Twenty-Seven-Year Institutional Experience With Surgery for Adults With Congenital Heart Disease.

BACKGROUND: Given improved contemporary survival of adults with congenital heart disease (ACHD), we aimed to evaluate trends in ACHD surgery and outcomes at a single center over a 27-year period. METHODS: Surgical databases were retrospectively queried for patients >18 years old who underwent ACHD surgery between January 1, 1994, and December 31, 2020. A total of 2,195 included patients underwent 2,425 cardiac surgical procedures within the specified time frame. Patients were grouped by era: I, 1994-2000; 2, 2001-2010; and 3, 2011-2020. Trends in primary cardiac diagnosis and surgical management were evaluated. RESULTS: The median age increased across the eras. The most common primary cardiac diagnoses (n = 2,425) overall were left ventricular outflow tract anomalies (n = 2,019, 83%), atrial septal defect (n = 407, 17%), right ventricular outflow tract anomalies (n = 360, 15%), and ventricular septal defect (n = 110, 4.5%). The most commonly observed procedures overall were operations on the left ventricular outflow tract (n = 1,633, 67%), aorta (n = 675, 28%), coronary arteries (n = 449, 19%), right ventricular outflow tract (n = 323, 13%), and atrial septal defect (n = 264, 11%). Major complications occurred in 10% of cases, and 58 patients died within 30 days of their operation yielding an operative mortality of 2.4%. CONCLUSION: To our knowledge, this is the largest single center report on surgery for adults with congenital heart disease. Surgery for ACHD has been performed at our center with relatively low morbidity and mortality over the last few decades.

Effect of an Intrapartum Pelvic Dilator Device on Levator Ani Muscle Avulsion During Primiparous Vaginal Delivery: A Pilot Randomized Controlled Trial.

INTRODUCTION AND HYPOTHESIS: The objective was to evaluate the safety and effectiveness of an intrapartum electromechanical pelvic floor dilator designed to reduce the risk of levator ani muscle (LAM) avulsion during vaginal delivery. METHODS: A multicenter, randomized controlled trial enrolled nulliparous participants planning vaginal delivery. During the first stage of labor, participants were randomized to receive the intravaginal device or standard-of-care labor management. The primary effectiveness endpoint was the presence of full LAM avulsion on transperineal pelvic-floor ultrasound at 3 months. Three urogynecologists performed blinded interpretation of ultrasound images. The primary safety endpoint was adverse events (AEs) through 3 months. RESULTS: A total of 214 women were randomized to Device (n = 113) or Control (n = 101) arms. Of 113 Device assignees, 82 had a device placed, of whom 68 delivered vaginally. Of 101 Control participants, 85 delivered vaginally. At 3 months, 110 participants, 46 Device subjects who received full device treatment, and 64 Controls underwent ultrasound for the per-protocol analysis. No full LAM avulsions (0.0%) occurred in the Device group versus 7 out of 64 (10.9%) in the Control group (p = 0.040; two-tailed Fisher's test). A single maternal serious AE (laceration) was device related; no neonate serious AEs were device related. CONCLUSIONS: The pelvic floor dilator device significantly reduced the incidence of complete LAM avulsion in nulliparous individuals undergoing first vaginal childbirth. The dilator demonstrated an acceptable safety profile and was well received by recipients. Use of the intrapartum electromechanical pelvic floor dilator in laboring nulliparous individuals may reduce the rate of LAM avulsion, an injury associated with serious sequelae including pelvic organ prolapse.

Frequency of Prenatal Care Visits: A Core Outcome Set for Prenatal Care Schedules.

Objective: The aim of this study is to develop a core outcome set for the frequency and modality of prenatal care visits. Material and Methods: A consensus development study was conducted in the United States with participants, including 31 health care professionals, 12 public policy members or public health payers, and 18 public members, representing 24 states. A modified Delphi method and modified nominal group technique were utilized. Results: Twenty-one potential core outcomes were developed by combining the outcomes reported in three systematic reviews that evaluated the frequency of prenatal care visits or modality of prenatal visit type (e.g., in person, telemedicine, or hybrids of both). Eighteen consensus outcomes were identified from the Delphi process, following which 10 maternal and 4 neonatal outcomes were agreed at the consensus development meeting. Maternal core outcomes include maternal quality of life; maternal mental health outcomes; the experience of maternity care; lost time; attendance of recommended visits; unplanned care utilization; completion of the American College of Obstetricians and Gynecologists-recommended services; diagnosis of obstetric complications-proportion and timing; disparities in care outcomes; and severe maternal morbidity or mortality. Neonatal core outcomes include gestational age at birth, birth weight, stillbirth or perinatal death, and neonatal intensive care unit admissions. Conclusions: The core outcome set for the frequency and modality of prenatal visits should be utilized in forthcoming randomized controlled trials and systematic reviews. Such application will warrant that in future research, consistent reporting will enrich care and improve outcomes. Clinical Trial Registration number: 2021.

