Emergency Obstetric Training Research Articles

Reducing maternal mortality on a countrywide scale: The role of emergency obstetric training

Training programmes to improve health worker skills in managing obstetric emergencies have been introduced in various countries with the aim of reducing maternal mortality through these interventions. In South Africa, based on an ongoing confidential enquiry system started in 1997, detailed information about maternal deaths is published in the form of regular 'Saving Mothers' reports. This article tracks the recommendations made in successive Saving Mothers reports with regard to emergency obstetric training, and it assesses the impact of these recommendations on reducing maternal mortality. Since 2009, South Africa has had its own training package, Essential Steps in the Management of Obstetric Emergencies (ESMOE), which the last three Saving Mothers reports have specifically recommended for all doctors and midwives working in maternity units. A special emphasis has been placed on the need for the simulation training component of ESMOE, also called obstetric 'fire drills', to be integrated into the clinical routines of all maternity units. The latest Saving Mothers report (2011-2013) suggests there has been little progress so far in improving emergency obstetric skills, indicating a need for further scale-up of ESMOE training in the country. The example of the KwaZulu-Natal province of South Africa is used to illustrate the process of scale-up and factors likely to facilitate that scale-up, including the introduction of ESMOE into the undergraduate medical training curriculum. Additional factors in the health system that are required to convert improved skills levels into improved quality of care and a reduction in maternal mortality are discussed. These include intelligent government health policies, formulated with input from clinical experts; strong clinical leadership to ensure that doctors and nurses apply the skills they have learnt appropriately, and work professionally and ethically; and a culture of clinical governance.

Myths and realities of training in obstetric emergencies

Training for intrapartum emergencies is a promising strategy to reduce preventable harm during birth; however, not all training is clinically effective. Many myths have developed around such training. These principally derive from misinformed beliefs that all training must be effective, cheap, independent of context and sustainable. The current evidence base for effective training supports local, unit-based and multi-professional training, with appropriate mannequins, and practice-based tools to support the best care. Training programmes based on these principles are associated with improved clinical outcomes, but we need to understand how and why that is, and also why some training is associated with no improvements, or even deterioration in outcomes. Effective training is not cheap, but it can be cost-effective. Insurers have the fiscal power to incentivise training, but they should demand the evidence of clinical effect; aspiration and proxies alone should no longer be sufficient for funding, in any resource setting.

Training program for the management of two obstetric emergencies within a French perinatal care network

ObjectivesTo evaluate the effectiveness of an interdisciplinary team training program based on simulated scenarios and focusing on two obstetrical emergency situations: shoulder dystocia and complicated breech vaginal delivery (CBVD). These situations are rare, so there are few opportunities for real-life training, yet their competent and efficient management is crucial to minimizing the risks to mother and child. Study designThe target population for training comprised the 450 professionals working in the French regional perinatal care network ELENA. An expert committee defined the topics for the training program, selected the simulated scenarios and developed the evaluation grids. The training sessions were conducted by two qualified and experienced professionals in each maternity unit. They comprised a theoretical introduction followed by practical exercises in management of simulated emergency situations by the participant teams, with the aid of a mannequin. Each team completed the exercises twice, their performances being filmed, reviewed and evaluated in each case. ResultsThe training sessions took place over 9 months between September 2012 and June 2013. A total of 298 professionals (obstetricians, residents in obstetrics, midwives and nursery nurses) were trained, representing 75% of the staff working in the ELENA perinatal care network. The results showed substantial and significant increases in the overall scores for management of the two emergency situations (from 74.5% to 91.4% for shoulder dystocia [p<0.0001], and from 67.2% to 88.4% [p<0.0001] for CBVD) as well as in the scores for all the specific areas of expertise assessed: safety, know-how, technique, team communication and communication with the patient. ConclusionThis study demonstrated the value of multidisciplinary team training for obstetric emergencies, encouraging the ELENA perinatal care network to implement an annual training program for its staff. Over and above our experience, the future establishment of a national education program to optimize the management of obstetric emergencies seems to be essential.

