Multiple-Choice Survey
Table 1 provides demographic information for study participants who responded to the RedCap survey. For the purposes of this study, only residents and attendings with at least 1–4 years of hospital practice were included in our analysis (n = 39). This meant that no first year residents were included, as they had less than 1 year of hospital practice.
Table 1
Demographics and practice patterns among survey respondants (n = 39)
|
Previous GO MOMS Training (%) (n = 24)
|
No Previous GO MOMS Training (%) (n = 15)
|
p-value1
|
Job Title
2nd Year Resident
3rd Year Resident
4th Year Resident
Attending
|
10 (41.7)
9 (37.5)
3 (12.5)
2 (8.33)
|
3 (20.0)
1 (6.7)
0 (0.0)
11 (73.3)
|
0.0002
|
Vaginal deliveries performed per month
0–10
10–30
>30
Not sure
|
8 (33.3)
6 (25.0)
10 (41.7)
0 (0.0)
|
10 (66.7)
2 (13.3)
2 (13.3)
1 (6.7)
|
0.0600
|
Cesareans performed per month
0–10
10–30
>30
Not sure
|
0 (0.0)
12 (50.0)
12 (50.0)
0 (0.0)
|
9 (64.3)
2 (14.3)
2 (14.3)
1 (7.1)
|
< 0.0001
|
Postpartum hemorrhages (more than 1000cc loss after delivery) per month
0–10
10–30
Not sure
|
23 (95.8)
1 (4.3)
0 (0.0)
|
13 (92.9)
0 (0.0)
1 (7.1)
|
0.6074
|
General Practice Patterns
|
|
|
|
Previously performed B-lynch
|
12 (50.0)
|
2 (13.3)
|
0.0378
|
When you did a B-Lynch, how many of them were done at time of C-sections?
All
Most
Some
Few
None
|
8 (66.7)
1 (8.3)
0 (0.0)
1 (8.3)
2 (16.7)
|
1 (50.0)
0 (0.0)
1 (0.0)
0 (0.0)
0 (0.0)
|
0.4066
|
When you did a B-Lynch, how many of them were done after vaginal deliveries?
All
Few
None
|
0 (0.0)
1 (8.3)
11 (91.7)
|
1 (50.0)
0 (0.0)
1 (50.0)
|
0.2747
|
How often after performing a B-Lynch did you still have to proceed to hysterectomy to control the bleeding?
Most of the time
Sometimes
A few times
Never
|
3 (25.0)
1 (8.3)
4 (33.3)
4 (33.3)
|
0 (0.0)
1 (50.0)
0 (0.0)
1 (50.0)
|
0.1099
|
Previously performed UBT
|
12 (50.0)
|
1 (6.7)
|
0.0061
|
When you did a UBT, how many of them were done at time of C-sections?
Some
Few
None
|
1 (7.7)
3 (23.1)
9 (69.2)
|
1 (50.0)
0 (0.0)
1 (50.0)
|
0.2857
|
When you did a UBT, how many of them were done after vaginal deliveries?
All
Most
Some
Few
None
|
5 (38.5)
2 (15.4)
2 (25.4)
1 (7.7)
3 (23.1)
|
0 (0.0)
0 (0.0)
0 (0.0)
1 (100.0)
0 (0.0)
|
0.4286
|
How often after performing a UBT did you still have to proceed to hysterectomy to control the bleeding?
Sometimes
A few times
Never
|
6 (48.2)
2 (15.4)
5 (38.5)
|
0 (0.0)
1 (50.0)
1 (50.0)
|
0.6571
|
1p-values calculated using Fisher’s Exact Test |
Table 2a compares where providers were first taught B-lynch and UBT based on whether or not they had received previous GO MOMS training. Participants without GO MOMS training were significantly less likely to have ever been taught UBT and B-Lynch (p = .03 and p = .01, respectively). Specifically, participants with previous GO MOMS training were more likely to have been taught B-lynch and UBT by the GO MOMS course or another resident or attending compared to those who had not received previous GO MOMS training (p = 0.008 and 0.006, respectively).