Extracorporeal Membrane Oxygenation in Pregnant and Postpartum Women With Critical Coronavirus Disease 2019 (COVID-19) Acute Respiratory Distress Syndrome: A Systematic Review and Meta-analysis.

OBJECTIVE: To estimate the maternal survival and live-birth rates in pregnant women with acute respiratory distress syndrome (ARDS) secondary to critical coronavirus disease 2019 (COVID-19) who are treated with extracorporeal membrane oxygenation (ECMO) by performing a systematic review and meta-analysis. DATA SOURCES: From database inception through August 2023, we explored MEDLINE, Web of Science, EMBASE, CINAHL, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials. Studies reporting maternal survival and live-birth rates in pregnant women with critical COVID-19 undergoing ECMO were included. METHODS OF STUDY SELECTION: Two reviewers separately ascertained studies, obtained data, and evaluated study quality. Summary estimates of maternal survival and live-birth rates were measured, and 95% CIs were calculated. TABULATION, INTEGRATION, AND RESULTS: Nine retrospective case series and 12 retrospective cohort studies were identified with 386 pregnant women with critical COVID-19 who underwent ECMO. Studies evaluated women that were treated from January 2020 to October 2022. Four studies were from the United States; three were from Turkey; two were from France; two were from Israel; and one each was from Columbia, Germany, Italy, Kuwait, Poland, Republic of Srpska, the United Arab Emirates, the United Kingdom, a consortium from Belgium, France, Switzerland, and an international registry. The pooled estimate of the maternal survival rate among pregnant patients who were initiated on ECMO was 75.6% (95% CI, 66.0-84.1%, I2 =72%). The pooled estimate of the live-birth rate among pregnant patients who were initiated on ECMO was 83.7% (95% CI, 76.8-89.6%, 153 neonates, I2 =11%). When the case series and cohort studies were examined separately, the results were similar. CONCLUSION: Among pregnant women with acute respiratory distress syndrome attributable to critical COVID-19 who were managed with ECMO, maternal survival and live-birth rates were high. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42023442800.

Routine Prenatal Care.

The one-size-fits-all model of prenatal care has remained largely unchanged since 1930. New models of prenatal care delivery can improve its efficacy, equity, and experience through tailoring prenatal care to meet pregnant people's medical and social needs. Key aspects of recently developed prenatal care models include visit schedules based on needed services, telemedicine, home measurement of routine pregnancy parameters, and interventions that address social and structural drivers of health. Several barriers that affect the individual, provider, health system, and policy levels must be addressed to facilitate implementation of new prenatal care delivery models.

Cesarean Delivery Rate in Nulliparous Women in the Second Stage of Labor When Using Zhang Compared With Friedman Labor Curves: A Systematic Review and Meta-analysis.

OBJECTIVE: To estimate the cesarean delivery rate in the second stage of labor in nulliparous women when using the Zhang compared with the Friedman labor curve by performing a systematic review and meta-analysis. DATA SOURCES: We explored MEDLINE, EMBASE, Web of Science, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials for studies comparing the cesarean delivery rate in the second stage of labor in nulliparous women when using the Zhang compared with the Friedman labor curve. METHODS OF STUDY SELECTION: Two reviewers separately ascertained studies, obtained data, and gauged study quality. The cesarean delivery rate was compared, and odds ratios (ORs) with 95% CIs were estimated. TABULATION, INTEGRATION, AND RESULTS: Five retrospective cohort studies and two randomized controlled trials were identified with 20,165 nulliparous women (10,861 with the Zhang labor curve vs 9,304 with the Freidman labor curve). Studies evaluated women with delivery from June 2010 to May 2017. Two studies were from the United States; two were from Israel; and one each was from China, France, and Norway. The median point prevalence of cesarean delivery in the second stage was 4.0% (95% CI 2.1-14.5%) in cases managed with the Zhang labor curve compared with 5.6% (95% CI 1.8-28.6%) in cases managed with the Friedman labor curves. The overall cesarean delivery rate in the second stage of labor was similar when the Zhang labor curve compared with the Friedman labor curve was used (pooled OR 0.86, 95% CI 0.47-1.57, I2=93%). When the two randomized controlled trials were excluded, the results of the cohort studies continued to demonstrate that the overall cesarean delivery rate in the second stage of labor was similar (pooled OR 0.84, 95% CI 0.42-1.69, I2=92%). CONCLUSION: Nulliparous women have similar cesarean delivery rates in the second stage of labor when either the Zhang or Friedman labor curve is used. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42022346425.

