Obstetric Simulation Research Articles

Efficacy of Obstetric Simulation in the Learning of Skills Related to Birthing Care in Medical Students, Medellin-Colombia

Introduction: In Colombia, studies regarding the effectiveness of simulation-based medical training programmes are scarce. Objective: To evaluate the effectiveness of a simulationbased obstetric educational intervention in the learning of skills related to birthing care in medical students in Medellin (Colombia). Methods: A randomized experimental study of 28 students who received the intervention and 21 students who did not receive the intervention and served as the control group. A scale was constructed and psychometrically evaluated to measure competencies in three domains, Being, Knowing, and Doing, in birthing care; this scale was applied before and after the intervention, generating a rating between 0 (poorest) and 100 (best). The effectiveness of the educational intervention was evaluated using differences-indifferences and linear regression analysis. Results: The scale showed excellent psychometric properties in the domains of knowing and doing, with Cronbach’s α-value greater than 0.80; furthermore, 100% success in internal consistency, discriminant power, and content validity added to the high explained variance. The intervention did not generate significant changes in the competency in the being domain and was effective in improving competencies in the Knowing and Doing domains, with increases of 23.9 and 27.2 points, respectively. Conclusion: The simulation-based birth-related skills learning programme was effective in increasing the competencies of knowing and doing in medical students.

Simulation Training in Obstetrics.

Simulation now permeates all levels of training in obstetrics and maternal-fetal medicine. We will review the role of obstetric simulation through the continuum of training and practice. Simulation allows learners to acquire skills in a nonthreatening environment while avoiding harm to patients. Simulation in obstetrics evolved from a learning tool for students and residents, to a method for experienced physicians to learn new procedures and reenter the full breadth and depth of practice. Specialty boards and credentialing organizations recognize simulation training as an innovative approach to assess and assure technical, clinical, and teamwork skills.

Improving Interprofessional Communication Utilizing Obstetric Simulation Training

BACKGROUND: Effective interprofessional communication requires clear, concise, and respectful participation from each provider. Simulation has been shown to improve teamwork and patient safety in nonobstetric fields. Whether the benefit of interdisciplinary participation in simulation extends to the obstetric population is unknown. METHODS: We conducted a prospective educational trial involving obstetric residents and L&D nurses. Participants were administered a pretest examining their perception of interprofessional communication and cooperation with responses measured on a Likert scale. Participants then underwent an obstetric simulation, watched their video-taped performance, participated in a structured debrief and educational session, and then repeated the simulation. Following the simulation, they were administered a posttest to assess changes in their perception of communication and cooperation. RESULTS: Eighteen L&D nurses and 17 obstetric residents participated in the trial. Following simulation, participants were more likely to report that they feel respect from other providers (P=.0087), use closed-loop communication (P<.001), designate a clear leader (P=.0009), read back verbal orders (P=.0002), conduct a nonaccusatory debrief (P=.0491), and view both their communication and communication from others as clear and effective (P=.0043 and P=.0042, respectively). DISCUSSION: Obstetric simulation can be used to improve effective interprofessional communication and cooperation. Continued use of interdisciplinary simulation in obstetrics should be encouraged to promote a commitment to patient safety.

Using Interprofessional OSCE-Based Simulation Collaboration to Teach Obstetrics to Second-Year Medical Students

BACKGROUND: We have shown that it is possible to introduce an obstetric simulation program to preclinical 2nd-year medical students. In the second year of our obstetrics simulation curriculum for 2nd-year medical students, we introduced OSCE assessment in collaboration with the nursing school educator with the program occurring in the nursing school simulation center in November 2015. METHODS: Students rotated through three stations: 1) simulated vaginal delivery demonstrated by nurse educator and OBGYN resident; 2) MFM faculty gave interactive presentation on fetal heart rate (FHR), a student nurse then role played with students and they were assessed by OSCE format; and 3) OBGYN resident and faculty taught and assessed students on cervical dilation using cervical models. Students completed surveys on attitude, knowledge before, after and 7 months postcurriculum. RESULTS: Of 95 students, mean scores for the FHR OSCE were: identifies FHR baseline=0.97, identifies FHR variability=0.92, provides accurate identification of periodic pattern=0.73, identifies FHR category=0.67 and orders appropriate medical interventions=0.93. For the cervical station OSCE, the mean score on cervical examination skills after training was 75%. For the knowledge questions on obstetrics and fetal heart rate monitoring, students obtained a mean prescore of 2.57±0.09, postsimulation the mean score increased to 3.24±0.11 (P=.12). Presimulation; students scored their comfort level with obstetric procedures as 12.2±0.63, after simulation the mean score increased to 28±0.63 (P<.001). DISCUSSION: We have demonstrated the feasibility of an OSCE-based inter-professional educational curriculum utilizing nursing, physician and resident faculty instructing medical students and nursing students jointly. For FHR teaching, the concept of FHR category was the most challenging for the students to grasp. The course improved students' short-term knowledge but had dropped back to baseline by 7 months. Students' comfort level increased immediately posttraining and decreased but was still higher than baseline at 7 months. Further curriculum development is undergoing on increasing long term knowledge gain.