Team training for safer birth

Effective and coordinated teamworking is key to achieving safe birth for mothers and babies. Confidential enquiries have repeatedly identified deficiencies in teamwork as factors contributing to poor maternal and neonatal outcomes. The ingredients of a successful multi-professional team are varied, but research has identified some fundamental teamwork behaviours, with good communication, proficient leadership and situational awareness at the heart. Simple, evidence-based methods in teamwork training can be seamlessly integrated into a core, mandatory obstetric emergency training. Training should be an enjoyable, inclusive and beneficial experience for members of staff. Training in teamwork can lead to improved clinical outcomes and better birth experience for women.

Onsite training of doctors, midwives and nurses in obstetric emergencies, Zimbabwe.

ProblemIn Zimbabwe, many health facilities are not able to manage serious obstetric complications. Staff most commonly identified inadequate training as the greatest barrier to preventing avoidable maternal deaths.ApproachWe established an onsite obstetric emergencies training programme for maternity staff in the Mpilo Central Hospital. We trained 12 local staff to become trainers and provided them with the equipment and resources needed for the course. The trainers held one-day courses for 299 staff at the hospital.Local settingMaternal mortality in Zimbabwe has increased from 555 to 960 per 100 000 pregnant women from 2006 to 2011 and 47% of the deaths are believed to be avoidable. Most obstetric emergencies trainings are held off-site, away from the clinical area, for a limited number of staff.Relevant changesFollowing an in-hospital train-the-trainers course, 90% (138/153) of maternity staff were trained locally within the first year, with 299 hospital staff trained to date. Local system changes included: the introduction of a labour ward board, emergency boxes, colour-coded early warning observation charts and a maternity dashboard. In this hospital, these changes have been associated with a 34% reduction in hospital maternal mortality from 67 maternal deaths per 9078 births (0.74%) in 2011 compared with 48 maternal deaths per 9884 births (0.49%) in 2014.Lessons learntIntroducing obstetric emergencies training and tools was feasible onsite, improved clinical practice, was sustained by local staff and associated with improved clinical outcomes. Further work to study the implementation and effect of this intervention at scale is required.

Prevention of brachial plexus injury-12years of shoulder dystocia training: an interrupted time-series study.

To investigate management and outcomes of incidences of shoulder dystocia in the 12years following the introduction of an obstetric emergencies training programme. Interrupted time-series study comparing management and neonatal outcome of births complicated by shoulder dystocia over three 4-year periods: (i) Pre-training (1996-99), (ii) Early training (2001-04), and (iii) Late training (2009-12). Southmead Hospital, Bristol, UK, with approximately 6000 births per annum. Infants and their mothers who experienced shoulder dystocia. A bi-monthly multi-professional 1-day intrapartum emergencies training course, that included a 30-minute practical session on shoulder dystocia management, commenced in 2000. Neonatal morbidity (brachial plexus injury, humeral fracture, clavicular fracture, 5-minute Apgar score <7) and documented management of shoulder dystocia (resolution manoeuvres performed, traction applied, head-to-body delivery interval). Compliance with national guidance improved with continued training. At least one recognised resolution manoeuvre was used in 99.8% (561/562) of cases of shoulder dystocia in the late training period, demonstrating a continued improvement from 46.3% (150/324, P<0.001) pre-training, and 92% (241/262, P<0.001) in the early training period. In parallel there was reduction in the brachial plexus injury at birth (24/324 [7.4%, P<0.01], pre-training, 6/262 [2.3%] early training, and 7/562 [1.3%] late training. There are significant benefits to long-term, embedded training programmes with improvements in both management and outcomes. A decade after the introduction of training there were no cases of brachial plexus injury lasting over 12months in 562 cases of shoulder dystocia.

