The Problem

idea series teaching residents quality improvementThe peri-mortem cesarean section, rebranded in recent years as the “Resuscitative Hysterotomy”, is a potentially lifesaving procedure for both a pregnant mother and her child. It is both daunting and infrequently performed, necessitating frequent review of indications, techniques, and pitfalls to ensure the best possible outcome for mother and baby. The decision to perform this procedure should be made only in pulseless women with a uterine fundus above the umbilicus, which indicates a gestation of >20 weeks.1,2 Prior studies suggest the procedure should be performed within 5 minutes of maternal cardiac arrest in order to maximize the probability of favorable maternal neurologic outcome and the secondary goal of fetal survival.3 Given the paucity of clinical exposure to this potentially-life saving intervention, resuscitative hysterotomy is an ideal candidate for simulation-mediated deliberate practice.

The Innovation

To date, there are only a few commercially-manufactured resuscitative hysterotomy task-trainers available, and each tends to be costly to purchase and maintain.4–6 Appendix 1 lists the commercially available resuscitative hysterotomy models.

To address these issues, the authors sought to develop a homegrown, high-fidelity, realistic, tissue-based task trainer, easily incorporated into an inexpensive childbirth simulator with the overarching goals of:

  • Enhancing procedural training of resuscitative hysterotomies
  • Integrating this simulation model into any clinical or pre-clinical environment for an immediate, hands on, rapid cycle deliberate practice with EM residents.

ACGME Milestones

In accordance with the ACGME EM Milestones, the biosimulation resuscitative hysterotomy model affords the learners opportunities to practice:

  • Patient Care (PC1 – Emergency Stabilization, PC4 – Diagnosis, PC9 – General Approach to Procedures)
  • Medical Knowledge (MK)
  • Interpersonal and Communication Skills (ICS2 – Team Management)

Educational Theory Behind the Innovation

Rapid cycle deliberate practice (RCDP) is a novel educational practice gaining traction in healthcare. RCDP represents a conceptual model for skill acquisition that provides for timely and focused education.7 

Simulation training, with integration of RCDP, presents a ripe opportunity to:

  • Review procedural steps
  • Support the development of a mental model between medical providers
  • Deliberately practice procedural skills under the supervision of a senior resident or faculty member for formative feedback
  • Support the development of muscle memory for procedural skills

Learners Targeted

This activity is designed for emergency medicine residents.

Group Size

The ideal group size is 6-10 learners per model.


Table 1: Biosimulation Model Materials and Cost

Pork Belly (12 lbs)$36
Pig Skin (3 lbs)$7.50
Squid (2 whole)$3.00
Pig stomach of adult size, multiple$10
Clear plastic grocery bagsFree from grocery store
Foley catheter x 2Expired supply (ED)
3L tap waterFree from sink
Gaumard S500 Original Childbirth Simulator (includes non-articulating simulation baby fetus)Loan from the Rector Clinical Skills & Simulation Center
Gaumard S500 Articulating NewbornLoan from the Rector Clinical Skills & Simulation Center
Suction tubingExpired supply (ED)
Umbilical cord tubing from foley catheterExpired supply (ED)
Suture (3-0 to 0-0 nylon, any type)Expired supply (OR)
Laceration trayExpired supply (ED)
GlovesExpired supply (OR)
Blunt scissorsLoan from ED
Scalpel (10 blade)Expired supply (ED)
Absorbent floor matsExpired supply (ED)
PPE (mask, gown, boots)Expired supply (ED)

Detailed Description of the Innovation

Two high-fidelity, tissue-based task-trainer models were constructed and tested on a convenience sample of 14 EM residents. Participants included 5 PGY-1 residents, 6 PGY-2 residents, and 3 PGY-3 residents. The simulation occurred during the monthly journal club literature review, held in a classroom on the medical campus. The simulated human placenta, bladder, and uterus were constructed through the use of porcine skin, porcine stomach, and a squid mantle, and secured in place with nylon sutures. The amniotic sac was constructed with a transparent plastic bag that contained a flexible Sim Baby and was filled with warm water, representing amniotic fluid, through a Foley catheter. Each model was placed into a Guamard S500 Childbirth Simulator with an overlying porcine belly to simulate the gravid abdomen. Each model required <1 hour for assembly.

Figure 1. Step-by-step instruction guide for the hybrid biosimulation model for resuscitative hysterotomy.

Emergent hysterotomy was first demonstrated by an EM faculty facilitator. Learners then proceeded with hands-on deliberate practice. Errors in technique were immediately corrected at each step, and preceding steps were reviewed prior to continuing the procedure. Learners were cycled twice through both simulators with rapid cycle feedback, utilizing the micro-debriefing format (feedback was delivered immediately as each step in the procedure was performed). The biosimulation models were reset between procedures via reimplantation of the fetus model with placenta inside new plastic bags with all previous lacerations repaired with nylon suture. Formal quantitative and qualitative feedback were solicited at the end of the workshop using a previously validated survey for low-fidelity resuscitative hysterotomy by Sampson et al.6

Lessons Learned

Quantitative evaluation of the simulated training session was extracted through a 5-item questionnaire using a 5-point Likert-type scale, ranging from a score of 1 (strongly disagree) to 5 (strongly agree). [Figure 2].

The response rate was 100% from participants. Responses were overwhelmingly positive [24.13 (+/- 1.36)].