Interdisciplinary Obstetric Simulation for Common Obstetric Emergencies

BACKGROUND: Duty hour restrictions limit trainee exposure to obstetric emergencies. Additionally, nursing turnover creates an area of need for increased education for preparation for these emergencies. Simulation has been used to improve physician performance, communication, and medical documentation; however, whether these benefits extend to all providers is understudied. METHODS: We conducted a quasi-randomized prospective educational trial targeted toward L&D nurses with less than 2 years' experience and junior obstetric residents. Participants were exposed to a pretest examining their knowledge (multiple choice, yes/no, free text responses) and comfort level (measured utilizing the Likert scale) with three common obstetric emergencies: shoulder dystocia, emergency cesarean delivery, and eclampsia. Participants underwent a simulation of one of the scenarios, watched their video-taped performance, participated in a debrief and educational session, and then repeated the simulation. Participants were administered a posttest following the simulation. RESULTS: Eighteen L&D nurses and 17 obstetric residents participated. Examination of the pre- and posttest results revealed improvements in the comfort level with shoulder dystocia maneuvers (P=.0178), communication during a shoulder dystocia (P=.0339), medical management of an eclamptic seizure (P=.0190), and knowledge of how to appropriately administer magnesium to an eclamptic patient without an IV (P=.0047). DISCUSSION: Interdisciplinary collaboration through the use of obstetric simulation can be utilized to improve knowledge and comfort necessary for the management of obstetric emergencies for both obstetric residents and L&D nurses.

What Is New in Obstetrics and Gynecology Simulation?: Best Articles From the Past Year.

This month we focus on obstetrics and gynecology simulation. Dr. Burda discusses four recent publications, which are concluded with a "bottom line" that is the take-home message. The complete reference for each can be found in on this page, along with direct links to the abstracts.

Keeping in time: Issues affecting the sustainability of obstetric emergency simulation training in outer metropolitan, rural and remote centres in Western Australia.

Obstetric emergency simulation training is an evidence-based intervention for the reduction of perinatal and maternal morbidity. In Western Australia, obstetric emergency training has been run using the In Time course since 2006. The study aimed to determine if the provision of In Time train the trainer courses to outer metro, rural and remote units in Western Australia had led to sustained ongoing training in those units. Ten years following the introduction of the course, we performed a survey to examine which units are continuing to run In Time, what are the perceived benefits in units still utilising In Time, and what were the barriers to training in units that had discontinued. A link to an online survey was sent to the units where In Time training had occurred. Telephone enquiries were additionally used to ensure a good response rate. The survey response rate was 100%. Six of the 11 units where training had been provided continue to run In Time. Units where training had discontinued had done so in order to take up alternatives, or as a result of trainers leaving. Of the units who had discontinued training, one wished to recommence In Time. Local in situ training in obstetric emergencies as exemplified by the In Time course remains a popular and valued training intervention across Western Australia. This training may be of particular benefit to small and remote units, but these are the areas in which training is hardest to sustain.

Developing a Canadian Curriculum for Simulation-Based Education in Obstetrics and Gynaecology: A Delphi Study.

As obstetrics and gynaecology (Ob/Gyn) residency training programs move towards a competence-based approach to training and assessment, the development of a national standardized simulation curriculum is essential. The primary goal of this study was to define the fundamental content for the Canadian Obstetrics and Gynecology Simulation curriculum. A modified Delphi technique was used to achieve consensus in three rounds by surveying residency program directors or their local simulation educator delegates in 16 accredited Canadian Ob/Gyn residency programs. A consensus rate of 80% was agreed upon. Survey results were collected over 11 months in2016. Response rates for the Delphi were 50% for the first round, 81% for the second round, and 94% for the third round. The first survey resulted in 84 suggested topics. These were organized into four categories: obstetrics high acuity low frequency events, obstetrics common events, gynaecology high acuity low frequency events, and gynaecology common events. Using the modified Delphi method, consensus was reached on 6 scenarios. This study identified the content for a national simulation-based curriculum for Ob/Gyn residency training programs and is the first step in the development of this curriculum.

Shoulder Dystocia and Neonatal Resuscitation: An Integrated Obstetrics and Neonatology Simulation Case for Medical Students.