BJOG Editor's Choice

Women choose to have an elective caesarean section for the delivery of their second child for a variety of reasons. Most cases relate to previous caesarean section, some because of psychological reasons, such as unresolved delivery-related post-traumatic stress disorder, and others because of previous physical maternal birth trauma. The last includes previous serious perineal tears, the rate of which appears to be increasing across Europe. In the UK the rate of third- and fourth-degree perineal tears in primiparous women tripled from 1.8% to 5.9% during the period 2000–12 (Gurol-Urganci et al. BJOG 2013;120:1516–25) and in Finland it rose from 0.5% in 1997–99 to 1.8% in 2006/07 (Räisänen et al. Prev Med 2009;49:535–40). In Norway, in primiparous women, the rate rose from 0.6% in 1967 to 7% in 2004 and did so in parallel for both instrumental and noninstrumental deliveries. The rise persisted after adjusting for demographic and other risk factors and confounders (Baghestan et al. Obstet Gynecol 2010;116:25–34). Whether this rise is as a result of more accurate reporting or a change in practice is unclear. It has been suggested that the ‘hands off’ practice for normal delivery, promoted from the 1960s and 1970s (McCandlish, J Midwifery Womens Health 2001;46:396–401), may have contributed to the increased occurrence of obstetric anal sphincter injuries in noninstrumental deliveries. In the 1980s, when I was a very junior obstetrician and my wife was a very junior midwife, I am sure I was part of a culture where mild (e.g. 3a) tears as a result of an instrumental delivery were under-reported. At the same time my wife was part of a culture where midwives were expected to be very ‘hands on’ with their deliveries and even a second-degree tear was considered a heinous crime and would have the midwife brought before a formidable and unsympathetic midwifery sister. Regardless of the reasons for the increase in rate, a previous anal sphincter injury has important implications for a future delivery. On page 1695 Edozien et al. report findings from a UK-wide study of 639 402 primiparous women who had a singleton, vaginal, live birth between 2004 and 2011, and who also had a second birth by March 2012. They measured the mode of delivery and recurrence of tears at the second birth. For women who had a vaginal delivery at second birth, the rate of third/fourth-degree tear was 7.2% in women with a previous third/fourth-degree tear compared with 1.3% in women without. The latter finding is similar to most previous reports from smaller studies and will assist in counselling women who have had a previous anal sphincter injury. The rate of elective caesarean for the second birth in women who have had previous sphincter injury was 24%, a figure that is much higher than the range of 6–18% reported previously in other countries, but remarkably similar to the figure of 22% of UK obstetricians who, according to a recent survey, would recommend an elective caesarean section to prevent anal incontinence following previous anal sphincter injury (Fernando et al. BMC Health Serv Res 2002;2:9). Whether this advice is sound is unclear. The rate of faecal incontinence 12 years after delivery does not differ between women who have only elective caesarean sections and women who have only vaginal deliveries (MacArthur et al. BJOG 2011;118:1001–7). If we are to practice evidence-based obstetrics then a return to the ‘hands on’ approach to delivery may be a better solution, for which there is increasing evidence of benefit (Hals et al. Obstet Gynecol 2010;116:901–8; Stedenfeldt et al. BJOG 2014;121:83–91). Around 15% of cases of cerebral palsy are clearly attributable to adverse events during labour, of which nearly one-half are probably avoidable. On page 1720, using published data regarding the incidence and aetiology of cerebral palsy, Leigh et al. simulated the outcomes of a hypothetical cohort of UK live births using survival and quality-adjusted life-years analysis. They calculated that 207 (95% confidence interval 169–245) cases of asphyxia-related cerebral palsy were projected among UK children born during 2014, causing a loss valued by the NHS at £62.9 million. One proposed strategy to reduce error in the management of labouring women is the introduction of Practical Obstetric Multi-Professional Training (PROMPT), which involves hospital-based training comprising short lectures and scenario-based simulation training in obstetric emergencies delivered by trainers drawn from the hospital staff. On page 1710 we present a study from Australia on the effects of the introduction of PROMPT in eight maternity units, which includes an analysis of the effects on neonatal outcome in a total of 43 408 babies born before and after the time of its introduction. About 50% of all possible staff were trained in the first year of the programme. Statistically significant positive effects of training on neonatal outcomes are shown in Figures 1 and 2.