Nearly all residents indicated that the model:

  • Accurately represented of human anatomy: [4.63 (+/- 0.62)]
  • Helped them become more familiar with the procedure: [4.94 (+/- 0.25)]
  • Effectively prepared them to perform resuscitative hysterotomy: [4.88 (+/- 0.34)]
  • Resulted in knowledge gained that would be directly applicable to future clinical shifts [4.75 (+/- 0.58)]

Qualitative feedback highlighted learners’ appreciation for this novel, tissue-based simulation task trainer that allowed for hands-on practice.

Suggestions for improvement included:

  • Increase the number of models available
  • Simulate ongoing CPR during the procedure to reflect a more realistic clinical scenario
  • Provide a visual printout of the procedural steps with the model.

All participants recommended that the training session be available to future learners.

Figure 2. Evaluation of simulation model. All survey questions (1-5) were adapted from Sampson et. al’s survey analysis of a low-fidelity resuscitative hysterotomy model. Likert scale ranged from 1 (Strongly Disagree) to 5 (Strongly Agree).

The study was limited in power due to being at a single center, and the small sample size of EM learners.  This project was able to reproduce the survey questions previously described by Sampson et. al on a low-fidelity resuscitative hysterotomy model with a smaller sample size (n=9).6  Due to the small sample sizes from both studies, statistical significance was unable to be obtained. Nevertheless, both studies showed the preference for hands on simulation over traditional lectures and reading alone, the improvement in procedural competency, and usefulness for future emergency department shifts.


Resuscitative hysterotomy is a high-stakes, low-frequency procedure that demands provider practice and confidence. Review of procedural steps, indications, and materials needed is imperative to the success of this procedure. Our hybrid, tissue-based hysterotomy model represents a feasible opportunity for training. The model is cost-conscious, easily reproducible, and portable, and allows for ample deliberate practice of the procedure.

Appendix 1: Obstetrical Simulation Models/Task Trainers/Simulators

Gaumard Advanced Childbirth Simulator CS500 “OB Susie”$595
Simulaids Obstetrical Manikin 180$660
3B Scientific Birthing Simulator Basic$942
3B Scientific Birthing Simulator PRO$1,423
3B Scientific Birthing Simulator$1,945
Kyoto Kagaku Vaginal Delivery Assistance Simulator$4,000
Adam, Rouilly DESPERATE DEBRA$6,400
Limbs & Things PROMPT Birthing Simulator – Standard$5,835
Limbs & Things Caesarean Section Module Prompt Flex (add-on)+$2,370
Operative Experience C-Celia – Obstetric Simulator for Fetal Extractions at Cesarean Deliveries$13,300- $19,200
Gaumard NOELLE S550$4,295
Nasco Life/form Lucy Maternal and Neonatal Birthing Simulator – Basic Lucy$5,900
Laerdal SimMom$30,000
Simulaids SMART MOM Basic Birthing Simulator$30,600
Gaumard Victoria S2200$56,500


Read more about the IDEA Series.

Lipman S, Cohen S, Einav S, et al. The Society for Obstetric Anesthesia and Perinatology consensus statement on the management of cardiac arrest in pregnancy. Anesth Analg. 2014;118(5):1003-1016. [PubMed]
Einav S, Kaufman N, Sela H. Maternal cardiac arrest and perimortem caesarean delivery: evidence or expert-based? Resuscitation. 2012;83(10):1191-1200. [PubMed]
Katz V. Perimortem cesarean delivery: its role in maternal mortality. Semin Perinatol. 2012;36(1):68-72. [PubMed]
Nadhir N, LeClair C, Ahmed A, Podolej G. The casserole perimortem cesearean section model. JetEM. 2017;2:22-28.
Adams J, Cepeda B, Baker L, et al. Management of Maternal Cardiac Arrest in the Third Trimester of Pregnancy: A Simulation-Based Pilot Study. Crit Care Res Pract. 2016;2016:5283765. [PubMed]
Sampson C, Renz N, Wagner J. An inexpensive and novel model for perimortem cesarean section. Simul Healthc. 2013;8(1):49-51. [PubMed]
Taras J, Everett T. Rapid Cycle Deliberate Practice in Medical Education – a Systematic Review. Cureus. 2017;9(4):e1180. [PubMed]
Elaine Smith, MD

Elaine Smith, MD

Attending Physician
Envision EMCare
Dimitrios Papanagnou, MD, MPH, EdD(c)

Dimitrios Papanagnou, MD, MPH, EdD(c)

Vice Chair for Education
Department of Emergency Medicine
Assistant Dean, Faculty Development
Department of Emergency Medicine
Thomas Jefferson University Hospital
Philadelphia, PA
Elizabeth Teixeira, MD

Elizabeth Teixeira, MD

Resident Physician
Department of Emergency Medicine
Thomas Jefferson University Hospital
Philadelphia, PA
Lawrence Lau, MD

Lawrence Lau, MD

Attending Physician
Kaiser Permanente
San Leandro Hospital and Fremont Hospital
Mitch Berman, MD

Mitch Berman, MD

Resident Physician
Department of Emergency Medicine
Thomas Jefferson University Hospital
Philadelphia, PA
Xiao Chi (Tony) Zhang, MD, MS

Xiao Chi (Tony) Zhang, MD, MS

Medical Education Fellow
Department of Emergency Medicine
Thomas Jefferson University Hospital
Philadelphia, PA