300,000 women die during childbirth every year and 99% of these are from low-income and middle income countries. The World Health Organization stresses the need to concentrate on improving education and universal access to cesarean sections to improve maternal and perinatal outcomes.
Postpartum hemorrhage, however, is recognized as a major contributor to maternal mortality. Lack of skills and poorly resourced facilities are some of the factors that exacerbate the situation and are also likely to lead to a hysterectomy. Although planned hysterectomies can be prepared for, emergency cesarean hysterectomies (c-hysts) put extra strain on residents, their departments and resources. Training for planned hysterectomies can be arranged with the obstetrics department in advance, ensuring that medical students are well equipped for learning. Emergency procedures are more difficult to teach due to the sporadic and unpredictable nature of such events. Creating a highly realistic, hands-in-the-body emergency training environment hasn’t been possible until recently.
OEI medical simulators replicate the intense experience of both elective and emergency procedures. They are fully operable and feature incredibly accurate and tactile anatomy, realistic blood and fluids, and are uniquely designed to provide learners with a high-adrenaline, real-world operative experience. Dr Russ Jelsema, Medical Director, Reproductive Health at Natera, has 25 years of clinical practice and risk management experience at provider, hospital, and hospital system levels and 30 years of teaching at graduate and post graduate level. He states that high-quality, extensive and immersive simulation training gives surgeons the clarity and confidence needed for emergency situations. While there’s an inevitable focus on the baby during a cesarean section, “the key to successful outcomes is Mom”. Jelsema believes that providing the type of training that OEI simulators offer helps a surgeon to feel confident enough to “take a breath and decide what the next course of action will be.”
This is an important part of training because it’s easy to continue with the more complex aspects of total hysterectomies that aren’t always necessary. Bladder and bowel dysfunction may present after the loss of nerve ganglia, conditions that are closely associated with the removal of the cervix. Jelsema is quick to point out that medical practitioners need to understand the effects on the patient if her cervix is removed and whether it is an entirely necessary procedure during a hysterectomy, planned or otherwise. A total hysterectomy removes the uterus and the cervix but not always the ovaries. If the ovaries are to be removed, a bilateral salpingoophorectomy, BSO, is performed in addition to the hysterectomy. A supracervical hysterectomy removes just the uterus and leaves the cervix in place. In certain situations, cancer treatment for example, there is no other option than to remove the cervix along with the uterus and/or ovaries. Cesarean hysterectomies are performed postpartum and usually as an emergency rather than a planned procedure.
Around 4% of women experience postpartum hemorrhage which tends to be more common with a cesarean birth. During pregnancy, blood flow through uterine circulation increases significantly and, to accommodate this increase, the uterine vasculature undergoes luminal expansion and an increase in wall mass. This process is referred to as outward hypertrophic remodelling or arteriogenesis. Blood loss and postpartum hemorrhage is of particular concern to obstetric teams. There are different treatments available but if none succeed and the patient is still in a critical condition, hysterectomy is a viable option.
A long and complicated history
Hysterectomies have had an interesting history and a rather complex development. The first planned hysterectomy was a vaginal hysterectomy performed by Konrad Langenbeck, best known for developing the technique ‘Langenbeck’s amputation’. However, there is almost no written record of what happened or of the outcome. The first properly recorded and deliberate opening of the the abdomen in order to remove an ovarian cyst, was performed in 1809, in Kentucky, by Ephraim McDowell. Charles Clay, in Manchester, England, unfortunately got his diagnosis wrong when he operated on a patient in 1843, who died soon after the operation. The following year he performed the surgery on another patient but she, too, died post-operatively. It wouldn’t be until 1853 when the first successful abdominal hysterectomy would be performed by Ellis Burnham although he, too, got his diagnosis wrong. This time, though, the patient survived. Prior to this, vaginal hysterectomies had been performed from the middle ages, usually for the extirpation of an inverted uterus. Patients rarely survived, which isn’t surprising as these operations were conducted without anesthesia and complications of hemorrhage, peritonitis, exhaustion and sepsis were often the culprits. It was common practice, at this time, to leave a long ligature to encourage the drainage of pus but Thomas Keith, from Scotland, realised that by cauterizing the cervical stump he was able to improve survival rates considerably.
Hysterectomies had a shocking rate of mortality of up to 70% until the mid 1930’s when the use of anesthesia, antibiotics and other medical advances were introduced, reducing the rate to 8%. Hysterectomies saw very limited improvement or development until the late 1980’s when the first laparoscopic hysterectomy would be achieved by Harry Reich, in Kingston, Pennsylvania (1988).
Medical simulation is both a thorough and cost-effective teaching method, ensuring that medical practitioners are fully prepared for all eventualities. It is important that general surgeons have access to continued education in obstetrics and open abdomen simulators that support hemorrhage control and emergency c-hyst training. With the Emergency Hysterectomy Trainer from OEI, medical professionals are able to practice on an open abdomen with bleeding and perform a fully operable removal of the uterus. Simulation directly influences patient safety. In 2008, the American College of Obstetricians and Gynecologists (ACOG) founded the Simulations Working Group to establish simulation as a pillar in education for women’s health, through collaboration, advocacy, research and the development and implementation of multidisciplinary simulations-based educational resources and opportunities. As there has been a 30% decrease in the number of abdominal hysterectomies performed by residents, operating room experience can be in short supply.
Therefore, simulation training can be an important tool to boost residency experience. Until the introduction of OEI’s Emergency Hysterectomy Trainer, there have been almost no simulation models available for teaching abdominal hysterectomy. With the availability of complete, highly-realistic and integrated training solutions for the entire labor and delivery continuum of care, OEI is transforming how medical simulation looks and feels!
Learn more about OEI’s suite of Labor and Delivery simulators. Click here