Reducing maternal mortality is a global challenge to be faced with actions and strategies that support the Sustainable Development Goals (SDGs) proposed by the United Nations Organization (ONU) [Organização das Nações Unidas - ONU] and which will contribute to achieving the 2030 Agenda (ONU, 2015, ONU, 2018). Among these initiatives, since 2018 and along with the Brazilian Ministry of Health (Ministério da Saúde, MS), the Pan American Health Organization (PAHO) [Organização Pan-Americana da Saúde (OPAS)] and the World Health Organization (WHO) have adopted the “Zero Maternal Deaths due to Haemorrhage” strategy, to accelerate the reduction of maternal morbidity and mortality due to Post-Partum Haemorrhage (PPH) ([PAHO], 2018, Osanan et al., 2018).

PPH is an obstetric emergency that ranks second among the causes of maternal deaths. It consists in a clinical condition characterized by blood loss above 500 ml after a vaginal delivery and of 1,000 ml after a C-section and which can cause haemodynamic instability (PAHO, 2018).

In 2014, a systematic analysis carried out by the WHO signalled haemorrhage as the main direct cause of maternal death at the global level, with 611,000 estimated cases between 2003 and 2009. The global 27.1% rate (95% UI: 19.9-36.2) varied from 16.3% in developed countries to 36.9% in the North of Africa, whereas it was 23.1% in Latin America. PPH is especially due to avoidable causes that are reversible by means of prophylactic interventions, indicating the need to prioritize policies, programs and funding to reduce maternal deaths at the regional and global levels (Say et al., 2014).

Dynamic and appropriate care of haemorrhagic obstetric emergencies by strengthening professional competencies for their management is fundamental to prevent maternal deaths and understand one of the main axes of the “Zero Maternal Deaths due to Haemorrhage” strategy (PAHO, 2018). Therefore, it also up to universities to promote technical and scientific education and create means that allow Obstetrics and Nursing students to develop skills in a safe place, so as to adequately manage this complication in real life.

In this perspective, simulation-based teaching has been incorporated into Higher Education curricula in the health area, as well as in other professions such Aeronautics, Chemical or Nuclear Industries, where it has been implemented for years now, as it allows obtaining a high training level and practicing recognition and treatment of situations that can lead to harms, without endangering any life. Its main principles are grounded on ensuring safety and preventing critical errors (Sánchez et al., 2013).

Currently, simulation methods and instruments focused on interactive learning have been used, combining theory and clinical practice and stimulating critical and reflective thinking. These aspects are essential to improve teaching quality, providing development of diverse knowledge, skills and attitudes that contribute to professional training (Nascimento and Magro, 2018, Ferreira et al., 2018, Kaneko and Lopes, 2019, Silva et al., 2020).

Several studies point to the benefits of using simulation in teaching PPH care as an opportunity for the students to increase their self-confidence in the clinical environment and experience a situation that is oftentimes not witnessed (Gray; Cavner, 2017). This strategy is an opportunity to learn how to administer appropriate drugs in PPH, favouring patient safety in real emergencies (Deering et al., 2009), as well as to expand knowledge about the management of post-partum haemorrhagic conditions (Marshall et al., 2015, Kato and Kataoka, 2017), aiming to reduce blood loss estimates and promote early treatment (Toledo et al., 2010).

A scoping review that synthesized the main strategies for teaching clinical reasoning in the advanced clinical practice context found that simulations were the most used among the different strategies, namely: Telehealth-enabled standardized patient meetings; Branching path simulation; Virtual simulation with iSimulate; Simulated “on-call” scenarios; Simulations with an academic electronic health record; Simulations and Technology-enhanced boundary objects; Simulated patient-simulation-based learning experiences; Clinical simulation; and Simulation-enhanced interprofessional education. However, it is necessary to employ different teaching strategies to stimulate critical thinking, improve diagnostic reasoning, refine clinical judgment and strengthen decision-making (Giuffrida et al., 2023).

Typically, PPH simulations follow a defined script where the specific cause of the bleeding is sought and the appropriate treatment is applied, based on the “4Ts” mnemonic: 1. Tone - It refers to rigidity of the uterine muscles and presence of contractility; its reduction or absence represents the leading cause of PPH; 2. Trauma - It deals with the traumas caused during childbirth, such as vaginal canal, cervix or uterus lacerations and uterine inversion; 3. Tissue - It includes retention of placental debris or some degree of placental accreta; and 4. Thrombin - Pre-existing or acquired coagulation disorders (Macedo and Lopes, 2018, [PAHO], 2018).

Through the observation, experience and evaluation of clinical simulations on PPH, together with undergraduate Midwifery students from a public university in the state of São Paulo, Brazil, specific concern arose when noticing that the students had difficulties performing the actions in the correct sequence required by the simulated case. In this activity, even in a controlled environment, anxiety, nervousness and fear of making mistakes were evident in the assessments, rendering the simulated experience highly stressful.

According to Lavoie et al. (2022), this is perhaps explained when they state that apprentices need clinical and exposure experience to enough cases to understand the particularities of the complications presented by the patients. As they expand their experiences, they achieve anticipatory thinking for mental simulation processes.

In the Anaesthesiology simulated activities, Gaba et al. (2001) mention 15 key points to promote learning of technical and cognitive competencies in crisis management. Putting leadership into practice and knowing how to follow it, using cognitive resources and working as a team stand out as important aspects; however, they eventually represent gaps in obstetric emergency simulations, which require teamwork, a leader to indicate the due actions and proficiency and promptness to timely perform these actions.

We noticed these gaps in the PPH simulations, as the students oftentimes lack clinical experience to access appropriate cognitive resources to solve the simulated case. Thus, the proposal was to create an instructional support tool that, in a structured way, would indicate the PPH care measures based on the PAHO guidelines (2018) adopted in Brazil to assist students in simulated stations.

The literature cites validation of scenarios (Andrade et al., 2019), classification forms in PPH simulation (Deering et al., 2009) and contents (Mota et al., 2021); however, there are no tools that the students can handle quickly and safely to guide their actions and make up for cognitive resources during academic training. In general, the forms or checklists are in possession of the professors or instructors, who verify the students' performance in the simulated activities.

Therefore, this study aimed at describing the creation and validation process of an instructional, didactic and self-applied support tool for teaching-learning Post-Partum Haemorrhage care in simulated settings.