Improving Postpartum Haemorrhage Management Using Simulation in Senegal : Midterm Results

Objective: To assess a training approach in Emergency Obstetric and Neonatal Care (EmONC) to strengthen skills of healthcare providers and reduce maternal mortality. Materials and methods: The approach was based on the skills training using the so-called “humanist” method and “life saving skills”. Simulated practice took place in the classroom through thirteen clinical stations summarizing the clinical skills on EmONC. The evaluation was done in all phases and the results were recorded in a database to document the progress of each learner. Results: We trained 432 providers in 10 months. The increase in technical achievements of each participant was documented through a database. The combination of training based on the model “learning by doing” has ensured learning and mastering all EmONC skills particularly postpartum haemorrhage management and reduced missed learning opportunities. Conclusion: The impact of training on postpartum haemorrhage management and maternal mortality is a major challenge in terms of prospects.


Introduction
Maternal mortality, which is the most extreme tip of the existing inequality between women in poor and rich countries, remains very high in sub-Saharan Af-

Preliminaries
The aim of this training was to prepare participants for the The participants were midwives and nurses working in Dakar maternity hospitals in the capital and inland areas, some of which were 800 km from the capital.They were chosen mainly because they worked alone without a doctor.
We obtained the consent of the Ethics Committee of the hospital for this study.We analysed the results obtained in the form of average per evaluation stage (initial, mid-stage and final) and projected on a diagram to assess the ag-Open Journal of Obstetrics and Gynecology gregation.

Pedagogic Acquisition Method
The approach was based on competencies using the "humanist" training modelled by JHPIEGO [1] and the life-saving skills developed since 2007 by the Liverpool School of Tropical Medicine and the Royal College of Obstetricians and Gynaecologists [2].The simulated practice took place in the classroom through clinical stations in which the different clinical skills related to the EONC were developed.At each station, an initial assessment of the participant was carried out, which enabled him to assess his level of competence.A trainer demonstrated competence and then mentored the participant to the master's level.Each participant had to validate the skill on one station before moving on to the next.
A leaflet describing the steps of each clinical procedure allowed the learner to follow the demonstration, to practice and to appreciate its progression.
We present here the results of the competences related to the prevention and the management of the immediate postpartum haemorrhage by uterine atony.
These included the active management of the third stage of labor (AMTSL), the manual removal of the placenta in the case of placental retention, the management of immediate postpartum haemorrhage by uterine atony and the uterine bimanual compression.For each of these skills, a clinical situation was presented; the provider performed the tasks of the competence.At the end of the training in the classroom, two formative supervision visits on the site of each provider made it possible to complete the training in real situations.This article reports the results of the first phase; the visits to the site have not yet been completed.

Teaching Material
Two teaching manuals were used: a reference manual published by the World Health Organization [3] and a trainer's guide developed and validated by the Health Ministry.Numerous anatomical models (Figure 1) as well as equipments and consumables were used to make the clinical situations of the different stations as realistic as possible.

Assessment Method
The theoretical evaluation consisted of the administration of a prior questionnaire and a mid-stage questionnaire.A performance of at least 85% was required.The practical evaluation used a checklist and included an initial, midterm and a final assessment for each skill.A computerized database generating graphs was filled.During the formative supervision on the provider's site, the trainer, using the same checklists, assessed the performance of the provider in real-life situations, thus allowing the database to be filled.The claimant was declared competent after passing the theoretical assessment and practical classroom assessments and during the two formative supervision visits.

Results
A total of 432 providers were trained according to this approach between July and December 2015 after 25 training sessions.
The majority of the participants were midwives (97.4%).The others were nurses.
Mean initial assessment of the 432 participants for AMTSL, manual placenta extraction, management of immediate postpartum haemorrhage by uterine atony and bimanual compression of the uterus were 51.1%, 46%, 29.3% and 17.8% respectively (Figure 2).The average of 85% judged to be minimal to vali-date competence was reached by almost all participants in the mid-term evaluation with an average of 94.5%, 94%, 94.6 and 94.2% for 4 skills respectively.Only those participants who did not validate a competency at the mid-term evaluation (score <85%) resumed the training after a training session.They validated the competence upon obtaining a mark of 85% or more.Figure 3 shows the results of the final evaluation.

