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In Situ Simulation Training to Combat Maternal Hemorrhage

Mother holding her baby girl
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Figures from the Centers for Disease Control and Prevention (CDC) show that the maternal mortality rate has more than doubled since 1987, reaching an alarming high of 17.3 maternal deaths per 100,000 live births.

Worse, the CDC estimates that 60% of maternal deaths reviewed in a study were preventable.

The Joint Commission has recently issued seven Elements of Performance (EPs) related to maternal hemorrhage, requiring hospitals to address:

1. Performing a hemorrhage risk assessment using an evidence-based tool upon admission to labor and delivery (L&D) and postpartum care. This risk assessment can be performed on paper or (preferably) in the mother’s electronic medical record.

2. Development of written procedures for hemorrhage management. The goal is to standardize on an evidence-based approach to minimize delays and foster
effective communication among team members.

3. Standardization of a hemorrhage supply kit. Hospitals should have a crash cart dedicated to maternal hemorrhage that has all the elements on board, along with anything else the hospital and delivering clinicians prefer.

4. Delivery of role-specific staff and provider education about the organization’s OB hemorrhage procedures. For the care team to function optimally in an emergency, everyone must know the procedures to follow in the event of a hemorrhage. Although not required, in situ simulations that allow staff to practice organizational procedures in actual clinical settings are encouraged. This education should be delivered during orientation, when there are changes in procedures, and annually. Ensuring readiness in this way will make an impressionable impact on maternal outcomes.

In situ simulation training to combat maternal hemorrhage on a postpartum hemorrhage simulator

5. Conducting hemorrhage drills. Multidisciplinary simulation of emergency events is essential to uncovering gaps in education or procedures as well as improving staff response time and recognition of a worsening condition. Drills should be conducted annually at a minimum.

6. Performing OB hemorrhage case reviews. A standardized approach to assessment of the response team and effectiveness of treatment in actual situations is an invaluable tool for gathering key information that can improve future patient experiences.

7. Providing patient and family education. At a minimum, education should include the signs and symptoms of postpartum hemorrhage during hospitalization and instructions on when to seek care as well as signs and symptoms for when to seek immediate care.

The Joint Commission promulgated these standards to affect training prior to, performance during and review afterwards of maternal mortality instances.

EP 4 and 5 speak directly to the training of staff which will ensure care providers know how to spot hemorrhage and quickly treat it.

Nurses delivering a baby

For the care team to function optimally in a true emergency, it is essential that all members know the procedures they should follow in the event of hemorrhage. Although not required, in situ simulations that allow staff to practice organizational procedures in actual clinical settings are encouraged. [i]

Conduct drills at least annually to determine system issues as part of on-going quality improvement efforts. Drills include representation from each discipline identified in the organization’s hemorrhage response procedure and include a team debrief after the drill.

Multidisciplinary drills give an organization the opportunity to practice skills and identify system issues (e.g., unwillingness of the blood bank to release blood products despite authorization for this in the procedure) in a controlled environment. It is crucial to have members from as many disciplines identified in theorganization’s response procedure as possible available during drills to  be able to test each level of the emergency and identify areas of improvement. This is crucial for identifying weaknesses in the response system and to identify opportunities for improvement. Organizations should assess their level of proficiency to determine the frequency drills should be performed; organizations that have reached a high level of mastery may need less frequent drills. [ii]

These regulations went into effect in July of 2020. However, due to COVID, on-site surveys at this time are being postponed. This gives hospitals time to ascertain their current training structures and limitations in order to meet the regulations when surveys are reinstated.

In situ simulations that allow staff to practice organizational procedures in actual clinical settings are encouraged by the Joint Commission and are recommended by the American College of Obstetrics and Gynecology’s Simulations Working Group. The ACOG Simulations Working Group goes on to say:

Acquiring phenomenal clinical and surgical skills during obstetric-gynecologic residency training has always been of paramount importance. Increasing emphasis on patient safety and risk management concerns have presented convincing arguments, including strategies for ensuring that residents develop a solid foundation in teamwork, effective communication, basic surgical techniques, and demonstration of skill competencies. This should occur before residents participate in actual surgical skills and procedures in hospital operating theaters.[iii]

Operative Experience, Inc. (OEI) provides the world’s only fully operative, hands-in-the-body simulators for mastering emergency labor and delivery procedures, including one specifically designed to teach the interventions necessary to combat maternal hemorrhage. The simulators provide unprecedented anatomical and surgical fidelity; standard instruments can be used to incise, dissect, retract and suture realistic tissue; and realistic simulated amniotic fluid
and blood make for real world learning.

The Postpartum Hemorrhage Control Simulator teaches the following skills:

· Complex lacerations and uterine artery injuries

· Hemorrhage control techniques including Bakri balloon, B-Lynch suture, Hayman suture and O’Leary stitch

· Teamwork and human factors training for hemorrhage control in an emergency C-Section

In addition to a solid simulation tool, OEI recommends a multidisciplinary drill approach once skills are built using the simulator.

For example, outline every department that interfaces with the care team in the execution of a maternal hemorrhage incident. The Joint Commission example in EP5 is an unwillingness of a blood bank to release blood products. These other system level departments should be included in drills so the entire system can be examined for areas of weakness.

This will require communication and cooperation with all areas of the hospital that impact maternal hemorrhage. Make sure to share success stories system wide as well to increase buy in and cooperation.

Labor and delivery practice on a labor and delivery simulator

Once your team and systems reach a high level of mastery, you can calibrate how often you need to run the drills to keep proficient. The Joint Commission recommendation is at least annually, and best practice is whenever your protocol changes.


[i] “Practice Bulletin No. 183: Postpartum Hemorrhage.” Obstetrics & Gynecology. 2017;130(4):e168-e186. American College of Obstetricians and Gynecologists.
“Preparing for Clinical Emergencies in Obstetrics and Gynecology.” ACOG Committee Opinion No. 590. Obstetrics & Gynecology. 2014;123:722-725.

[ii] American College of Obstetricians and Gynecologists. “Preparing for Clinical Emergencies in Obstetrics and Gynecology.” ACOG Committee Opinion No. 590. Obstetrics & Gynecology. 2014;123:722-725. Kyryabina E, et al. “What is the Value of Health Emergency Preparedness Exercises? A Scoping Review Study.” International Journal of Disaster Risk Reduction. 2017;21:274-283. Lee A, et al. “Intrapartum Maternal Cardiac Arrest: A Simulation for Multidisciplinary Providers.” MedEdPORTAL. 2018;14:1-8

[iii]ACOG Simulations Working Group main page, https://www.acog.org/en/Education%20and%20Events/Simulations/About, 2020

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