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Can Simulator Training Help Turn the Tide in Maternal Mortality?

Newborn baby immediately after delivery

According to the CDC, the maternal mortality rate for the United States in 2018 was 17.4 maternal deaths per 100,000 live births.   On an international scale, this places the US at 55th, just behind Russia (17 per 100,000) and just ahead of Ukraine (19 per 100,000). [i]

When women of color older than 30 are considered as a subset in the US, their rate of mortality in childbirth is four to five times as high as that of caucasian women. One specific area of complication for these women is postpartum hemorrhage (PPH).

These preventable events are the cause of 27% of maternal deaths worldwide and 11% of U.S. maternal deaths.  A full 20% of women who experience a hemorrhage have no identifiable risk factors.[ii]

Compared to vaginal delivery, women undergoing cesarean delivery (CD) incur the highest risk of PPH and hemorrhage-related morbidity.

A concerning statistic reported by Centers for Disease Control & Prevention indicates that the rate of postpartum hemorrhage is rising sharply.  PPH procedures to control hemorrhage per 10,000 delivery hospitalizations increased from 4.3 in 1993 to 21.2 in 2014. For postpartum hemorrhage with blood transfusions, this occurred 7.9 times per 10,000 delivery hospitalizations in 1993 and later spiked to 39.7
per 10,000 in 2014.[iii]

Pressure upon treatment teams is intense.  The stakes for these families and the institutions who care for them are high. One way to reduce variations of care and protect patients and families is to increase team readiness for these situations with scenario-based learning leveraging a high-fidelity cesarean section surgical simulator.

Simulation training is a proven method of learning and has many benefits.  The Accreditation Council for Graduate Medical Education (ACGME) now requires simulation to be utilized in Obstetrics and Gynecology (OB/GYN) training programs.

Obstetric simulations demonstrate positive effects on clinical outcomes for a variety of obstetric applications, including shoulder dystocia, operative vaginal delivery, emergent cesarean delivery, and postpartum hemorrhage.  Simulations can also improve teamwork in response to obstetric emergencies as participating in simulations allows learners to examine their communication techniques, successes and failures in a safe environment.

Non-obstetricians may benefit from simulation training in the event they need to perform or assist in a cesarean section.  Practical applications of this might include combat deployments, humanitarian missions, or when practicing at a remote location. Simulation may also be useful in rural or low resource areas where an experienced OB/GYN may not be immediately available.

A recent study was published by Lisa Foglia, et. al, (Creation and Evaluation of a Cesarean Section Simulator Training Program for Novice Obstetric Surgeons)[iv] that used Operative Experience’s Emergency Obstetrics Suite and compared the use of this simulator with traditional teaching methods. The objective of the study was to evaluate the performance of a high-fidelity simulator program to train novice providers on cesarean delivery and postpartum hemorrhage management.  The results of this study are impressive.

Study Methodology:

Residents from three separate military training hospitals were invited to participate by a study administrator who had no role in residency oversight or evaluation. Enrollment was offered to all OB/GYN interns, Family Medicine senior residents, and General Surgery senior residents. Trainees were excluded if they previously served as primary surgeon for a cesarean section during their residency. 

  1. All participants attended a standardized didactic lecture.  This lecture covered:
  2. the indications for cesarean,
  3. procedural steps of the case, and
  4. medical and surgical postpartum hemorrhage management techniques.
  5. Participants were then placed into two groups, with one group to receive simulation-based training and the other no additional training. 
  6. The simulation-based group underwent training with cesarean section task-specific simulators for the procedures of skin incision, uterine incision, delivery of the fetus, wound closure, and operative interventions for postpartum hemorrhage including placement of uterine compression sutures and repair of a uterine artery laceration. The didactic-only group did not receive any simulation training.
  7. After the lecture and training, an evaluation was scheduled approximately six to eight weeks later.  All residents had their performance of a complete cesarean section and management of a postpartum hemorrhage evaluated on a high-fidelity simulator. Evaluators did not know who was in which group.
  8. Participants were presented a standardized scenario of a primigravid woman with arrest of dilation. They were instructed to conduct pre-operative counseling and to describe pre-operative care. Each participant was assisted during the operation by a person acting as a scrub tech who provided instruments as requested, but otherwise did not offer guidance about technique or interventions. A standard cesarean section instrument set was utilized, along with standard drapes. After delivery of the fetus, the scenario was complicated by a postpartum hemorrhage secondary to both uterine artery laceration and uterine atony. The hemorrhage scenario concluded if appropriate management occurred or after five minutes had elapsed. At this point, they were instructed to proceed with closing the uterine and abdominal incisions. When the procedure was complete, the participants were asked to verbalize postoperative orders


Participants were scored using a standardized evaluation form created for each portion of the procedure. Additional evaluations were adapted from previously published literature to assess technical surgical skills and teamwork/communication.