Discussion
Obstetricians and midwives face extreme emergencies that need to be managed quickly, efficiently and in a team environment.These situations, which are often   Postpartum haemorrhage, which is the main obstetric complication, was the subject of a station in its most frequent variant: uterine atony.We felt it was more relevant, more frequent and more systematic.Only two out of 432 participants had attained the initial rating for the 15-step skill, using teamwork skills and basic gestures in maternal resuscitation.Participants realized after the demonstration that small gestures could make a difference and that systematization and teamwork were crucial in the management of obstetric emergencies.A study conducted in 2007 showed that training by simulation could highlight the various dysfunctions during obstetric emergencies.The postpartum haemorrhage scenario was repeated within six months and demonstrated an improvement in the management of this complication [8].Birch compared three methods of teaching and training postpartum haemorrhage: courses, simulation and mixed teaching courses and simulation.The scores evaluated were higher after the different courses but better for the mixed method.It is also in this group that one finds the best perception of the theoretical knowledge acquired, the highest level of confidence and the lowest level of anxiety [9].The bimanual compression technique was a new skill for most participants but was easy to master with averages after demonstration reaching easily more than 90%.

Conclusion
The simulated practice ensures the learning and mastery of all the skills of the EONC and minimizes the risks during the practice in patients.The main challenge remains twofold: to document the impact of this training on emergency obstetric care indicators and to integrate this training modality into basic training (medical school, midwifery school).
How to cite this paper: Gueye, M., Diallo, M., Gueye, M.D.N., Gasama, O., Diouf, A.A., Niang, M.M., Diadhiou, M., Niassy, A.C., Gueye, S.M.K., Dieme, M.E.F., Mbaye, M., Moreira, P.M., Diouf, A. and Moreau, J.C. (2017) Improving Postpartum Haemorrhage Management Using Simulation in Senegal: Midterm Results.Open Journal of Obstetrics and Gynecology, 7, 1292-1299.https://doi.org/10.4236/ojog.2017.713132M. Gueye et al.DOI: 10.4236/ojog.2017.7131321293 Open Journal of Obstetrics and Gynecology rica.While the majority of pregnancies and births occur without incident, about 15% of all pregnant women will experience a potentially life-threatening complication requiring skilled care.Haemorrhage is the leading cause.The introduction of the concept of Emergency Obstetric and Neonatal Care (EONC) will contribute to the reduction of maternal and infant mortality and morbidity by better monitoring of pregnancy, childbirth and postpartum, early detection and appropriate treatment of the morbid factors and pathologies encountered, hence the need to strengthen the skills of health workers in this area.Conventional training in EONC often combines theoretical training in the classroom with the limitations linked to the fact that emergencies are not programmable for learning during the training session.The objective of this work was to present an innovative approach to continuing education in EONC, focusing on the management of postpartum haemorrhage in Senegal, the general principle of which was to master essential gestures in simulated practice in classroom before practicing in a real situation, all supported by a continuous evaluation of the performance of the provider.The approach was based on competencies using the "humanist" training modelled by JHPIEGO [1] and the life-saving skills developed since 2007 by the Liverpool School of Tropical Medicine and the Royal College of Obstetricians and Gynaecologists [2].
rare, are serious and must be dealt with by experienced staff.Yet, because of the increasing number of learners and the scarcity of teachers in maternity hospitals, exposure to critical situations has become less frequent.In this study, we identified the inability of some providers to identify obstetric emergencies.Management was affected by the lack of technical skills, but also the importance of interpersonal and interdisciplinary communication problems.Haemorrhage is the most important cause of maternal death in the world.More than half of all GATPA: Active management of the third stage of labor; Extraction manuelle du placenta: Manual removal of the placenta; Hémorragie: Management of immediate postpartum haemorrhage by uterine atony; Compression bimanuelle: Uterine bimanual compression.

Figure 2 .
Figure 2. Distribution of participants according to initial assessment.

Figure 3 .
Figure 3. Distribution of participants according to midterm and final assessments.