Team training in obstetric and neonatal emergencies using highly realistic simulation in Mexico: impact on process indicators

BackgroundIneffective management of obstetric emergencies contributes significantly to maternal and neonatal morbidity and mortality in Mexico. PRONTO (Programa de Rescate Obstétrico y Neonatal: Tratamiento Óptimo y Oportuno) is a highly-realistic, low-tech simulation-based obstetric and neonatal emergency training program. A pair-matched hospital-based controlled implementation trial was undertaken in three states in Mexico, with pre/post measurement of process indicators at intervention hospitals. This report assesses the impact of PRONTO simulation training on process indicators from the pre/post study design for process indicators.MethodsData was collected in twelve intervention facilities on process indicators, including pre/post changes in knowledge and self-efficacy of obstetric emergencies and neonatal resuscitation, achievement of strategic planning goals established during training and changes in teamwork scores. Authors performed a longitudinal fixed-effects linear regression model to estimate changes in knowledge and self-efficacy and logistic regression to assess goal achievement.ResultsA total of 450 professionals in interprofessional teams were trained. Significant increases in knowledge and self-efficacy were noted for both physicians and nurses (p <0.001- 0.009) in all domains. Teamwork scores improved and were maintained over a three month period. A mean of 58.8% strategic planning goals per team in each hospital were achieved. There was no association between high goal achievement and knowledge, self-efficacy, proportion of doctors or nurses in training, state, or teamwork score.ConclusionsThese results suggest that PRONTO’s highly realistic, locally appropriate simulation and team training in maternal and neonatal emergency care may be a promising avenue for optimizing emergency response and improving quality of facility-based obstetric and neonatal care in resource-limited settings.Trial registrationNCT01477554

Emergency peripartum hysterectomy and risk factors by mode of delivery and obstetric history: a 10-year review from Helsinki University Central Hospital.

This study aims to estimate the occurrence of emergency peripartum hysterectomy (EPH) and to quantify its risk factors in connection with the mode of delivery and the obstetric history of patients at the Helsinki University Central Hospital, Finland. In a retrospective, matched case-control study we identified 124 cases of EPH from 2000 to 2010 at our hospital. These were matched with 248 control patients. The incidence rate of EPH was 9.9/10,000. Patients whose current delivery was vaginal, and had a cesarean section (CS) in their history had a six-fold risk for EPH. Women who underwent their first CS had a nine times higher risk, while patients who currently underwent CS and had a history of previous CS, had a 22 times higher risk. Those who experienced prostaglandin-E1 induction had a five-fold risk. Maternal age >35 years, previous curettage, and twin pregnancy were identified as significant risk factors. In 41 cases, interventions to reduce bleeding were performed. Obstetric emergency training and guidelines for massive hemorrhage should be established in any delivery department. Moreover, all possible precautions should be taken to avoid the first CS if it is obstetrically unnecessary. Induction with prostaglandin-E1, maternal age >35 years, previous curettage, twin pregnancies, and early gestation were identified as risk factors for EPH.

Introducing an obstetric emergency training strategy into a simulated environment

Midwifery educators are challenged to produce registrants who are fit for practice at the point of registration with competence at the heart of this expectation. In addition to achieving expertise in normal pregnancy, it is recognised that students need to have the skills of critical decision making where normal processes become adversely affected. An evaluation was undertaken with final year direct entry midwifery students using questionnaires and focus group interviews to determine whether simulated learning, such as the Practical Obstetric Multi-Professional Training (PROMPT) package, for emergency obstetric training would enhance self-efficacy and confidence levels in preparation for post-registration practice. The main themes that emerged from the study indicate that this style of learning increased midwifery students’ feelings of self-efficacy; highlighted the importance of a safe learning environment; reduced their anxiety regarding their ability to make decisions in clinical practice and reinforced confidence in their level of knowledge.

Board 439 - Research Abstract High-Fidelity Low-Tech Team Training in Obstetric and Neonatal Emergencies in Rural Mexico Changes Provider Knowledge, Self-Efficacy, Team Coordination and Identifies Latent Systems Errors. (Submission #814)

Board 439 - Research Abstract High-Fidelity Low-Tech Team Training in Obstetric and Neonatal Emergencies in Rural Mexico Changes Provider Knowledge, Self-Efficacy, Team Coordination and Identifies Latent Systems Errors. (Submission #814)

Emergency obstetric simulation training: How do we know where we are going, if we don't know where we have been?