Evaluators were oriented to the form and expectations of ‘done but not accurate’ versus ‘done and accurate’ by two senior investigators, and the same person at each facility conducted all evaluations. Participants were given a final pass/fail assessment for the entire simulation based on the entire score and the evaluators’ subjective assessment of whether or not the participant safely and effectively performed the task.


The study showed that the simulation trained group had significantly better performance for the cesarean section procedural steps (56.6 +/- 12.3 vs 42.7 +/- 14.7; p=0.007) as well as hemorrhage management (22.3 +/- 5.7 vs. 13.6 +/- 6.1; p=0.0002).

They also had significantly higher overall scores for all aspects of the simulation (129.9 +/- 23.8) vs. 101.0 +/- 32.4; p=0.008) . There were no differences in preoperative counseling and management, postoperative management, overall technical skills, or teamwork.  

Overall, 79% of the simulation group passed the evaluation, while only 47% of the control group passed.


From the study: 

“Participants trained with a combination of didactic education and simulators versus didactic education alone performed significantly better on all procedural aspects of a cesarean section and hemorrhage management on a high-fidelity simulator, demonstrating that simulation-based training allows trainees to gain procedural experience while decreasing patient risk.”

Because this was a smaller study, the authors did not analyze success factors for each type of participant (OB/GYN, general surgery or family medicine).  However, it is important to note that OB/GYN residents generally learn to perform cesarean sections through an apprenticeship model involving learning, reviewing, and observing the steps of the procedure, and then operating under close observation.

General surgery residents do not routinely receive training in cesarean deliveries, and Family Practice residents may have variable exposure depending on their residency program and interests.  

The traditional educational construct is limited in several aspects including the unpredictability of disease occurrence and patient presentation, variations in patient anatomy, high-stress environments, and presumed increase in patient risk due to the inexperience of a novice surgeon.  General Surgery and Family Practice physicians may need to perform or assist with a cesarean section in urgent cases, or if they practice in rural or low resource areas.

It becomes apparent given these variances in presentation and backgrounds that best in class simulations are valuable training tools.

The study goes on to state:

“Simulation allows the trainee to gain procedural experience while eliminating patient risk and decreasing cognitive stress on the learner. It facilitates the provision of safe care while still meeting the learning goals of the trainee. Simulated complications and emergencies provide the opportunity to perform multiple repetitions until comfort and proficiency are achieved. In our study, one of the most striking differences was the improved management of postpartum hemorrhage by those who underwent simulation-based training.”

Study authors also felt the need is great for better training using a high-fidelity simulator such as Operative Experience’s Emergency Obstetrics Suite.  The study goes on to suggest that the “creation of a full cesarean section simulation-training program is relevant to both military and civilian providers. The majority of procedures performed for non-military female patients during humanitarian missions are for gynecologic or obstetric care. One study reported that 20% of deployed OB/GYNs performed at least one cesarean section while in a combat zone. Any surgeon, OB/GYN, or Family Medicine physician who is deploying or going on a humanitarian mission may be asked to perform a cesarean delivery and manage any associated complications. There is also evidence that even obstetric residents may not feel competent in some basic tasks within their own field.”


Operative Experience (OEI) was honored to be chosen as the provider of simulation-based education for this study.  All simulation is not the same. 

OEI’s training systems provide a cost-effective supplement to residency training, expanding experiential opportunities and provide additional practice beyond those procedures most often encountered during residential training.  The OEI Emergency Obstetrics Suite, used in this study, provides learners with the world’s only fully-operative, hands-in-the-body simulators for mastering C-Section, fetal extraction, postpartum hemorrhage and emergency hysterectomy procedures.


Incorporation of a simulation-based training model into pre-deployment or pre-humanitarian mission training may improve knowledge of the procedure, confidence in performing or assisting, and enhance skills related to hemorrhage management. Further, we found that a simulation-training plan could easily be incorporated into residency programs.

Future plans include permanently incorporating cesarean section simulation into residency training, creating standardized video instruction in addition to lectures, adding simulation training for patient counseling and team communication skills, and evaluating surgical skills on live patients.

Learn more about OEI’s Labor and Delivery training solutions.

 [i]Maternal Mortality, https://www.cdc.gov/nchs/maternal-mortality/index.htm

[ii] WHO, WHO recommendations for the prevention and treatment of postpartum hemorrhage, 2012, ISBN 978 92 4 154850 2

[iii]Gavigan, S. and Rosenberg, N,(November 2019), 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/

[iv] Foglia L M, Eubanks A A, Peterson L C, et al. (September 09, 2020) Creation and Evaluation of a Cesarean Section Simulator Training Program for Novice Obstetric Surgeons. Cureus 12(9): e10324. doi:10.7759/cureus.10324

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