps are consistently cited as contributors to adverse outcomes in obstetrics. The Critical Care in Obstetrics Course provides an innovative experience by combining brief interactive didactics with the opportunity to practice and implement the knowledge gained with hands-on simulation. Most participants have never worked together, which creates a unique environment to evaluate the importance of teamwork and communication. OBJECTIVE This study aimed to evaluate the association between teamwork and medical management in high-fidelity critical care simulations. STUDY DESIGN The participants were separated into multidisciplinary teams and taken through simulations, including placental abruption, hypertensive emergency, eclampsia, sepsis, cardiac arrest, venous thromboembolism, diabetic ketoacidosis, and thyroid storm. Facilitators completed a validated checklist assessment for each group's performance in medical care and teamwork. Each element was rated on a scale from 1 to 5, with 1 being unacceptable and 5 being perfect. We evaluated 5 communication measures, including the use of closed-loop communication and orientation of new team members. A Spearman correlation was used to evaluate the relationship between total medical management and total teamwork scores and specific measures of team communication. Receiver operating characteristic curves were created for total teamwork score as a predictor of good or perfect medical management. RESULTS A total of 354 multidisciplinary teams participated in 1564 high-fidelity simulations. There was a significant correlation between medical management and teamwork and communication scores for all scenarios. The strongest correlation was for the total teamwork score for all simulations (ρ=0.84). Teamwork scores were highly predictive of medical management scores with an area under the curve of at least 0.88 for all simulations, although this was not significant for diabetic ketoacidosis. CONCLUSION The quality of teamwork and communication correlated with the quality of clinical performance in newly formed multidisciplinary teams. This demonstrates the importance of teamwork training, with a focus on key communication tools and strategies, among medical providers to optimize the management of complex and emergent obstetrical conditions.
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Affiliation(s)
- Sarah E Detlefs
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Dr Detlefs)
| | - Dena Goffman
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY (Dr Goffman)
| | - Rae A Buttle
- University of the Incarnate Word School of Osteopathic Medicine, San Antonio, TX (Ms Buttle)
| | | | - Loralei L Thornburg
- Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY (Dr Thornburg)
| | - Michael R Foley
- Banner-University Medical Center Phoenix, The University of Arizona College of Medicine-Phoenix, Phoenix, AZ (Dr Foley)
| | - Shad Deering
- Department of Obstetrics and Gynecology, Christus Health, Baylor College of Medicine, San Antonio, TX (Dr Deering).
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Voillequin S, Rozenberg P, Ravaud P, Rousseau A. Promptness of oxytocin administration for first-line treatment of postpartum hemorrhage: a national vignette-based study among midwives. BMC Pregnancy Childbirth 2022; 22:353. [PMID: 35461215 PMCID: PMC9034651 DOI: 10.1186/s12884-022-04648-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/31/2022] [Indexed: 11/24/2022] Open
Abstract
Background Postpartum hemorrhage (PPH) remains a leading cause of maternal morbidity and mortality worldwide. Midwives play a key role in the initial management of PPH. Uterotonic agents are widely used in its prevention and treatment, with oxytocin the first-line agent. Nonetheless, a standardized guideline for optimal dose and rate of administration has not been clearly defined. The aim of this study was to investigate French midwives’ practices regarding first-line oxytocin treatment and the factors influencing its delayed administration. Methods This multicenter study was based on clinical vignettes of PPH management collected using an anonymous online questionnaire. A random sample of midwives from 145 maternity units in France from 15 randomly selected perinatal networks were invited to participate by email. The Previously validated case vignettes described two different scenarios of severe PPH. Vignette 1 described a typical immediate, severe PPH, and vignette 2 a less typical case of severe but gradual PPH They were constructed in three successive steps and included multiple-choice questions proposing several types of clinical practice options at each stage. For each vignette separately, we analyzed the lack of prompt oxytocin administration and the factors contributing to them, that is, characteristics of the midwives and organizational features of maternity units. Bivariate analysis and multivariable logistic regression analysis were applied. Results In all, 450 midwives from 87 maternity units provided complete responses. Lack of promptness was observed in 21.6% of responses (N = 97) in Vignette 1 and in 13.8% (N = 62) in Vignette 2 (p < .05). After multivariate analysis, the risk of delay was lower among with midwives working in university maternity hospitals (ORa 0.47, 95% 0.21, 0.97) and in units with 1500 to 2500 births per year (ORa 0.49, 95% CI 0.26, 0.90) for Vignette 1. We also noticed that delay increased with the midwives’ years of experience (per 10-year period) (ORa 1.30, 95% CI 1.01, 1.69). Conclusions This study using clinical vignettes showed delays in oxytocin administration for first-line treatment of PPH. Because delay in treatment is a major cause of preventable maternal morbidity in PPH, these findings suggest that continuing training of midwives should be considered, especially in small maternity units. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-04648-5.
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Affiliation(s)
- S Voillequin
- Department of Obstetrics and Gynecology, Strasbourg University Hospital, Strasbourg, France. .,INSERM UMR1018 "Clinical Epidemiology Team", Research Center on Epidemiology and Population Health (CESP), UVSQ, Paris Saclay University, Villejuif, France. .,Midwifery Department, Strasbourg University, Strasbourg, France.
| | - P Rozenberg
- INSERM UMR1018 "Clinical Epidemiology Team", Research Center on Epidemiology and Population Health (CESP), UVSQ, Paris Saclay University, Villejuif, France.,Department of Obstetrics and Gynecology, Poissy-Saint Germain Hospital, Poissy, France
| | - Ph Ravaud
- INSERM UMR1153, Centre of Research Epidemiology and Statistics (CRESS), Université de Paris, Paris, France.,Center for Clinical Epidemiology, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpital Hôtel Dieu, Paris, France
| | - A Rousseau
- INSERM UMR1018 "Clinical Epidemiology Team", Research Center on Epidemiology and Population Health (CESP), UVSQ, Paris Saclay University, Villejuif, France.,Department of Obstetrics and Gynecology, Poissy-Saint Germain Hospital, Poissy, France
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In Reply. Obstet Gynecol 2021; 138:943-944. [PMID: 34794157 DOI: 10.1097/aog.0000000000004610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Association of Simulation Training with Rates of Medical Malpractice Claims Among Obstetrician-Gynecologists. Obstet Gynecol 2021; 138:943. [PMID: 34794156 DOI: 10.1097/aog.0000000000004609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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