Dying during pregnancy, delivery, or soon after having a baby is more common in the U.S. than in any industrialized nation. It's called "maternal mortality," and it's nearly three times more likely for Black women than white women.
To help save lives, a growing number of U.S. hospitals are using obstetric simulation centers where medical teams can practice for life-threatening situations that can happen during labor and childbirth. One of the places doing this is NYC Health + Hospitals/Elmhurst in Queens, NY, which delivers 180 babies in a typical month.
Elmhurst’s Mother-Baby Simulation Center features a specially designed full-body mannequin of color, along with a mannequin infant. The center puts doctors, nurses, and other medical professionals through simulated – but realistic – obstetric emergencies such as maternal hemorrhage, dangerously high blood pressure, sudden cardiac arrest, and emergency C-section. They also train to handle cord prolapse, when the umbilical cord drops through the mom’s cervix into the vagina ahead of the baby, potentially cutting off the baby’s oxygen supply.
Elmhurst serves one of the most diverse communities in the country, with residents from over 100 countries speaking more than 100 different languages in its surrounding neighborhoods, says Frederick Friedman, MD, NYC Health + Hospitals/Elmhurst’s director of OB/GYN Services.
“Our simulation team is very happy that the new mannequin we have to simulate OB complications is a mannequin of color, which is more realistic for our patient population,” Friedman says.
Practicing for a Crisis
At Elmhurst, some simulations are scheduled to prepare new resident physicians for the most common obstetric emergencies. Others come as a surprise, just as a real life crisis can unfold.
“We might come running down the hallway with a ‘patient’ who has a cord prolapse, requiring emergency delivery -- that’s almost always a C-section,” Friedman says. “We’ll yell, ‘Cord prolapse, triage,’ and see how fast we can get the team assembled, how long it takes the anesthesiologist to prepare, how soon we have a scrub nurse ready for surgery,” as if the mannequin “patient” is a real person.
These simulations focus on high-risk situations that don’t happen often, such as severe postpartum bleeding (hemorrhage) or a mother who is having seizures from eclampsia (high blood pressure), Friedman explains. “It’s hard to develop skills in an emergency that might only occur in 1% of cases, where an individual doctor or nurse could go years without encountering it.”
The chance for doctors, nurses, and other medical professionals to gain experience with obstetric emergencies is even lower at hospitals that have fewer deliveries than the busy Elmhurst, says obstetric simulation expert Shad Deering, MD, an OB/GYN professor, specialist in maternal-fetal medicine, associate dean at Baylor College of Medicine, and medical director for simulation at CHRISTUS Healthcare System.
“If you’re doing only 10 deliveries a month, and the risk of postpartum hemorrhage is about 5%, you can go several months to a year without having one,” Deering says. “Obstetric emergencies happen with enough frequency that we really need to be prepared for them -- but not enough, especially in lower-volume places, that the teams get the preparation they need.”
Can practicing with even the most realistic mannequin and simulated emergency situation really improve how a medical team performs when there’s a real person bleeding uncontrollably during delivery?
A number of studies say yes. Simulation training has been shown to:
- Reduce injuries to babies that have shoulder dystocia, in which their shoulders are impacted by the mom's pelvic bones during a vaginal delivery.
- Shorten the time it takes to diagnose cord prolapse and improve its management.
- Reduce the time from deciding that an emergency C-section is needed to delivering the baby.
“Obstetrics is one of the only places in medicine where we have two patients at the same time,” Deering says, referring to the mother and the baby. “This means that we have to very quickly and acutely balance the needs of both patients.”
“Since labor and delivery teams change often, nurses and doctors may not have worked together much before,” Deering says. “We have a constantly rotating team where everyone has to understand their roles and responsibilities and be able to execute them flawlessly at a moment’s notice, when everything is going great until suddenly everything is going wrong.”
Not every hospital can have a large, high-tech simulation lab with expensive, high-quality mannequins. But they don’t necessarily need that kind of a setup, Deering says.
“In a fancy simulation lab, you can ask for blood products and they just show up, which isn’t exactly realistic. But if you’re running a simulation in your regular L&D ward with a relatively inexpensive, mid-range mannequin, you have to run and get your supplies and come back just like you would in reality,” Deering says. “We’ve actually had a situation where we were running an emergency delivery simulation in one room and then were called in to manage the exact same real emergency next door!”
Besides giving labor and delivery teams the opportunity to hone their skills in responding to emergency situations, simulations can help identify specific problems within a hospital’s setup, like access to certain supplies. Understanding how unconscious bias may affect their care decisions is also part of the training.
“When we create simulations, we can build in situations that might help us identify where disparities in care may be, so that we can start to address them,” Deering says. “So it’s not just about ‘Did you give the right medication for hemorrhage?’ but also, ‘How well did you communicate with the patient and family, were there any potential cultural issues you did or didn’t address?’”
As with the new mannequin at Elmhurst Hospital, new obstetric simulators now have more color options, so that hospitals can choose from mannequins with a range of skin tones. “We need these simulators to look like our patients, and now we’re finally able to do that,” Deering says.
He says that every hospital where babies are delivered should have a simulator available to prepare the medical team for emergencies, noting that lower-cost mannequins are available for under $3,000, accompanied by free resources available from the American College of Obstetrics and Gynecology (ACOG) and its “Practicing for Patients” initiative to help make the most of simulation technology.
“To make a real difference in saving the lives of women and their babies, and reduce disparities in care, simulation has to be accessible to everyone and practiced on a regular basis,” Deering says. “We want any size labor and delivery unit in any hospital in the country to be able to do this.”
(For more on maternal mortality, listen to WebMD's Health Discovered podcast episode with Tonya Lewis Lee on her new Hulu documentary, Aftershock.)