Table 2
a. Previous training experience with B-lynch and UBT among survey respondants (n = 39)
|
Previous GO MOMS Training (%) (n = 24)
|
No Previous GO MOMS Training (%) (n = 15)
|
p-value1
|
Ever been taught B-Lynch
|
22 (91.7)
|
8 (53.3)
|
0.0153
|
First learned B-Lynch from:
GO MOMS Course
Another resident or attending
Independent study (read about it)
|
7 (31.8)
15 (65.2)
0 (0.0)
|
0 (0.0)
6 (75.0)
2 (25.0)
|
0.0086
|
Ever been taught UBT
|
19 (78.2)
|
6 (40.0)
|
0.0353
|
First learned UBT from:
GO MOMS Course
Another resident or attending
Independent study (read about it)
|
13 (68.4)
3 (15.8)
3 (15.8))
|
0 (0.0)
4 (66.7)
2(33.3)
|
0.0068
|
1p-values calculated using Fisher’s Exact Test |
Table 2
b. Previous teaching experience and comfort with B-lynch and UBT among survey respondants (n = 39)
|
Previous GO MOMS Training (%) (n = 24)
|
No Previous GO MOMS Training (%) (n = 15)
|
p-value1
|
Taught B-lynch to another
|
13 (54.2)
|
1 (6.7)
|
0.0049
|
Comfort with B-Lynch
Can do without supervision
Can do with supervision
Not comfortable
|
6 (25.0)
13 (54.2)
5 (20.8)
|
0 (0.0)
2 (18.2)
9 (81.8)
|
0.0030
|
Taught UBT to another
|
9 (39.1)
|
4 (28.6)
|
0.7245
|
Comfort with UBT
Can do without supervision
Can do with supervision
Not comfortable
|
11 (45.8)
7 (29.2)
6 (25.0)
|
2 (14.3)
4 (28.6)
8 (57.1)
|
0.1014
|
1p-values calculated using Fisher’s Exact Test |
Table 2b compares provider comfort with B-lynch and UBT based on whether or not they had received previous GO MOMS training. Participants with previous GO MOMS training reported feeling more comfortable doing B-lynch with and without supervision and were also more likely to have taught B-lynch to someone else compared to those who had not received previous GO MOMS training (p = 0.003 and 0.004, respectively). However, there was no difference between those with and without previous GO MOMS training in terms of comfort with UBT or teaching UBT to others.
Qualitative Interviews
In total, 11 participants took part in the qualitative interviews. Eleven themes were generated from qualitative analysis. Themes included hospital practice patterns and use of techniques (UBT and B-lynch), hospital resource and personnel limitations, decision-making hierarchies, challenging nature of emergencies, and impact of SBT (Table 3).
Table 3
Themes and illustrative quotes pertaining to themes
Hospital Practice Patterns and Use of Techniques (UBT + B-Lynch)
|
Lack of practice and exposure to techniques (B-lynch and UBT)
|
• B-Lynch: Lack of practice
• B-Lynch: Not done routinely
• UBT: Never used
• UBT: Less frequent than B-Lynch
|
It’s the technique. We know the technique from our books, but in the moment, it’s difficult. We just don’t do it that often. So if we practice more, it won’t be as big of a deal to do it
|
Importance of overall practice patterns, context, order of techniques for managing hemorrhage
|
• Start conservatively (medications, massage)
• Hysterectomy in emergency
• Management – patient/situation dependent
|
They’d start with medications. If that didn’t work, they’d try B-Lynch or Uterine artery ligation. If it’s the patient’s first baby … well actually for everyone … they’d try to conserve the uterus. Then, they’d try a balloon. Then a hysterectomy. If the patient is unstable, they might go to hysterectomy.
It’s not just the number of children the woman has had. The reality is that hysterectomy comes with other risks too like injury to the bladder and other things. There are a lot of risks. So it’s not just the number of children she’s had [that influences us to do or not do a hysterectomy]. We look at the patient situation and see if the hemorrhage that can be controlled [with other conservative measures].
|
Success of techniques (B-lynch and UBT) when performed
|
• B-lynch: Avoid hysterectomy
• UBT: Effective (in atony)
• Both: Controlled hemorrhage
|
For the patient it went really well, there wasn’t a need for hysterectomy, it went really well, I think it’s an alternative that we have, that we can use if we have the knowledge and know how to do it, because if we don’t do it adequately it won’t work. At least the experience I had was positive, it went well.
|
Hospital Resource and Personnel Limitations
|
UBT Challenges: Resource limitations (time, supplies)
|
• Lack of supplies (Bakri)
• Lack of supplies on hand (condom)
• Time delay
|
Not everyone knows how to place [UBT], the majority of us have never done it, and second because there aren’t any. In the labor area where postpartum hemorrhage happens the condoms and everything to do it are not very available, it takes time to get all the materials. So it’s lost time.
|
Decision-Making Hierarchy
|
Attending Decision-Making
|
• Attendings make the decisions
• Need to involve attendings
• Attendings unfamiliar
|
Attendings in our hospital are not familiar with this suture (B-lynch). So it’s not something we use because when we find ourselves dealing with an obstetric hemorrhage, usually we call the attending to make a decision together, so when an attending doesn’t have experience doing this type of suture they don’t feel comfortable doing it with us, who are in training.