Frequency of Prenatal Care Visits: Protocol to Develop a Core Outcome Set for Prenatal Care Schedules.

BACKGROUND: Prenatal care, one of the most common preventive care services in the United States, endeavors to improve pregnancy outcomes through evidence-based screenings and interventions. Despite the prevalence of prenatal care and its importance to maternal and infant health, there are several debates about the best methods of prenatal care delivery, including the most appropriate schedule frequency and content of prenatal visits. Current US national guidelines recommend that low-risk individuals receive a standard schedule of 12 to 14 in-office visits, a care delivery model that has remained unchanged for almost a century. OBJECTIVE: In early 2020, to mitigate individuals' exposure to the SARS-CoV-2 virus, prenatal care providers implemented new paradigms that altered the schedule frequency, interval, and modality (eg, telemedicine) of how prenatal care services were offered. In this paper, we describe the development of a core outcome set (COS) that can be used to evaluate the effect of the frequency of prenatal care schedules on maternal and infant outcomes. METHODS: We will systematically review the literature to identify previously reported outcomes important to individuals who receive prenatal care and the people who care for them. Stakeholders with expertise in prenatal care delivery (ie, patients or family members, health care providers, and public health professionals and policy makers) will rate the importance of identified outcomes in a web-based survey using a 3-round Delphi process. A digital consensus meeting will be held for a group of stakeholder representatives to discuss and vote on the outcomes to include in the final COS. RESULTS: The Delphi survey was initiated in July 2022 with invited 71 stakeholders. A digital consensus conference was conducted on October 11, 2022. Data are currently under analysis with plans to submit them in a subsequent manuscript. CONCLUSIONS: More research about the optimal schedule frequency and modality for prenatal care delivery is needed. Standardizing outcomes that are measured and reported in evaluations of the recommended prenatal care schedules will assist evidence synthesis and results reported in systematic reviews and meta-analyses. Overall, this COS will expand the consistency and patient-centeredness of reported outcomes for various prenatal care delivery schedules and modalities, hopefully improving the overall efficacy of recommended care delivery for pregnant people and their families. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/43962.

Outcomes Following Extracorporeal Membrane Oxygenation for Severe COVID-19 in Pregnancy or Post Partum.

Importance: Existing reports of pregnant patients with COVID-19 disease who require extracorporeal membrane oxygenation (ECMO) are limited, with variable outcomes noted for the maternal-fetal dyad. Objective: To examine maternal and perinatal outcomes associated with ECMO used for COVID-19 with respiratory failure during pregnancy. Design, Setting, and Participants: This retrospective multicenter cohort study examined pregnant and postpartum patients who required ECMO for COVID-19 respiratory failure at 25 hospitals across the US. Eligible patients included individuals who received care at one of the study sites, were diagnosed with SARS-CoV-2 infection during pregnancy or up to 6 weeks post partum by positive nucleic acid or antigen test, and for whom ECMO was initiated for respiratory failure from March 1, 2020, to October 1, 2022. Exposures: ECMO in the setting of COVID-19 respiratory failure. Main outcome and measures: The primary outcome was maternal mortality. Secondary outcomes included serious maternal morbidity, obstetrical outcomes, and neonatal outcomes. Outcomes were compared by timing of infection during pregnancy or post partum, timing of ECMO initiation during pregnancy or post partum, and periods of circulation of SARS-CoV-2 variants. Results: From March 1, 2020, to October 1, 2022, 100 pregnant or postpartum individuals were started on ECMO (29 [29.0%] Hispanic, 25 [25.0%] non-Hispanic Black, 34 [34.0%] non-Hispanic White; mean [SD] age: 31.1 [5.5] years), including 47 (47.0%) during pregnancy, 21 (21.0%) within 24 hours post partum, and 32 (32.0%) between 24 hours and 6 weeks post partum; 79 (79.0%) had obesity, 61 (61.0%) had public or no insurance, and 67 (67.0%) did not have an immunocompromising condition. The median (IQR) ECMO run was 20 (9-49) days. There were 16 maternal deaths (16.0%; 95% CI, 8.2%-23.8%) in the study cohort, and 76 patients (76.0%; 95% CI, 58.9%-93.1%) had 1 or more serious maternal morbidity events. The largest serious maternal morbidity was venous thromboembolism and occurred in 39 patients (39.0%), which was similar across ECMO timing (40.4% pregnant [19 of 47] vs 38.1% [8 of 21] immediately postpartum vs 37.5% postpartum [12 of 32]; P > .99). Conclusions and Relevance: In this multicenter US cohort study of pregnant and postpartum patients who required ECMO for COVID-19-associated respiratory failure, most survived but experienced a high frequency of serious maternal morbidity.

