Management Of Postpartum Hemorrhage Research Articles

Quantification of blood loss in obstetric haemorrhage: implications on intervention and transfusion

Key content Postpartum haemorrhage accounts for 27% of all maternal deaths. Incorrect quantification of blood loss can lead to unnecessary interventions, such as the transfusion of blood products, which is not without risk. During pregnancy, cardiovascular changes may explain how blood loss can occur rapidly, with pregnant women tolerating large volumes of blood loss before a change in clinical signs is seen. Several methods are used to quantify blood loss, such as visual estimation, volumetric, gravimetric, colorimetric and photometric. The Obstetric Bleeding Strategy for Wales (OBS Cymru) project, which standardised management of obstetric haemorrhage in Wales using a four‐stage approach, showed a statistically significant improvement in outcomes. Different definitions of postpartum haemorrhage make it difficult to compare available evidence. Further studies are required combining the use of point‐of‐care tests and quantitative techniques to help improve morbidity and mortality associated with obstetric haemorrhage. Learning objectives To understand the physiological changes in pregnancy and how they affect postpartum haemorrhage. To know the different available methods of quantifying blood loss. To review the point‐of‐care tests used to guide transfusion and management of postpartum haemorrhage. Ethical issues Understanding the advantages and disadvantages of different methods of quantifying blood loss is essential to providing appropriate and safe care. Inaccuracy in measurement increases the risk of morbidity and mortality, in addition to complications of unnecessary treatments.

A Clinical Study on Management of Major Primary Postpartum Haemorrhage at Tertiary Care Centre

Introduction Postpartum Haemorrhage (PPH) remains one of the leading causes of maternal morbidity and mortality worldwide . It is estimated that about one quarter to one half of preventable maternal deaths are because of haemorrhage . It is defined by the royal college of obstetrician and gynaecologist ( RCOG) as blood loss from the genital tract within the first 24 hours after birth of at least 500ml ( minor) and at least 1000ml ( major)Early transfusion of blood and blood products prevent from developing coagulopathy . Causes of post-partum haemorrhage (PPH) are commonly ascribed to the four Ts (tone, trauma, tissue, 4 thrombin). Uterine atony is responsible for most of cases . Aims and objectives 1. To know the current clinical practice in management of major primary postpartum haemorrhage at tertiary care centre 2. To evaluate the causes of major primary postpartum haemorrhage Methodology This study aimed to assess the clinical practices used by Pannadhay Mahila Hospital, Udaipur. in managing major PPH. A retrospective study of the management of PPH over a period of 2 months from march 2023 to april 2023 was carried out. The Following criteria were examined: history of previous PPH causes of PPH, use of oxytocin in the first stage for more than 6 hours. role of blood transfusion, presence of senior faculty, and type of uterotonics used. Results: a total of 50 patients were diagnosed with major PPH among which 26 had caesarean delivery. Two major risk factors were analysed, one was Use of oxytocin in first stage for more than 6 hours and History of previous PPH. Uterine atony was commonest cause in 64% of cases followed by retained product of conception. Use of uterotonics were analysed among the patients which was consistent with current practice guideline. Conclusion: This study indicates that the management of women with major PPH in Pannadhay Mahila Hospital Udaipur is consistent with the current clinical practice. Uterine atony is responsible for most of cases. Early, aggressive, and coordinated intervention by health care professionals is critical in minimizing blood loss to ensure optimal clinical outcomes in management of women with major PPH

The impact of the Safe Delivery Application on knowledge and skills managing postpartum haemorrhage in a low resource setting: a cluster randomized controlled trial in West Wollega region, Ethiopia