Obstetric emergencies contribute significantly to maternal morbidity and mortality. Current training in the management of obstetric emergencies in Australia and internationally focusses on utilising a multidisciplinary simulation-based model. Arguments for and against this type of training exist, using both economic and clinical reasoning. To identify the evidence base for the clinical impact of simulation training in obstetric emergencies and to address some of the concerns regarding appropriate delivery of obstetric emergency training in the Australian setting. A literature search was performed to identify research undertaken in the area of obstetric emergency training. The initial literature search using broad search terms identified 887 articles which were then reviewed and considered for inclusion if they provided original research with a specific emphasis on the impact of training on clinical outcomes. Ninety-two articles were identified, comprising evidence in the following clinical situations: eclampsia, shoulder dystocia, postpartum haemorrhage, maternal collapse, cord prolapse and teamwork training. Evidence exists for a benefit in knowledge or skills gained from simulation training and for the benefit of training in small units without access to high-fidelity equipment or facilities. Evidence exists for a positive impact of training in obstetric emergencies, although the majority of the available evidence applies to evaluation at the level of participants' confidence, knowledge or skills rather than at the level of impact on clinical outcomes. The model of simulation-based training is an appropriate one for the Australian setting and should be further utilised in rural and remote settings.

G146(P) The Impact of Teamwork and Practical Skills Training in Obstetric Emergencies and Neonatal Resuscitation at a Tertiary Hospital in Ethiopia

AimsTo evaluate the effect on the stillbirth rate at a tertiary institution in a low-resource setting through the development of a multi-disciplinary training programme using local trainers.MethodsTwenty-one senior staff (anaesthetists,...

The obstetric caseload of a physician-based helicopter emergency medical service: case review and recommendations for retrieval physician training

BackgroundThe Greater Sydney Area Helicopter Emergency Medical Service provides physicians for undertaking prehospital and inter-hospital critical care. We quantified the obstetric caseload of our service with respect to primary diagnosis...

Critique of the pre-hospital obstetric emergency training course: ALSG

Pre-hospital obstetric incidents account for a significant number of emergency calls to the ambulance service, with obstetric emergencies being one of the most challenging situations that pre-hospital practitioners encounter. The mortality associated to obstetric emergencies has shown significant decline over recent years due to improved obstetric education, advances in surgery and improved maternal care. Additionally, the development of the Confidential Enquiry into Maternal and Child Health (CEMACH) has identified patterns of sub-optimal practice and has provided recommendations on how to improve the maternity services and obstetric care available to all pregnant patients. One of the most influential recommendations to come out of this document was the apparent need to improve education of basic, intermediate and advanced life support in obstetric emergencies, which lead to the introduction of advanced obstetrics and gynaecology becoming compulsory elements within the paramedic curriculum. The need for organisation and ambulance trusts to provide specialist training into obstetric emergencies was also identified within this enquiry (Confidential Enquiry into Maternal and Child Health, 2007; Advanced Life Support Group, 2010). In order facilitate the development of prehospital obstetric education; several programmes have been written which allowed for paramedics to maintain their continuous personal development through the competition of a short ‘crash course’ in obstetric care. One of the most successful courses of this type available to prehospital clinicians is the pre-hospital emergency training course (POET) delivered by the advanced life support group. Within this article, a review of this course will take place in order for readers to gain an understanding into the course content and the benefits of undertaking such course as part of the clinician’s continuous personal development. The authors of this article have recently completed the POET course, held in Manchester, which was the inspiration for this piece.

