- Updated: June 29, 2026
Epidemiology and Pathology of EPH
Emergency peripartum hysterectomies are rare, with a global pooled incidence of 1.1/1,000 births (3). However, lower-income populations are substantially more likely to undergo EPH (3/1,000 births) compared to high-income settings (0.7/1,000 births). Income disparity has an even more dramatic effect on global maternal fatality rates: an overall incidence of 3.2 deaths per 100 EPH obscures an alarming 11.2/100 EPH for lower-income settings, compared to 1.0/100 EPH for high-income settings.
The vast majority of EPHs are indicated by uterine atony, placental pathology, and uterine rupture, but the relative frequencies of each vary substantially depending on factors such as socioeconomic status and clinical setting. Uterine atony (failure of the uterus to contract adequately after delivery) is the overall leading cause of postpartum hemorrhage, accounting for around 27% of cases globally. Placenta accreta spectrum (PAS) disorders are disproportionately more likely to occur in high-income settings, while uterine rupture is more frequent in low-income settings.
In many high-income countries, PAS incidence has increased concomitantly with cesarean delivery, even overtaking uterine atony as the leading cause of EPH. Notably, cesarean delivery and prior cesarean section are strong risk factors for PAS-related EPH, with each additional cesarean section conferring more risk (4).
EPH Simulators Improve Outcomes
The pedagogical argument for simulation in EPH rests on a straightforward problem: trainees cannot reliably acquire competence in a procedure they rarely see.
Dr. Russ Jelsema, Medical Director of Reproductive Health at Natera, brings 25 years of clinical practice and 30 years of teaching to this question. He’s seen firsthand how high-pressure emergency situations can cause even skilled surgeons to lose their footing.
During a cesarean section, attention naturally centers on the baby. But as Dr. Jelsema emphasizes, focusing on the mother is critical to a successful outcome. When hemorrhage escalates, surgeons need the kind of trained instinct that allows them to pause, assess, and choose the right next step — rather than defaulting to the most complex intervention available.
That matters because not every hysterectomy needs to be a total one. A supracervical hysterectomy removes the uterus while leaving the cervix intact, which can reduce the risk of bladder and bowel dysfunction caused by the loss of nerve ganglia. A total hysterectomy (removing both the uterus and cervix) is sometimes unavoidable (as in cancer treatment), but it carries additional risks that residents need to understand deeply before they’re in a position to make that call under pressure.
Indeed, confidence and competence deficits among OB/GYN residents have been well documented, and research shows that even a single one-hour session using a low-fidelity bench model simulation produces significant gains in trainee confidence and knowledge (5,6). When high-fidelity simulators with integrated bleeding systems are used in full-team rehearsals, the benefits extend beyond individual technical skill to encompass communication, role clarity, and crisis resource management (7,8).
The argument for simulation is bolstered by the finding that high-volume hospitals have significantly lower rates of EPH-associated morbidity and mortality compared to low-volume hospitals (9). For trainees and clinicians who are not in high-volume hospitals, the rarity of EPH presents a barrier to achieving the anatomical fluency and technical composure that predict successful outcomes. Medical simulations are removing these barriers by offering controlled, repeatable EPH exposure that complements the traditional “see, do, learn” apprenticeship model of surgical education.
Simulation training has proven so effective that the American College of Obstetrics and Gynecology (ACOG) founded the ACOG Simulation Working Group in 2008 with the goal of integrating standardized and validated simulations-based curricula into all OB/GYN residency programs (11). ACOG now offers continuing medical education credit for advanced surgical simulation programs. Mounting evidence from ACOG and others continues to support the transferability of simulation-based skills to live operative performance.