Use of a pocket-device point-of-care ultrasound to assess cervical dilation in labor: correlation and patient experience.

OBJECTIVES: To estimate the correlation of cervical dilation between pocket-device point-of-care transperineal ultrasound (TPUS) and digital cervical examination (DCE). METHODS: Laboring pregnant individuals ≥37 weeks of gestation presenting were prospectively evaluated for cervical dilation with a handheld pocket-sized ultrasound (Butterfly iQ+®) applied to the perineum, with a blinded DCE directly following. Subjects completed a survey to rate pain and for any preference from the examinations. To detect a moderate correlation (r=0.5) between TPUS and DCE, with an alpha of 0.05 and power of 80%, a sample size of 30 examinations were needed. RESULTS: From April 2022 to July 2022, 30 pregnant individuals were assessed. The median cervical dilation by TPUS vs. DCE was 5.1 and 5 cm, respectively, with a Pearson's correlation coefficient, r=0.86 (95% CI 0.72 to 0.93), p<0.001. Transperineal ultrasound had a significantly less pain score than DCE, median pain score 0 vs. 2 for TPUS and DCE respectively, p<0.001. All individuals preferred the TPUS over the DCE. CONCLUSIONS: Measurement of cervical dilation using a pocket-device point-of-care TPUS has a strong positive correlation with DCE and offers a non-invasive, convenient alternative to traditional digital exams in term, laboring patients.

YouTube as a source of patient information on external cephalic version.

OBJECTIVES: To assess the quality and content of information regarding external cephalic version on YouTube. METHODS: YouTube was searched using the phrase "external cephalic version" (ECV) to identify informative videos by two independent reviewers. Videos were included if: (1) in English; (2) available November 20, 2021; (3) related to ECV. Videos were excluded if: (1) duration exceeded 15 min; (2) target audience was not patients or the general public; (3) not in English; (4) were advertisements or news clips; (5) did not relate to ECV. The Global Quality Scale was used to assess overall quality of selected videos. A content score was developed based on guidelines from the American College of Obstetricians and Gynecologists. Video quality was also categorized as "slightly useful", "useful" and "very useful". The Patient Education Materials Assessment Tool (PEMAT) for audiovisual materials was used to score understandability and actionability. RESULTS: Of 60 videos screened, 31 met inclusion criteria. They were classified as People or Blogs (n=19, 61%) or Education (n=12, 39%). Videos were calculated to be "slightly useful" (n=10, 32%), "useful" (n=18, 58%), or "very useful" (n = 3, 10%). The PEMAT - understandability was less in the "slightly useful" compared to the combined "useful" and "very useful" groups, p<0.01. No differences existed between total usefulness score and category, p=0.6. CONCLUSIONS: Most videos were useful, but few were very useful. These results highlight the importance of thorough counseling regarding this procedure.

Obstetric Care Consensus #11, Pregnancy at age 35 years or older.

Centers for Disease Control and Prevention data from 2020 demonstrate the continued upward trend in the mean age of pregnant individuals in the United States. Observational studies demonstrate that pregnancy in older individuals is associated with increased risks of adverse pregnancy outcomes-for both the pregnant patient and the fetus-that might differ from those found in younger pregnant populations, even in healthy individuals with no other comorbidities. There are several studies that suggest that advancing age at the time of pregnancy is associated with greater disparities in severe maternal morbidity and mortality. This document seeks to provide evidence-based clinical recommendations for minimizing adverse outcomes associated with pregnancy with anticipated delivery at an advanced maternal age. The importance and benefits of accessible health care from prepregnancy through postpartum care for all pregnant individuals cannot be overstated. However, this document focuses on and addresses the unique differences in pregnancy-related care for women and all those seeking obstetrical care with anticipated delivery at the age of 35 years or older within the framework of routine pregnancy care. This Obstetric Care Consensus document was developed using an a priori protocol in conjunction with the authors listed above.