BackgroundPostpartum haemorrhage is one of the leading causes of maternal mortality in low-income countries. Improving health workers' competencies in obstetric emergencies in low-income settings, has been recognized as an important factor in preventing maternal mortality and morbidity. mHealth interventions in maternal and newborn health care has shown the potential to improve health service delivery. Strong study designs such as randomized controlled trials are missing to estimate the effectiveness of the mHealth interventions.MethodsBetween August 2013 and August 2014, 70 health facilities in West Wollega Region, Ethiopia were included and randomized to intervention or control in a cluster randomized controlled trial. At intervention facilities birth attendants were provided with a smartphone with the SDA installed. Of 176 midwives and “health extension workers,” 130 completed at 12 months follow-up. At baseline and after 6- and 12-months participants were assessed. Knowledge was tested by a Key Feature Questionnaire, skills by an Objective Structured Assessment of Technical Skills in a structured role-play scenario.ResultsBaseline skills scores were low and comparable with a median of 12/100 in the intervention and the control group. After 6 months skills had doubled in the intervention group (adjusted mean difference 29.6; 95% CI 24.2–35.1 compared to 1·8; 95% CI – 2.7 to 6.3 in the control group). At 12 months skills had further improved in the intervention group (adjusted mean difference 13.3; 95% CI 8.3–18.3 compared to 3.1; 95% CI – 1.0 to 7.3 in the control group). Knowledge scores also significantly improved in the intervention group compared to the control (adjusted mean difference after 12 months 8.5; 95% CI 2.0–15.0).ConclusionThe Safe Delivery App more than doubled clinical skills for managing postpartum haemorrhage among birth attendants making it an attractive tool to reduce maternal mortality.Trial registration: Clinicaltrial.gov Identifier NCT01945931. September 5, 2013.

Improving blood product management in placenta accreta patients with severe bleeding: institutional experience

BackgroundPlacenta accrete spectrum (PAS) is a significant risk factor for postpartum hemorrhage and effective blood product management is critical in ensuring patient safety. In PAS patients undergoing cesarean section (CS) blood transfusion management guided by the combined clinical experience of the anesthesiologist and surgeon with point-of-care coagulation testing appears safe and effective. We describe and evaluate our experience and identify potential areas for improvement with blood product management in this patient population. MethodsA retrospective chart review of peri-operative demographic, anesthetic, and obstetric data was conducted for all patients with PAS undergoing CS between 2012 and 2018 at our center. To facilitate a practical evaluation of blood product management, we divided patients into two groups based on the severity of bleeding. ResultsA total of 221 parturients with PAS underwent CS, with 133 in group 1 requiring excessive amounts of transfusion and 88 in group 2 requiring management similar to other uncomplicated CS cases. There were no deaths or instances of disseminated intravascular coagulation, and intensive care unit admission occurred in five cases (2.2%). Patients in group 1 had higher mean nadir values of intra-operative hemoglobin and platelet count. We observed a high rate of missing data for peri-operative measurement of lactate and fibrinogen, PAS grade documentation, and temperature monitoring. ConclusionGiven no significant morbidity or mortality, clinical judgment in experienced centers appears safe for the management of PAS patients undergoing CS. The adoption of an institutional protocol and point-of-care coagulation testing could decrease over-transfusion and associated complications.

Effect of the postpartum hemorrhage intervention package implementation in a fourth-level hospital in Latin America.

To evaluate the effectiveness of the implementation of intervention packages for postpartum hemorrhage (PPH) management in pregnant women hospitalized in a High Obstetric Complexity Unit in a Latin American country. Retrospective cohort study including pregnant women with PPH attended between January 2011 to December 2019. Three periods of time were defined according to management strategies We performed univariate and multivariate robust Poisson regression logistic models for each of the outcomes derived from each period. We included 602 patients. There was a reduction in period 3 of the incidence of massive PPH (16% versus 12% P < 0.001, relative risk [RR] 0.61, 95% confidence interval [CI] 0.44-0.85; P = 0.003), major surgery (24%, 13%, 11%, P = 0.002, RR 0.54, 95% CI 0.33-0.883; P = 0.014), and admission to the intensive care unit (ICU) (14%, 7%, 6.1%, P = 0.0, RR 0.40, 95% CI 0.17-0.96 P = 0.00). The implementation of PPH intervention packages in a hospital in a middle-income country from Latin America, led to a significant decrease in the incidence of massive bleeding, the rate of major surgery, and the ICU stay of pregnant women affected by this condition.

Review of Current Insights and Therapeutic Approaches for the Treatment of Refractory Postpartum Hemorrhage.