Here [at the conference], as you can see, the residents are getting training. There are only two attendings here, and we’ve done this training before. Each hospital has their own attendings. So part of the issue is that the training needs to be done with the attendings from all the hospitals... they (the attendings) are the ones who have to learn and put [the skills] into practice...It’s not the resident’s responsibility [to make decisions]. It’s our [attending's] responsibility.
|
Hierarchy and lack of trainee autonomy
|
• Residents not responsible for decision-making
• Need to consult attending/superior
|
If you’re a medical student or trainee, it’s not your choice. It’s the attending who makes the decision always. If it’s an emergency situation and they think it would help, they would do it. In the situation I saw, I was a resident helping the attending. I observed but the attending placed the [B-lynch] sutures.
|
Challenging Nature of Emergencies
|
Challenging to learn during emergency
|
• Stressful and difficult to learn in real life
• Hard to learn in an emergency
|
It’s hard to learn in real life when a patient’s life is in danger and there’s such a high level of concern.
|
Emergency decision-making:
Pressure, stress, and fear
|
• Quick decision-making
• Need to be confident
|
I was alone. I was really stressed out. I didn’t do the best job. [In an emergent situation], my instinct would be to do a hysterectomy because I didn’t have time to wait. I didn’t have access to a blood bank. In reality, I couldn’t think about [uterine sparing measures like a B-Lynch].
Again, the fact that [UBT] is not done very often, [the barrier] is fear. It is fear that this technique will not be secure or successful because we don’t have a lot of practice with this [technique]. We have more practice in the OR... I think that the fear is one of the things that prevents us ([which is why] we don’t use [UBT] a lot).
|
Impact of Simulation Training, GO MOMS Program
|
Effectiveness of Simulation for Learning: Safe Practice
|
• Technical aspects of skill
• Introduction of new skills
|
The program is great. The models are really good and help us figure out the technical aspects of these skills.
|
Positive influence of GO MOMS
|
• Seen changes in practice since GO M MOMS
• B-Lynch more common after GO MOMS introduction
|
I think the most powerful thing that you have showed us is the B-lynch. We now are using a lot of more B-lynch. Before this, we really don’t use it. Never.
|
Desire for more training and practice
|
• Need for regular trainings
• More practice wanted
|
We took the course, but we aren’t constantly reinforcing, doing simulation workshops, for example, so I think we are not as comfortable with this method.
|
*”Attending” was translated from the Spanish word for “boss” (“jefe”) |
The qualitative analysis demonstrated that unfamiliarity and time/resource limitations influenced the ability of providers, especially residents and trainees, to implement new procedures (or new ways of doing existing procedures). For example, UBT was a procedure many were familiar with, but due to limited Bakri balloons, lack of supplies on hand, and lack of practice, UBT uptake was a significant challenge. Conversely, B-lynch was more easily implemented given the comfort in the OR and readiness of supplies.
Not everyone knows how to place [UBT], the majority of us have never done it, and second because there aren’t any. In the labor area where postpartum hemorrhage happens the condoms and everything to do it are not very available, it takes time to get all the materials. So it’s lost time.
Multiple interview respondents noted the importance of attendings in decision-making and that decision-making hierarchies impacted procedure implementation. If attending physicians were unfamiliar with a certain procedure, it seemed less likely that residents would be able to implement it.
Attendings in our hospital are not familiar with this suture (B-lynch). So it’s not something we use because when we find ourselves dealing with an obstetric hemorrhage, usually we call the attending to make a decision together, so when an attending doesn’t have experience doing this type of suture they don’t feel comfortable doing it with us, who are in training.
Chart Review
Eighty-two patient charts were analyzed before and after the introduction of GO MOMS training. Table 4 provides characteristics of these patients. Overall, there were more UBTs performed after the introduction of GO MOMS compared to before GO MOMS was introduced, although this difference was not significant (p = 0.06). There was no difference in the number of B-lynch sutures performed before and after the introduction of GO MOMS training.
Table 4
Characteristics of patients with post-partum hemorrhage (pre vs post-GO MOMS training)
Treatment Type for PPH
|
Pre-GO MOMS training (%) (n = 37)
|
Post-GO MOMS Training (%) (n = 45)
|
p-value1
|
|
Blood Transfusion only
|
4 (10.81)
|
5 (11.11)
|
> 0.999
|
|
Blynch
|
4 (10.81)
|
4 (8.89)
|
> 0.999
|
|
Hysterectomy
|
12 (32.43)
|
10 (22.22)
|
0.2991
|
|
UBT
|
0 (0)
|
5 (11.11)
|
0.0608
|
|
Uterine Artery Ligation
|
3 (8.11)
|
3 (6.67)
|
> 0.999
|
|
Other (meds, packing, D&C, etc)
|
22 (59.46)
|
18 (40.00)
|
0.0794
|
Maternal Death
|
0 (0)
|
1 (2.22)
|
> 0.999
|
1p-values calculated using Fisher’s Exact Test or Chi-squared Test |