Simulation as a Life-Saving Tool
Emergency peripartum hysterectomy (EPH) is an uncommon, life-saving obstetric procedure that is used in cases of intractable peripartum hemorrhage. With an incidence of just 1 in 1,000 births, many OB/GYN residents will see only a handful of cases during their training. Multiple studies have determined that EPH simulations provide trainees and clinicians with crucial hands-on experience that helps to prepare them for a real emergency, and simulations-based curricula have become integral components of obstetric-gynecologic residency training.
OEI’s Emergency Hysterectomy Trainer is the first simulator specifically designed to fill this gap. It features an open abdomen with an integrated bleeding system, anatomically accurate representations of the uterus, ovaries, bladder, ureters, and uterine arteries, and 10 replaceable uteri for repeated practice. Trainees can perform a fully operable removal of the uterus — with realistic blood flow — in a high-stakes environment that mirrors the real thing without the real consequences.
The result is residents who have felt that adrenaline before it matters. Who have made the decision between supracervical and total hysterectomy in simulation, not for the first time in an OR. That preparation is what translates into better outcomes for mothers.
References:
1. Harvey SV, Pfeiffer RM, Landy R, Wentzensen N, Clarke MA. Trends and predictors of hysterectomy prevalence among women in the United States. Am J Obstet Gynecol. 2022;227(4):611.e1-611.e12. doi: 10.1016/j.ajog.2022.06.028.
2. Tsolakidis D, Zouzoulas D, Pados G. Pregnancy-related hysterectomy for peripartum hemorrhage: a literature narrative review of the diagnosis, management, and techniques. Biomed Res Int. 2021;2021:9958073. doi: 10.1155/2021/9958073.
3. Kallianidis AF, Rijntjes D, Brobbel C, Dekkers OM, Bloemenkamp KWM; van den Akker T. Incidence, indications, risk factors, and outcomes of emergency peripartum hysterectomy worldwide: a systematic review and meta-analysis. Obstet Gynecol. 2023;141(1):35-48(14). doi: 10.1097/AOG.0000000000005022.
4. Morlando M, Collins S. Placenta accreta spectrum disorders: challenges, risks, and management strategies. Int J Womens Health. 2020;12:1033-1045. doi: 10.2147/IJWH.S224191.
5. Frenn R, Heisler E, Chen G, Zoorob D. Improving resident comfort with peripartum cesarean hysterectomy through the use of low-fidelity simulation models. Cureus. 2024;16(9):e69056. doi: 10.7759/cureus.69056.
6. Syamsuri DD, Askandar Tjokroprawiro B, Kurniawati EM, Utomo B, Kuswanto D. Simulation-based training using a novel Surabaya hysterectomy mannequin following video demonstration to improve abdominal hysterectomy skills of obstetrics and gynecology residents during the COVID-19 pandemic in Indonesia: a pre- and post-intervention study. J Educ Eval Health Prof. 2022;19:11. doi:10.3352/jeehp.2022.19.11.
7. Weiss TG, Rentea RM. Simulation Training and Skill Assessment in Obstetrics and Gynecology. [Updated 2023 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026. Available from: https://www.ncbi.nlm.nih.gov/sites/books/NBK560508/
8. Rajan G, Tang BN, Ganeshan M, Jeganathan T. Simulation training in cesarean delivery. Am J Obstet Gynecol. 2026;233(6S):S385-S403. doi: 10.1016/j.ajog.2025.07.025.
9. McLauchlan NR, Frasier LL, Fisher L, Carroll J, Christian CW, Delaney A, Cave KJ, Gallagher JJ, Rose S, Morris JB, Kaufman E, Cannon JW. High-Fidelity Bleeding Control Simulation Scenario During Medical Student Orientation Improves Students’ Self-Reported Ability to Identify and Treat Life-Threatening Bleeding with 3-year Follow-up. J Surg Educ. 2024;81(10):1484-1490. doi:10.1016/j.jsurg.2024.07.007.
10. Simulations Working Group. American College of Obstetricians and Gynecologists. Updated February 2021. Accessed April 10, 2026. https://www.acog.org/education-and-events/simulations/about