Refractory postpartum hemorrhage (PPH) affects 10-20% of patients with PPH when they do not respond adequately to first-line treatments. These patients require second-line interventions, including three or more uterotonics, additional medications, transfusions, non-surgical treatments, and/or surgical intervention. Multiple studies have suggested that patients with refractory PPH have different clinical characteristics and causes of PPH when compared to patients who respond to first-line agents. This review highlights current insights into therapeutic approaches for the management of refractory PPH. Early management of refractory PPH relies on both hypovolemic resuscitation and achievement of hemostasis, with an emphasis on early blood product replacement and massive transfusion protocols. Transfusion needs can be more rapidly and accurately identified through point-of-care tests such as thromboelastography. Medical therapies for the treatment of refractory PPH involve treatment of both uterine atony as well as the underlying coagulopathy, with the use of tranexamic acid and adjunct therapies such as factor replacement. The principles guiding the management of refractory PPH include restoring normal uterine and pelvic anatomy, through the evaluation and management of retained products of conception, uterine inversion, and obstetric lacerations. Intrauterine vacuum-induced hemorrhage control devices are novel methods for the treatment of refractory PPH secondary to uterine atony, in addition to other uterine-sparing surgical procedures that are under investigation. Resuscitative endovascular balloon occlusion of the aorta can be considered for cases of critical refractory PPH, to prevent or decrease ongoing blood loss while definitive surgical interventions are performed. Finally, for patients with critical hemorrhage resulting in hemorrhagic shock, damage control resuscitation (a staged surgical approach focused on restoring normal physiologic recovery and maximizing tissue oxygenation prior to proceeding with definitive surgical management) has been shown to successfully control refractory PPH, with an overall mortality decrease for obstetric patients.

Postpartum haemorrhage in high-resource settings: Variations in clinical management and future research directions based on a comparative study of national guidelines.

To compare guidelines from eight high-income countries on prevention and management of postpartum haemorrhage (PPH), with a particular focus on severe PPH. Comparative study. High-resource countries. Women with PPH. Systematic comparison of guidance on PPH from eight high-income countries. Definition of PPH, prophylactic management, measurement of blood loss, initial PPH-management, second-line uterotonics, non-pharmacological management, resuscitation/transfusion management, organisation of care, quality/methodological rigour. Our study highlights areas where strong evidence is lacking. There is need for a universal definition of (severe) PPH. Consensus is required on how and when to quantify blood loss to identify PPH promptly. Future research may focus on timing and sequence of second-line uterotonics and non-pharmacological interventions and how these impact maternal outcome. Until more data are available, different transfusion strategies will be applied. The use of clear transfusion-protocols are nonetheless recommended to reduce delays in initiation. There is a need for a collaborative effort to develop standardised, evidence-based PPH guidelines. Definitions of (severe) PPH varied as to the applied cut-off of blood loss and incorporation of clinical parameters. Dose and mode of administration of prophylactic uterotonics and methods of blood loss measurement were heterogeneous. Recommendations on second-line uterotonics differed as to type and dose. Obstetric management diverged particularly regarding procedures for uterine atony. Recommendations on transfusion approaches varied with different thresholds for blood transfusion and supplementation of haemostatic agents. Quality of guidelines varied considerably.

Baseline rotational thromboelastometry (ROTEM) values in a healthy, diverse obstetric population and parameter changes by pregnancy-induced comorbidities

Background Point-of-care testing provides a representation of the patient’s coagulability status during effective postpartum hemorrhage management. Baseline values of rotational thromboelastometry (ROTEM) have not yet been reported in a heterogeneous obstetric population. This study aimed to establish a baseline for a diverse population representative of the United States. The secondary aim was to evaluate the association of these hematologic parameters with comorbidities, race, and socioeconomic factors. Methods The study was a retrospective review of collected ROTEM values of women undergoing vaginal or cesarean delivery with a history of or at risk for postpartum hemorrhage. Patients were divided into healthy and comorbid groups. Exclusion criteria for both groups included active or recent bleeding, receipt of blood products or clot-enhancing factors, and liver disease. Mean values of ROTEM by race and comorbidities were included. Median values were reported for intrinsic pathway thromboelastometry (INTEM), extrinsic pathway thromboelastometry (EXTEM), and fibrin polymerization thromboelastometry (FIBTEM) amplitude at 10 minutes (A10) and 20 minutes (A20), coagulation time, clot formation time, and maximum clot firmness. Results A total of 681 records were reviewed; 485 met inclusion criteria, and 267 met healthy criteria. The mean (standard deviation) demographics for maternal age (years), body mass index (kg/m2), and gestational age (weeks) were 32.2 (5.7), 34 (7.3), and 35.4 (5), respectively. The median INTEM, EXTEM, and FIBTEM A10 were 63, 65, and 23 mm. The mean for INTEM, EXTEM, and FIBTEM A10 was increased for those who were Black or obese, whereas a decreased FIBTEM and EXTEM A10 was noted in those who were Asian or those who had the hemolysis, elevated liver enzymes, low platelet syndrome. Conclusions Our heterogeneous population presents ROTEM values within the interquartile range of those previously reported in European studies. Black race, obesity, and preeclampsia were associated with hypercoagulable profiles.

