A review of Lutgendorf et al., “Evaluation of a Simulation and Teamwork Training Program to Improve Postpartum Hemorrhage Outcomes” (BJOG, 2024)
Postpartum hemorrhage complicates roughly 6% of deliveries worldwide, and it remains one of the leading causes of preventable maternal morbidity and mortality in the United States. For years, labor and delivery teams have turned to simulation-based training and team-based hemorrhage bundles as a response; and for years, the honest assessment has been that while simulation clearly improves skills and team performance in the lab, rigorous evidence connecting it to actual patient outcomes has been harder to come by.
That’s what makes a 2024 study by Lutgendorf and colleagues, published in BJOG (International Journal of Obstetrics & Gynecology), worth a careful read.
The research team evaluated OB-STaT (Obstetric Simulation Training and Teamwork) across eight hospitals in the U.S. Military Health System and rather than measuring how well teams performed in a simulation, they asked a harder question: did anything change for real patients?
The answer, as is so often the case in medicine, is nuanced. And the nuances are where things get interesting.
Training at Scale, Right on the Unit
OB-STaT is a standardized, four-hour, interprofessional simulation curriculum delivered in situ. Meaning right on the labor and delivery unit, not in an offsite training center.
The curriculum covers the full escalation ladder of hemorrhage response:
- Massive transfusion protocols
- Rapid transfusion systems
- Uterine balloon tamponade
- Compression sutures
- Uterine artery ligation
- Peripartum hysterectomy
- Neonatal resuscitation
What stands out is the breadth of who was trained. Across the eight hospitals, 54 teams and 721 staff members completed the curriculum; 72% of all assigned staff. That included OB/GYN physicians and residents, midwives, nurses, anesthesia providers, pediatricians, family medicine physicians, corpsmen, blood bank personnel, radiology, and OR techs. This wasn’t a course for the hemorrhage response team. It was a course for the whole floor.
The study design was a before-and-after chart review comparing six months of deliveries before training to six months after, with a one-month washout period excluded at each site.
In total, the analysis covered:
- 9,980 deliveries
- 5,059 before
- 4,921 after
What Didn’t Move — and What Did
Here’s the finding that will disappoint anyone looking for a simple headline: the rate of postpartum hemorrhage itself didn’t change. PPH occurred in 5.48% of deliveries before training and 5.14% after, not a statistically significant difference. Overall transfusion rates, ICU admissions, and surgical interventions were similarly flat.
One important caveat before drawing conclusions from that: the study was statistically powered to detect a drop from a historical 2% PPH rate down to 1%.
The actual observed rate was around 5%; meaning the study wasn’t really designed to detect the change it was looking for. The “no change” finding deserves an asterisk.
But the secondary outcomes tell a different story:
| Outcome | Before Training | After Training | Significance | Notes |
|---|---|---|---|---|
|
Composite maternal morbidity* |
6.35% |
5.28% |
Improved (p = 0.03) |
– |
|
Massive transfusions |
21 cases |
9 cases |
Cut by 57% (p = 0.043) |
Four or more units |
|
No PPH medications used |
85% |
55% |
Shifted dramatically |
Sharply increased use of multiple uterotonic types |
|
Tranexamic acid (TXA) use |
2.7% |
4.8% |
Nearly doubled (p < 0.001) |
Used for PPH treatment |
|
Hysterectomy |
0 cases |
5 cases |
Rose from zero |
Examined case by case; concluded as appropriate, life-saving use of last-resort intervention |
*> A measure combining PPH, hysterectomy, transfusion of four or more units, and ICU admission for hemorrhage.
The Confound That Might Actually Be the Point
One secondary finding deserves its own spotlight.
The share of deliveries documented as “increased PPH risk” jumped from 8.7% before training to 41.6% after. The authors are candid that this likely reflects improved documentation, EMR changes adding risk-factor checkboxes coincided with the study, rather than a true quadrupling of clinical risk, and they flag it as a limitation.
But there’s another way to read it.
If simulation training sharpens a team’s recognition and documentation of risk, and that recognition cascades into earlier, more aggressive treatment, then better documentation may be part of the mechanism rather than just noise. Teams that see risk sooner treat it sooner.
An Honest Accounting of the Limitations
The authors don’t oversell, and neither should we. This was a before-and-after design with no control group, so the training can’t be cleanly isolated from other concurrent changes like those EMR updates. There was no way to confirm which providers on duty for any given delivery had actually completed the training. Blood loss measurement methods varied across sites. The hysterectomy numbers are too small to lean on. And the follow-up window was only six months. The durability of these gains is an open question, one the authors explicitly pose as the next research priority: how often do teams need to drill to sustain improvement?
So What’s the Takeaway?
Nothing here is definitive, and the study doesn’t claim otherwise.
But the pattern is coherent and consistent with prior literature: simulation training may not prevent hemorrhage from occurring, but it appears to change how systems respond when it does wiht:
- Faster recognition
- Earlier medication
- Better escalation
- Fewer catastrophic outcomes like massive transfusion
Composite morbidity fell even as documented risk rose.
The other lesson worth carrying forward is reach. The authors connect their results to earlier work by Pattinson and colleagues, which found meaningful reductions in mortality from severe hemorrhage when more than 80% of staff were trained.
OB-STaT reached 72%. Training everyone, not just the designated response team, may be a quiet prerequisite for results like these.
Training for the Moment That Matters
Studies like this one reinforce why hands-on, team-based hemorrhage training belongs on the unit and why the fidelity of that training matters.
Operative Experience’s emergency OB simulation portfolio, including the C-Celia family of simulators, offers the world’s only “hands-in-the-body” surgical simulators for obstetric emergencies. Allowing teams to physically perform the interventions this study’s curriculum covers, from uterine balloon tamponade to cesarean delivery and peripartum hysterectomy, on anatomy that looks, feels, and responds like the real thing.
For the last-resort scenario the OB-STaT teams drilled and the one this study’s five real-world cases underscore; OEI’s emergency hysterectomy simulator features an anatomically accurate open abdomen and integrated bleeding system with a fully operable removal of the uterus, so teams can rehearse the complete procedure, not just talk through it.
Watch a video of the Emergency Hysterectomy simulation performed by NYU Langone Medical Center.
If your team is building or refreshing its hemorrhage response program, we’d welcome the conversation.
Reference:
Lutgendorf MA, et al. Evaluation of a simulation and teamwork training program to improve postpartum hemorrhage outcomes: A before-and-after study. BJOG. 2024.