M172 SIMULATION TRAINING IN OBSTETRIC EMERGENCIES

International Journal of Gynecology & ObstetricsVolume 119, Issue S3 p. S588-S588 Poster presentations M172 SIMULATION TRAINING IN OBSTETRIC EMERGENCIES K.L. Ng, K.L. NgSearch for more papers by this authorM.Y. Lim, M.Y. LimSearch for more papers by this authorE.K. Tan, E.K. TanSearch for more papers by this author K.L. Ng, K.L. NgSearch for more papers by this authorM.Y. Lim, M.Y. LimSearch for more papers by this authorE.K. Tan, E.K. TanSearch for more papers by this author First published: 22 October 2012 https://doi.org/10.1016/S0020-7292(12)61366-6AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume119, IssueS3Abstracts of XX FIGO World Congress of Gynecology and ObstetricsOctober 2012Pages S588-S588 RelatedInformation

127: Effectiveness of multidisciplinary team training in obstetric emergencies: a randomized controlled trial

127: Effectiveness of multidisciplinary team training in obstetric emergencies: a randomized controlled trial

PRONTO training for obstetric and neonatal emergencies in Mexico

Objective To evaluate the acceptability, feasibility, rating, and potential impact of PRONTO, a low-tech and high-fidelity simulation-based training for obstetric and neonatal emergencies and teamwork using the PartoPants low-cost birth simulator. Methods A pilot project was conducted from September 21, 2009, to April 9, 2010, to train interprofessional teams from 5 community hospitals in the states of Mexico and Chiapas. Module I (teamwork, neonatal resuscitation, and obstetric hemorrhage) was followed 3 months later by module II (dystocia and pre-eclampsia/eclampsia) and an evaluation. Four elements were assessed: acceptability; feasibility and rating; institutional goal achievement; teamwork improvement; and knowledge and self-efficacy. Results The program was rated highly both by trainees and by non-trainees who completed a survey and interview. Hospital goals identified by participants in the module I strategic-planning sessions were achieved for 65% of goals in 3 months. Teamwork, knowledge, and self-efficacy scores improved. Conclusion PRONTO brings simulation training to low-resource settings and can empower interprofessional teams to respond more effectively within their institutional limitations to emergencies involving women and newborns. Further study is warranted to evaluate the potential impact of the program on obstetric and neonatal outcome.

Practical simulation training for maternity care—where we are and where next

Improving maternal and perinatal care is a global priority. Practical simulation training for maternity care might prevent many of these deaths. There have been numerous evaluation studies published on the effectiveness of simulation training for obstetric emergencies, with increasing evidence that it is associated with improvement in clinical outcomes. Evidence has begun to move from subjective assessment of participants' experiences towards objective assessment of clinical outcomes. However, the results are not entirely consistent and, at present, all of the evidence associating training with improvements in clinical outcomes relates to neonatal outcomes. This review summarises recent progress in the evaluation of the effectiveness of simulation training for maternity care in both high- and low-resource settings, and presents a vision for ensuring that practical simulation training for maternity care can become an effective tool to reduce global maternal and perinatal morbidity and mortality.

Entrenamiento de equipos interdisciplinares en urgencias obstétricas mediante simulación clínica

Objectives To describe the healthcare team training in obstetric emergencies using clinical simulation with an interdisciplinary approach, developed at the Hospital virtual Valdecilla. Material and methods The program was aimed at health professionals involved in emergency obstetric care (obstetricians and gynecologists, anesthesiologists, intensivists and midwives). A working team was established to define the objectives, design the scenarios, and coordinate the completion of each course. Two simulation rooms were available with patient simulators, control rooms and audiovisual recording systems, an analysis room, a multipurpose classroom, and diverse medical and surgical equipment. To analyze the results of the program, the participants completed an evaluation survey. Results A total of 30 members of clinical teams underwent training in the clinical entities most frequently involved in cases of maternal mortality (postpartum hemorrhage, amniotic fluid embolism and eclampsia), selected from the results of a survey of maternal death mailed to 69 Spanish hospitals. Each course consisted of three clinical cases performed in the operating room, postpartum and birthing room, followed by a debriefing session. Participants rated the courses as highly useful, highlighted the opportunity provided by clinical simulation to practice without risk and to train teamwork skills, and would recommend their peers to undergo the same training. Conclusions Training of healthcare teams in obstetric emergencies using simulation with an interdisciplinary approach provides safe and effective practice of diagnostic and treatment algorithms, as well as of communication and teamwork skills, before these situations are met in daily practice.