Rate of Mesh Erosion After Sacrocolpopexy With Concurrent Supracervical Compared With Total Hysterectomy: A Systematic Review and Meta-analysis.

OBJECTIVE: To estimate the effect of concomitant supracervical hysterectomy compared with total hysterectomy during abdominal sacrocolpopexy on the rate of mesh erosion by performing a systematic review and meta-analysis of the existing literature. DATA SOURCES: From database inception through January 2022, we explored MEDLINE, Web of Science, EMBASE, CINAHL, ClinicalTrials.gov , and Cochrane Central Register of Controlled Trials. Studies comparing the rate of mesh erosion in women undergoing abdominal sacrocolpopexy who had concomitant supracervical hysterectomy compared with total hysterectomy were included. DATA EXTRACTION AND SYNTHESIS: Two reviewers separately ascertained studies, obtained data, and gauged study quality. The rate of mesh erosion was compared, and odds ratios (ORs) with 95% CIs were estimated. TABULATION, INTEGRATION, AND RESULTS: Nineteen studies with 10,572 women who underwent abdominal sacrocolpopexy were identified, including 4,285 women in the supracervical group and 6,287 women in the total hysterectomy group. The overall mean postprocedure follow-up time was 30.7±15.1 months (median 12.4, range 1.5-44.2). The median (95% CI) point prevalence of mesh erosion was 0.36% (0-1.9%) in women who had supracervical hysterectomy compared with 3.8% (1.8-8.7%) in women who had total hysterectomy. The overall rate of mesh erosion in women who had supracervical hysterectomy was lower compared with women who had total hysterectomy (pooled OR 0.26, 95% CI 0.18-0.38, I 2 0%). CONCLUSION: In women with symptomatic apical pelvic organ prolapse who undergo abdominal sacrocolpopexy with concomitant hysterectomy, supracervical hysterectomy is associated with a lower risk of mesh erosion compared with total hysterectomy. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42022301862.

Michigan Plan for Appropriate Tailored Healthcare in Pregnancy Prenatal Care Recommendations: A Practical Guide for Maternity Care Clinicians.

Prenatal care is an important preventive service designed to improve the health of pregnant patients and their infants. Prenatal care delivery recommendations have remained unchanged since 1930, when the 12-14 in-person visit schedule was first established to detect preeclampsia. In 2020, the American College of Obstetricians and Gynecologists, in collaboration with the University of Michigan, convened a panel of maternity care experts to determine new prenatal care delivery recommendations. The panel recognized the need to include emerging evidence and experience, including significant changes in prenatal care delivery during the COVID-19 pandemic, pre-existing knowledge of the importance of individualized care plans, the promise of telemedicine, and the significant influence of social and structural determinants of health (SSDoH) on pregnancy outcomes. Recommendations were derived using the RAND-UCLA appropriateness method, a rigorous e-Delphi method, and are designed to extend beyond the acute public health crisis. The resulting Michigan Plan for Appropriate Tailored Healthcare in pregnancy (MiPATH) includes recommendations for key aspects of prenatal care delivery: (1) the recommended number of prenatal visits, (2) the frequency of prenatal visits, (3) the role of monitoring routine pregnancy parameters (blood pressure, fetal heart tones, weight, and fundal height), (4) integration of telemedicine into routine care, and (5) inclusion of (SSDoH). Resulting recommendations demonstrate a new approach to prenatal care delivery that incorporates medical, SSDoH, and patient preferences, to develop individualized prenatal care delivery plans. The purpose of this document is to outline the new MiPATH recommendations and to provide practical guidance on implementing them in routine practice.

COVID-19 and its effect on Instagram adoption by #OBGYN residency programs.

