Simulation based education for the management
of postpartum hemorrhage
Guatemala City, Guatemala
Maternal Healthcare Worldwide
Maternal mortality is the death of a woman while pregnant or within 42 days of termination
of pregnancy. An estimated 576,000 maternal deaths occurredworldwide in 1990 with over
99% of deaths in developing nations. In 2005, women in Western and Central Africahad a 1
in 17 lifetime risk of maternal death (maternal mortality rate (MMR) 1,100 maternal deaths
per 100,000 livebirths) compared to a risk of 1 in 8,000 for women industrialized. (MMR 8
maternal deaths per 100,000 live births).1
In 2000, the United Nations signed the Millennium Development Goals (MDG) identifying
eight goals toaddress poverty,hunger, disease, education and gender equality. Improving
maternal health was the target of Goal 5. Goal 5A was to reduce by 75% the maternal
mortality ratio between 1990 to 2015. Goal 5B was to achieve, by 2015, universal access to
reproductive health, including antenatal care.2 Toreduce the MMR by 75% over25 years
there wouldneed to be a 5.5% annual decline.1 Between 1990 and 2005, there was a <1%
annual decline in MMR worldwide, however, this value is influenced by sub-Saharan Africa,
where the annual decline was only 0.1% despite accounting for 66% of all maternal deaths.
Between 2005 and 2015 there were improvements in the MMR, with an annual decline of
2.3% .3 Only 9 countries achieved MDG 5. Southern Africa whichhas the lowest MMR in
Africa, actually had an increase in their mortality rate since 1990.3
In keeping with the momentum of the MDG, the United Nations has adopted the Sustainable
Development Goals (SDGs).SDG 3.1 is to reduce the global MMR to less than 70 per 100,000
live births by 2030. Achieving the SDG target of a global MMR below 70 will require
reducing global MMR by an average of 7.5% each year between 2016 and 2030. To increase
healthcare equity, the World Health Organization (WHO) established a supplementary
national target that no country should have an MMR greater than 140 per 100,000 live
births. Methods to achieve these goals include: addressing inequities in access to and
quality of reproductive, maternal, and newborn health care services, ensuring universal
health coverage,addressing all causes of maternal mortality, strengthening health systems
to respond to the needs and priorities of women and girls and ensuring accountability.4
Maternal Healthcare in Guatemala
Guatemala has the highest fertility rate in Central America, with 3.6 children per woman in
2009. Howeverit also has a higher maternal mortality rate compared to the rest of Latin
America. In 1990, Latin America had an MMR of 124 maternal deaths per 100,000 births
compared to Guatemala, which had an MMR of 205 maternal deaths per 100,000 births. 3 In
2005, Guatemala still had a 1 in 71 lifetime risk of maternal death.1 Guatemala was one of
only 17 countries outside of Africawhere maternal morbidity is at least 15 per cent of the
disease burden in reproductive aged women.5
Of the maternal deaths, 70% were
indigenous women,and 46% died
giving birth at home.6 In 41% of
maternal deaths, the health services
did not have the necessary
preparations tohandle the
emergency. Forty-seven percent of
patients had significant barriers to
access of healthcare including lack
of transportation or money to pay
for it.7 The highest mortality rates
area in the Guatemalan Highlands,
called the “corridorof death,” which
is predominantly Mayan.8
Figures: Maternal mortality rates are highest in the rural indigenous regions.
To achievethe Millennium Development Goals, Guatemala created several officesand
programs that address the needs of women and indigenous peoples.9 The National Study of
Maternal mortality identified four delays for patients receiving perinatal care; lack of
awareness of medical emergencies, lack of empowerment for patients to seek help, lack of
transportation to facilities and inability of healthcare facilities to treat medical
emergencies.10 Complicating the issue is that in the indigenous regions of the country
obstetric care is provided by traditional Mayan birth attendants (comadronas or iyoma).
Mayans face language and cultural barriers, as well as a distrust of non-indigenous
(Ladinos) from a history of colonization.In 2010, Guatemala passed the Ley para la
Maternidad Saludable (Law forsafe motherhood) whichaddresses accessibility, equity,
gratuity and respect for multiculturalism in maternal health. Included in the law are a right
for “respect forcultural identity, values and customs of the indigenous communities” and “a
transition program forthe training of iyomatrained and certified at a technical level”.11
When Mayans do choose to seek Western medicine they typically only have access to health
posts that are run by auxiliary nurses or medical students. These government health posts
are more accessible and significantly cheaper than hospitals.12 Only 7% of Mayans report
consulting a doctoror hospital. In an effortto improve Mayan healthcare utilization, efforts
have been made to make healthcare more culturally sensitive. One example of this is Casa
Materna, a free program for high-risk pregnancies that partners with the local Mayan
community. At Casa Materna an auxiliary nurse performs most deliveries. The auxiliary
nurse is Mayan, from the local municipality, and speaks the local Mayan dialect and is
trained in the activemanagement of the third stage of labor, withan obstetrician available
as backup.13 Casa Materna has noticeably increased prenatal and postpartum in the Mayan
Seventy-six percent of Mayan people live in extreme poverty and health care expenditures
is less than 2.5 % of the gross domestic product.11 Lackof healthcare spending is a major
contributor to the high maternal mortality rate, as healthcare is not affordableor accessible.