Automated Alert System of Second-Line Uterotonic Drug Administration.

Multidisciplinary team management of postpartum hemorrhage (PPH) is needed to optimize care and improve outcomes. Lucile Packard Children's Hospital, Stanford, is a tertiary referral center with 4600 deliveries/y (>70% high-risk deliveries), and there have been times when the obstetric anesthesia team was alerted late or not at all for PPHs. Introduction of an automated alert process to the obstetric anesthesia team when a second-line uterotonic drug was administered has ensured prompt evaluation. Utilization of this automated drug alert system has improved communication and reduced failure to inform the obstetric anesthesiology team of PPH after vaginal and cesarean deliveries.

Binational confidential enquiry of maternal deaths due to postpartum hemorrhage in France and the Netherlands: Lessons learned through the perspective of a different contextof care.

To learn lessons for maternity care by scrutinizing postpartum hemorrhage management (PPH) in cases of PPH-related maternal deaths in France and the Netherlands. In this binational Confidential Enquiry into Maternal Deaths (CEMD), 14 PPH-related maternal deaths were reviewed by six experts from the French and Dutch national maternal death review committees regarding cause and preventability of death, clinical care and healthcare organization. Improvable care factors and lessons learned were identified. CEMD practices and PPH guidelines in France and the Netherlands were compared in the process. For France, new insights were primarily related to organization of healthcare, with lessons learned focusing on medical leadership and implementation of (surgical) checklists. For the Netherlands, insights were mainly related to clinical care, emphasizing hemostatic surgery earlier in the course of PPH and reducing the third stage of labor by prompter manual removal of the placenta. Experts recommended extending PPH guidelines with specific guidance for women refusing blood products and systematic evaluation of risk factors. The quality of CEMD was presumed to benefit from enhanced case finding, also through non-obstetric sources, and electronic reporting of maternal deaths to reduce the administrative burden. A binational CEMD revealed opportunities for improvement of care beyond lessons learned at the national level.

Effectiveness of Laqshya Guideline regarding Emergency Prevention and Management of Postpartum Haemorrhage (PPH) in Terms of Knowledge and Skills among Nursing Officers Working in Selected PHC &amp; CHC and District Hospital of Gurugram

Effectiveness of Laqshya Guideline regarding Emergency Prevention and Management of Postpartum Haemorrhage (PPH) in Terms of Knowledge and Skills among Nursing Officers Working in Selected PHC &amp; CHC and District Hospital of Gurugram

Interventions of Postpartum Hemorrhage.

Postpartum hemorrhage is a common and potentially life-threatening obstetric complication, with successful management relying heavily on early identification of hemorrhage and prompt intervention. This article will review the management of postpartum hemorrhage, including initial steps, exam-specific interventions, medical therapy, minimally invasive, and surgical interventions.

P46 Impact of simulation training of external aortic compression and uterine massage on management of postpartum haemorrhage: a study in Addis Ababa

P46 Impact of simulation training of external aortic compression and uterine massage on management of postpartum haemorrhage: a study in Addis Ababa

Evaluating the Effect of Interdisciplinary Simulation Training on Provider Comfort in the Management of Postpartum Hemorrhage (PPH) in a Low-Resource Setting [ID: 1363496

INTRODUCTION: Maternal mortality from postpartum hemorrhage (PPH) can be reduced through timely management. Interdisciplinary simulation-based training (SBT) has been shown to improve team response to PPH, but SBT is not widely available in low-resource settings. The purpose of this study is to assess the acceptability of SBT and its effect on interdisciplinary personnel’s self-efficacy in a low-resource setting. METHODS: A pilot low-fidelity PPH SBT program using PRONTOPack was conducted from November 2021 to September 2022 after an initial audit revealed inadequate training at a public teaching hospital with the highest national maternal mortality rate in the Dominican Republic. Thirty interdisciplinary providers were trained in two cohorts. Self-efficacy was assessed via anonymous, postsimulation surveys. RESULTS: One hundred percent of providers reported that the SBT was an effective form of training that will help them manage PPH in the future. In the first cohort (n=7), providers reported high comfort with their teamwork (4.57/5 S 0.49) and communication skills (4.29/5 S 0.45) after SBT. In the second cohort (n=23), 100% of trainees agreed that SBT improved their ability to communicate effectively, work in teams, and manage PPH. CONCLUSION: Low-fidelity interdisciplinary SBT was found to be useful in improving trainees’ self-perceived nontechnical skills in the management of PPH. Most notably, communication skills were improved between providers that routinely manage real-time PPHs in clinical practice. Next steps are to integrate and standardize SBT into the obstetric department’s workflow to train all personnel managing PPHs.

