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Table 4 Themes and illustrative quotes pertaining to themesa

From: Mixed methods evaluation of simulation-based training for postpartum hemorrhage management in Guatemala

Hospital Practice Patterns and Use of Techniques (UBT and 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 •Attending physicians make the decisions
•Need to involve attending physicians
•Attending physicians unfamiliar
Attendingsb 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.
  1. aQuotes represent the viewpoints of participants who had participated in GO MOMS training at least once prior to 2019.
  2. b“Attending” was translated from the Spanish word for “boss” (“jefe”)