In 2009, Guatemala adopted the Mi Familia Progresa program to help achieve MDG 5. The
program provides conditional cash transfers of up to 300 quetzales (US$40) per month to
pregnant mothers in fiveof the highest risk municipos provided the pregnant women agree
to preventive maternal-child health care services.14 The program saw increases in prenatal
coverage but the impact of payments on maternal mortality has not yet been evaluated.
Additionally, governmental health posts, while often poorly staffedand stocked, are
available free of charge.
While Guatemala did not achieve MD5
it is classified as “Making Progress”
having a 3.4% annual decrease in
maternal mortality since 1990,
compared to Latin America as a whole
whichonly had a 2.9% change.3
Guatemala is now on trackto achieve
MDG 5 between 2026-2030, while the
rest of Central America willnot achieve
MDG 5 until after 2040.15
Postpartum hemorrhage (PPH)isthe leading cause of
maternal mortality in low-income countries and the
primary cause of nearly one quarter of all maternal
deaths globally.16 PPHis the cause of almost half of
maternal deaths in Guatemala. The majority of PPH
cases can be avoided by activemanagement of the
third stage of labor including the use of prophylactic
uterotonics at the time of delivery. Of the 452
maternal deaths that occurredin Guatemala in 2013,
90 percent were preventable.17 Studies have shown
only 50% of providers perform an activemanagement of the third stage of labor.18
The WHO developed a list of 32 recommendations for the prevention of postpartum
hemorrhage including recommendations on uterotonics, uterine balloon tamponade and
surgical management of PPH.Recommendation 31 was that “the use of simulations of PPH
treatment is recommended forpre-service and in-service training programmes.” The
guideline developers place a high value on simulation-based education, including both hi-
tech and low-techprograms.16
Healthcare in Guatemala
Healthcare in Guatemala is divided into multiple sectors: public, private non-profitand
private for-profit. The public sector is Minesterio de Salud Publicay Asistencia Social
(MSPAS).Only 25% of Guatemalans have some form of health insurance and MSPAS is
expected to provide coveragefor the remaining 75% of the population free of charge.
MSPAS only receives a budget of 1% of the GDP and is subject to shortages. In reality only 3
out of 10 people below the poverty line seek any care 40% of the population has no access
There are multiple private non-profit sectors. IGSS (Guatemalan Social Security Institute)
insures government employees that pay into the system. Approximately 17% of the
population is covered by IGSS. Healthcare expenditure forIGSS is 5 times higher per capita
than forMSPAS. The Sistema Integrado de Atención a la Salud (SIAS) contracts withprivate
providers to provide healthcare in remote rural areas that have no access to health facilities.
Members of the armed forcesare covered through Sanidad Militar. Only 5% of the
population is covered by private for-profitinsurance. The majority of these patients (83%)
pay out of pocketfor their care.
Medical Workforcein Guatemala
Undergraduate medical education in Guatemala is a total of 7 years. There is one public
university and fourprivate universities offeringa medical degree, which are all located in
Guatemala City, Guatemala. There are several recently created satellite programs; three
are in Alta Verapaz, twoare in Quetzaltenango, and one is in Chiquimula. Cuba’s Latin
American Schoolof Medicine also trains students from Guatemala.7 The public university
Facultad de Ciencias Médicas de a Universidad de San Carlos de Guatemala is the oldest and
largest medical school. In the sixth year of medical education, medical students are
required to perform their EjercicioProfesionalSupervisado (EPS),whichhas a six-month
long rural program in whichstudents are stationed at 18 health posts throughout
Guatemala, encompassing 50,000 inhabitants.19 At private medical schoolssuch as the
Universidad Francisco Marroquin, the students also rotate at rural health centers. At the
student-run Barbara Health center in San Juan Sacatepéquez, students have a program to
reduce maternal and child morbidity and mortality rates. The students are supported by an
ancillary staff of midwives and community advocates and develop training plans forthe
staff. Health indicators such as maternal mortality, infant mortality and others have been
improved as a result of the presence of this program.20
The obstetrics and gynecology residency is four years total. The first year is internship year.