Recent Trends in Tranexamic Acid Use During Postpartum Hemorrhage in the United States [ID: 1380480

INTRODUCTION: The United States has one of the highest rates of maternal mortality among developed regions, and postpartum hemorrhage (PPH) accounted for 14% of all pregnancy-related deaths between 2017 and 2019. Several large studies have demonstrated decreased PPH rates with the use of tranexamic acid (TXA). Consensus has not yet been reached on the when to administer use of TXA. Little data exist regarding the prevalence of TXA use in obstetric patients with and without PPH. METHODS: Using a national database, we identified over 1.2 million pregnancies between January 1, 2015, and June 30, 2021. Pregnancy and delivery information was abstracted using ICD-10 codes. The GW Institutional Review Board approved the study protocol and waived the requirement for patient informed consent. RESULTS: Overall, TXA was used 1% of the time (12,394/1,262,574), and there was a fivefold increase in TXA use (0.5–2.5%) during the study period. Patients had similar demographic characteristics. Tranexamic acid use differed by geographic region. The use of TXA increased in both patients with PPH and those without. There was a greater increase in the number of patients who received TXA for prophylaxis of PPH than those who received it as treatment of PPH. CONCLUSION: This is the largest U.S. observational study to examine patterns of TXA use in obstetrics. Tranexamic acid was only administered in approximately 10% (4,586/43,928) of cases of PPH. This represents an opportunity to increase awareness for the role of TXA in management and prevention of PPH.

Maternal and Neonatal Outcomes in Pregnancies With Adenomyosis [ID: 1375447

INTRODUCTION: Adenomyosis is a common gynecologic disease involving the uterus with effect on pregnancy being poorly understood. This study aimed to evaluate the associations between adenomyosis and obstetrical and newborn outcomes. METHODS: Using the Healthcare Cost and Utilization Project–National Inpatient Sample from the United States, we conducted a retrospective cohort study of all birth-related admissions from 2016 to 2019. Pregnancies with adenomyosis were identified using the ICD-10 code N80.0, with the remaining pregnancies being the reference group. Multivariate logistic regression models, adjusting for baseline maternal demographics, were used to determine the effect of adenomyosis on pregnancy outcomes. In light of the diagnosis bias inherent in births by cesarean delivery, adjustment for mode of delivery was performed on all outcome analyses. RESULTS: Among the 2,943,532 women who delivered between 2016 and 2019, 1,084 had adenomyosis, for an overall prevalence of 36 cases per 100,000 births, which was stable throughout the study period. Adenomyosis in pregnancy was associated with increased frequency of placenta abruptio (odds ratio 1.67, 95% CI 1.17–2.39), preterm delivery (1.36, 1.16–1.59), preterm premature rupture of membranes (1.31, 1.07–1.61), postpartum hemorrhage (2.65, 2.14–3.27), postpartum transfusion (2.20, 1.62–2.99), disseminated intravascular coagulation (9.31, 4.15–20.92), sepsis (2.67, 1.60–4.45), congenital anomalies (1.95, 1.34–2.84), and intrauterine fetal demise (1.98, 1.02–3.84). CONCLUSION: Adenomyosis in pregnancy is associated with adverse obstetric and fetal outcomes. Pregnancies in patients with adenomyosis should be considered at higher risk and may benefit from delivering in centers capable of managing postpartum hemorrhage.