OBJECTIVES: Instagram (IG) is becoming one of the larger resource tools within medicine. Since the onset of the COVID-19 pandemic, it is becoming important for programs to improve virtual presence and outreach. We evaluated the adoption of IG by OB/GYN residency programs in the United States and aimed to see if highly ranked programs had higher utilization rates. METHODS: IG presence and engagement metrics were extracted for all ACGME accredited OB/GYN programs. Doximity residency navigator tool was used to obtain nationwide program rankings, and statistical analysis was performed to prove any significant correlation. Mann-Whitney U test, Cochran-Armitage test and Analysis of variance were used for analysis. IRB exemption was obtained. RESULTS: Seventy percent of programs (202/287) have IG presence, with the majority creating presence after the COVID pandemic began (115/202; 57%). Seventy-two percent (83/115) of these programs created their IG account once virtual interviews were announced. The top 25% of programs, as ranked on Doximity, have a higher number of posts, followers and likes when compared to the rest of the programs. CONCLUSIONS: The COVID-19 pandemic has led to increased adoption of IG by residency programs. Highly ranked and reputed programs have higher rates of activity, popularity, and engagement on IG.

Erythromycin vs azithromycin for treatment of preterm prelabor rupture of membranes: a systematic review and meta-analysis.

OBJECTIVE: This study aimed to estimate the effect of erythromycin vs azithromycin on the duration of latency and the rate of clinical chorioamnionitis in women with preterm prelabor rupture of membranes by performing a systematic review and meta-analysis of the existing literature. DATA SOURCES: From inception to October 2021, we explored MEDLINE, Scopus, Embase, CINAHL, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials. STUDY ELIGIBILITY CRITERIA: Studies comparing the duration of latency and the rate of clinical chorioamnionitis between women with preterm prelabor rupture of membranes who were treated with erythromycin and those who were treated with azithromycin at the time of diagnosis were included. METHODS: Here, 2 reviewers separately ascertained studies, obtained data, and gauged study quality. The mean length of latency and the rate of clinical chorioamnionitis were compared and mean differences and odds ratios with 95% confidence intervals were estimated. RESULTS: A total of 5 studies with 1289 women were identified. The mean length of latency in women with preterm prelabor rupture of membranes was similar between individuals treated with erythromycin and those treated with azithromycin: 6.6 days vs 6.7 days (mean difference, 0.07 days; 95% confidence interval, -0.45 to 0.60; I2, 0%). The median point prevalence rates of clinical chorioamnionitis were 25% (95% confidence interval, 12-32) in women treated with erythromycin and 14% (95% confidence interval, 9-24) in women treated with azithromycin. The overall clinical chorioamnionitis rate in women treated with azithromycin was lower than women treated with erythromycin (pooled odds ratio, 0.53; 95% confidence interval, 0.39-0.71; I2, 0%). CONCLUSION: The administration of azithromycin in women with preterm prelabor rupture of membranes was associated with a similar latency period but a lower rate of clinical chorioamnionitis than the administration of erythromycin.

Reducing Hemorrhage-Related Maternal Morbidity Using Interdisciplinary Simulation Training.

INTRODUCTION: Postpartum hemorrhage (PPH) remains a major cause of preventable maternal morbidity in the United States. Postpartum hemorrhage simulations were developed to improve provider recognition and treatment; however, there exist few studies that investigate their effects on individual outcomes. Our objective is to estimate the effect of a simulation-based educational intervention on PPH-related maternal morbidity outcomes. METHODS: We conducted a retrospective cohort analysis of hemorrhage outcomes at a single institution between March 2012 and January 2016 during the implementation of a high-fidelity PPH simulation. Women with PPH defined as an estimated blood loss greater than 500 mL for vaginal delivery and 1000 mL for cesarean delivery were included. The primary outcome was a composite of hemorrhage-related maternal morbidity (maternal death, hysterectomy, intensive care unit admission, blood transfusion, or unanticipated procedures to treat postpartum bleeding). Multivariable logistic regression adjusted for confounding variables between presimulation and postsimulation outcomes. RESULTS: During the study period, 19,927 deliveries occurred with 4.5% of patients (888) experiencing hemorrhage. Women in the presimulation (n = 278) versus postsimulation groups (n = 610) had similar demographics. Although the PPH rate increased after simulation [2.8% pre vs. 6.1% post, odds ratio (OR), 2.25; 95% confidence interval (CI), 1.95-2.60], composite hemorrhage-related morbidity was lower after simulation training (44% pre vs. 35% post; OR, 0.70; 95% CI, 0.52-0.93). This reduction persisted after adjusting for confounding variables of mode of delivery and time from delivery to first uterotonic use (adjusted OR, 0.66; 95%, CI 0.49-0.89). CONCLUSIONS: Despite an increased PPH rate, simulation education was associated with a reduction in a hemorrhage-related maternal composite morbidity.