Years two and three are spent at the residency teaching hospital. The final year of residency
is spent workingin the community. The majority of resident physicians are trained in
Guatemala City, Guatemala, with 824 out of 1525 MSPAS residents workingat just two
hospitals within the city.
In Guatemala in 2010, there were 16,043 licensed physicians, 9,447 of whom were working
in the profession. There is 11 physicians per 10,000 population overallin Guatemala, but
they are not evenly distributed geographically. In Guatemala city there are 36.1 physicians
per 10,000 population, whereas smaller departments such as Quiche´, has 1.4 physicians
per 10,000 population. Roughly 70% of all physicians are concentratedin Guatemala City.
The Ministry of Public Health has struggled to fill temporary positions in rural areas,
particularly in departments such as Quiche´ and Solola´. Given the difficulties in finding
doctors to provide ambulatory services in the Extension of Coverage Program, the
Ministry began to contract nurses forthese positions.
PART 2: GO MOMS SIMULATION
GO MOMS is a simulation based educational program on postpartum hemorrhage developed
by Kay Daniels, MDand colleagues. A major goal of the program is to demonstrate fertility-
sparing methods to control postpartum hemorrhage, in order to limit the number of
hysterectomies. Of the residents surveyed, almost
half said they perform postpartum hysterectomies
occasionally or more frequently.The GO MOMS
program consists of twolectures on postpartum
hemorrhage and misoprostol. Then the
participants are divided into groups and perform
simulations of B-Lynchsutures and uterine balloon
tamponade. Finally, the participants have a
practical simulation on PPHusing the wearable
MamaNatalie birthing simulator, shown at the
Dr. Daniels presented the program to an ACOG affiliatein Central America (CAFA) and was
approached by Dr. Edgar Herrarte whoworkswith obstetrics and gynecology resident
education at the IGSS hospital in Guatemala City, Guatemala. The primary goal of the GO
MOMS program was to perform the PPHsimulation to faculty and residents, to shadow
physicians at the local hospital, and to make introductions with the faculty for future site
visits. Secondary goals were to understand the Guatemalan healthcare system, obtain basic
information on how obstetrics and gynecology is practiced at the hospital, and identify
potential education gaps for future site visits. Four attending obstetrician gynecologists,
one resident and one Spanish translator traveled to Guatemala City in November 2016 to
teach the GOMOMS simulation to approximately 50 IGSS attending and resident physicians
over three days. Additionally, the GO MOMS teams performed a needs assessment
questionnaire forthe site and were allowed to shadow at the IGSS hospital Labor and
PART 3: NEEDSASSESSMENT:
The GO MOMS simulation was one of many possible simulations that can be easily
performed. One of the goals of the program was to perform a needs assessment for future
simulation based education at IGSS. Below are results from a questionnaire given to all GO
Activemanagement of third stage of labor
Most residents are very comfortablewith
activemanagement of the third stage of
labor. Residents have oxytocin,
methylergonovine and misoprostol
available, similar to the United States. The
IGSS pharamacy does not carry
prostoglandin F2 alpha, which is the only
uterotonic that can be redosed during the
management of postpartum hemorrhage in
the United States. At IGSS, methylergonovine can be given 0.125 mg IV every 5 minutes for
up to 5 doses. Guatemala also has carbetocin that is a longer acting analogue of oxytocin.
Misoprostol, a cheap, readily available, and effectiveuterotonic withminimal side effects, is
not readily available in Guatemala due to concerns it will be used as an abortifacent.
One third of residents (16 of 43 residents) stated that they had never practiced or observed
a B-Lynchsuture. The remaining residents said that they only used it very rarely.
To simulate a B-Lynchcompression suture we used models made of neoprene sewn
together to make a pouch.The teaching points of the B-Lynchstation were to have tactical
muscle memory in performing a B-Lynchsuture as well discuss the indications forB-Lynch
and correctsuture material.
Uterine Balloon Tamponade
The Bakri balloon system is commonly used in the United States to perform uterine balloon
tamponade. The costof a Bakri balloon is US $250 and is unavailable in developing
countries. As such, a majority of residents at IGSS had never used or even
seen a Bakri balloon. A cheaper alternative to the Bakri balloon is the
condom balloon, proposed by Akhter and colleagues in 2003.21 The
purpose of this simulation was to demonstrate the condom uterine
balloon as a cheap, safe and easy alternative management to postpartum hemorrhage.
The condom balloon tamponade is made from a condom, a foley catheter, a piece of string
or spare suture and sterile water or saline. The total cost of the device is less than US $5.
Using the neoprene vaginal models we had residents practice making and filling condom
Uterine Artery Ligation
Uterine artery ligation, or an “O’Leary
stitch” requires a laparotomy and is most
frequently used in cesarean section to
prevent PPH.The IGSS residents were
comfortably withO’Leary stitches and
practiced on the model uterus.