P28 Transforming postpartum haemorrhage management in a large tertiary obstetric unit: successes and challenges so far

P28 Transforming postpartum haemorrhage management in a large tertiary obstetric unit: successes and challenges so far

A CASE OF POSTPARTUM HEMORRHAGE DUE TO PLACENTA ACCRETA DIAGNOSED BY ANATOMOPATHOLOGY EXAM

Placenta accreta is a rare but potentially life-threatening condition in which the placenta invades the myometrium of the uterus. It is more common in women with a history of previous cesarean delivery, placenta previa, or uterine surgery. The diagnosis of placenta accreta can be challenging and is often madeintraoperatively or postoperatively. A 36-year-old gravida 4 para 3 woman presented with postpartum hemorrhage due to placenta accreta that was diagnosed by an anatomopathology exam. The management of postpartum hemorrhage typically involves several steps to stabilize the patient and control bleeding. In this case, the patient was resuscitated with intravenous fluids and blood transfusions, given uterotonic medications, and underwent emergency laparotomy to remove her uterus. An anatomopathology exam confirmed the diagnosis of placenta accreta, which had not been suspected during the initial assessment. The patients postoperative course was uneventful, and she was discharged on the seventh postoperative day. The management of PPH due to placenta accreta requires a multidisciplinary approach involving obstetricians, anesthesiologists, hematologists, and interventional radiologists. The initial management of PPH involves resuscitation and stabilization of the patient. The next step is to control bleeding by uterine massage and administration of uterotonic agents. If bleeding persists despite uterine massage and administration of uterotonic agents, surgical intervention should be considered, which includes uterine artery embolization, hysterectomy, and conservative management. The choice of surgical management depends on the severity of bleeding, hemodynamic stability, and the extent of placental invasion. Early diagnosis and management of placenta accreta are essential for the prevention of adverse outcomes, and a multidisciplinary approach is crucial for the successful management of this condition.

The clinical applications of interventional radiological techniques in obstetrics and gynaecology

Key content Uterine artery embolisation can be used as a minimally invasive technique for the management of benign gynaecological conditions refractory to other medical treatments. The Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Radiologists (RCR) recommend the use of interventional radiology (IR) techniques for the prophylaxis and management of postpartum haemorrhage. Interventional radiologists can percutaneously drain post‐operative collections or tubo‐ovarian abscesses. Interventional radiology plays a role in the management of early pregnancy complications such as ectopic pregnancy and gestational trophoblastic disease. Interventional radiology can aid the care of patients with gynaecological malignancies. Learning objectives To understand the various IR techniques applicable to obstetrics and gynaecology To understand the risk and benefit profiles of these techniques To understand when the techniques could be appropriate and how they compare to surgical alternatives Ethical issues There are limited data regarding the use of some IR procedures owing to the ethical issues of using experimental techniques to treat pregnant women or women who wish to conceive. The availability of IR procedures is hospital specific so treatment is not available to all who may benefit.

Assessment of the self-confidence of obstetrics & gynecology fellows to perform a postpartum hemostasis hysterectomy.

Hemostasis Hysterectomy (HH) is a last resort surgical procedure performed in situations of uncontrolled post-partum hemorrhage in maternity wards. The chances of being confronted with this situation are scarce during residency, and the situation is not well suited for teaching. Nevertheless, every obstetrician-gynecologist can be confronted with this stressful situation, and should therefore possess the surgical competence required, regardless of his routine practice. The aim of the present study is to evaluate clinical exposure and self-awareness concerning HH amongst obstetrics and gynecology residents and fellows. We performed a survey amongst French obstetrics and gynecology fellows. An anonymous survey was sent by email between December 1, 2020 to July 1, 2021. Half of the interrogated fellows had practiced (as operator) an HH during residency with a senior and only 22,6% in post-residency. During the last year of residency 70% of them had performed less than 10 scheduled hysterectomies as primary operator. The laparoscopic approach was the most frequently practiced. Very few hysterectomies were performed as primary operator. Fellows with a surgical or mixed activity (both gynecological surgery and obstetrical activity in current practice) felt significantly more capable of performing HH compared to those with exclusive obstetrical or reproductive medicine activity; respectively 60% vs 36%, p=0.008; Odds Ratio: 2.629 (95% CI 1.2214; 5.8094). The number of scheduled hysterectomies or HH performed as primary operator is very low during residency or fellowship. It remains largely inferior to the number deemed necessary in previous publications about the learning curve for scheduled hysterectomy, which varies from 18 to 80 interventions. Nowadays, the increasing number of residents, added to the decrease of hemostasis hysterectomies through better management of post-partum hemorrhage, pushes towards the development of specific training, such as "damage control simulation".