Operative Vaginal Delivery
The average cesarean section rate at IGSS in 2013 was 46%, with some providers having up
to 79% rate of cesarean section. Operative vaginal delivery is limited to the private sector.
Obstetric vacuums are not available at IGSS and two-thirdsof residents have never seen a
vacuum delivery.Obstetric forceps are available at IGSS but rarely used and are limited to
the private sector. One half of residents stated they had never practiced forceps deliveries.
Vaginal Hysterectomy and Urogynecology
GO MOMS TEAMhas developed a simulation based training course of vaginal hysterectomy
called GO GYN. Vaginal hysterectomy is the preferred minimally invasive method in
appropriately selected candidates. The course also simulates pessary fitting for pelvic organ
prolapse. Vaginal hysterectomy is taught to all residents at IGSS but resident experience
varies based on year of training. Most residents have not offered pessary to their patients.
Urinary incontinence is treated with Kegel exercises, oxybutynin or transobturator tape
(TOT).Vaginal prolapse is treated with hysterectomy or anterior and/or posterior
Most residents at IGSS are comfortable withcervicaldysplasia and colposcopy by the end of
their residency training. All residents report regularly performing Pap smears.
PART 4: SHADOWING
On the final day of the GO MOMS
simulation program the faculty and housestaff at IGSS invited a member of the GO MOMS
team to observe the Labor and Delivery Unit overnight. That night was a reportedly slow
night with 14 vaginal deliveries and 11 cesarean sections in 12 hours. Additionally multiple
postpartum tubal ligations were performed. Anecdotally, IGSS is the largest birthing
hospital in Central America and this high volume significantly influences their healthcare
A laboring woman delivering at IGSS first presents to a triage area. Approximately 100-150
triages are seen per day.Once it is determined that a patient is in active labor (>4cm
dilation) she is then transferred to the laboring room where there is a line of 16 beds with
women in various stages of labor. Given the high volume and limited space, patients are
expected to follow along a normal labor curveand progressing normally on oxytocin.
Oxytocindose is limited to 10 mu/min. Fetal monitoring is intermittent. The only induction
agents available are vaginal dinoprostone and foley balloons. Patients are allowed 12 hours
of induction time to achieve
Once the patient reaches the second stage and labors downshe is transferred across the hall
to the delivery rooms. Again, the patient is expected to follow a normal labor curve and if
labor is protracted she is recommended for cesarean delivery.Vacuum is unavailable and
forceps are not practical because adequate anesthesia is not available. Fundal pressure is
used in the second stage. Mediolateral episiotomy is standard for nulliparous women.
There were up to fiveoperating rooms being used overnight. Cesarean sections are
performed via Pfannenstiel incision. All gowns and drapes are made of reusable cloth. The
uterus is not exteriorized. All layers (including peritoneum and rectus muscles) are closed.
Nylon suture is used for the skin.
Postpartum is a shared space with up to 10 beds per room. Vaginal deliveries are
discharged postpartum day 1. Cesarean sections are discharged post-operative day 2.
PART 5: CONCLUSIONS
The staff and housestaff at IGSS were extremely welcomingand receptive to the GO MOMS
simulation based training. Obstetrics and gynecology education and training has many
similarities to training in the United States. The staff and housestaff provide evidence-based
health care favoringthe same resources (e.g. uptodate.com) used in the United States.
Differencesin practice are mainly due to cost ( Bakri, vacuum) or cultural preference
On the needs assessment questionnaire, many residents commented on their desire to learn
B-Lynchand uterine tamponade balloon. After shadowing Labor and Delivery,howeverthe
usefulness of the GO MOMS intervention at IGSS may be limited. Due to the high patient
volume and limited facilities, patients withany signs of labor dystocia are recommended to
have a cesarean section. This reduces the risk factors forpostpartum hemorrhage including
prolonged first and second stages, use of multiple induction agents, operative vaginal
delivery and chorioamnionitis. The high rate of cesarean section, however,is concerning for
developing morbidly adherent placenta whichis a cause of massive, life threatening PPH.
The IGSS hospital has a blood bank in case of emergency.
The goals of the GO MOMS trip were to perform a simulation based educational program,
collecta needs assessment, and establish a collaborative relationship forfuture site visits.
Based on the needs assessment, there is a role for future simulation based training at IGSS
in operative vaginal delivery and vaginal hysterectomy/urogynecology. At future IGSS visits
there is also a plan to review which PPHmanagement options are being implemented and
whichneed further simulation. Future GO MOMS simulations should target residents at the
public hospitals or medical students starting their EPSrural rotation—as these trainees
may likely manage postpartum hemorrhage in a nonhospital setting.
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