The new model in medical education of longitudinal clinical clerkships can be complemented by high-technology simulation, which provides a safe space for learners to consolidate clinical knowledge and practice decision-making skills, teamwork, and communication. We developed an interdisciplinary training intervention including a simulation case and structured debriefing to link clinical content between pediatrics and obstetrics at a major academic medical center. In this case, a 38-year-old female at 38 weeks gestation presents with onset of labor complicated by shoulder dystocia. After the appropriate maneuvers, a depressed neonate is delivered and requires resuscitation. Major equipment needed includes a high- or low-technology birthing mannequin and an infant mannequin. Fifty-four third-year medical students participated in this simulation-based intervention at the completion of their integrated pediatrics and obstetrics clerkship. Ninety-one percent of students agreed that the shoulder dystocia simulation was designed appropriately for their learning level and enhanced their ability to handle a risky delivery. Ninety-four percent agreed that the neonatal resuscitation simulation was designed appropriately for their learning level, and 89% reported an enhanced ability to handle a similar situation in the clinic following the intervention. The average overall ratings were 4.24 (SD = 0.61) and 4.06 (SD = 0.89) on a 5-point scale (1 = poor, 5 = excellent) for the obstetrics and pediatrics simulations, respectively. The integrated obstetrics and pediatrics scenario is feasible to run and clinically accurate. Two distinct areas of medicine in the third-year curriculum are logically incorporated into one cohesive simulation-based training intervention that students found positive and realistic.

Educating Rural Nursing Students About Appropriate Responses to Obstetric Emergencies

The increase in rural hospital closings coupled with a decrease in maternity services mean training nonobstetric personnel is essential when dealing with emergent obstetric situations. There is also a struggle to expose students to high-risk clinical situations. This project was initiated with bachelor of science in nursing (BSN) students in a rural area. To incorporate a rural community-level obstetric emergency simulation into a BSN maternal nursing course. The goal is to identify complications early in order to decrease maternal and infant morbidity and mortality. Students in a maternal–child nursing course were placed in a simulated rural emergency room setting and given obstetric emergent situations. The students previously completed content on pregnancy, labor, birth, and high-risk situations. At the end of the semester, students answered four critical thinking questions on a final examination regarding simulated situations. Students answered examination questions with a minimum of 75% accuracy. During obstetric emergencies, students demonstrated life-saving measures, including early identification, prioritizing interventions, and recall of useful resources. New graduate nurses with appropriate training will be better prepared to provide care in their communities. In addition, community health care training can increase preparedness in areas with low birth volumes and/or nonobstetric facilities. Use of obstetric emergency simulation training in clinics, for emergency medical services (EMS) and rural emergency departments can provide hands-on experience to licensed personnel within these settings. Collaboration with these professionals may help prevent adverse maternal and fetal outcomes.

Teamwork Assessment Tools in Obstetric Emergencies: A Systematic Review.

Team-based training and simulation can improve patient safety, by improving communication, decision making, and performance of team members. Currently, there is no general consensus on whether or not a specific assessment tool is better adapted to evaluate teamwork in obstetric emergencies. The purpose of this qualitative systematic review was to find the tools available to assess team effectiveness in obstetric emergencies. We searched Embase, Medline, PubMed, Web of Science, PsycINFO, CINAHL, and Google Scholar for prospective studies that evaluated nontechnical skills in multidisciplinary teams involving obstetric emergencies. The search included studies from 1944 until January 11, 2016. Data on reliability and validity measures were collected and used for interpretation. A descriptive analysis was performed on the data. Thirteen studies were included in the final qualitative synthesis. All the studies assessed teams in the context of obstetric simulation scenarios, but only six included anesthetists in the simulations. One study evaluated their teamwork tool using just validity measures, five using just reliability measures, and one used both. The most reliable tools identified were the Clinical Teamwork Scale, the Global Assessment of Obstetric Team Performance, and the Global Rating Scale of performance. However, they were still lacking in terms of quality and validity. More work needs to be conducted to establish the validity of teamwork tools for nontechnical skills, and the development of an ideal tool is warranted. Further studies are required to assess how outcomes, such as performance and patient safety, are influenced when using these tools.

Long-Term Skills Retention After Obstetric Simulation Training for Skilled-Birth Attendants in Rural Rwanda [9D

INTRODUCTION: The World Health Organization advocates for the presence of attendants at every birth skilled at managing normal pregnancies and obstetrical complications. We aimed to evaluate the long-term skills retention gained by skilled birth attendants (SBAs) who completed a spontaneous vaginal delivery (SVD) and postpartum hemorrhage (PPH) simulation-training program. METHODS: A pre-post intervention study was conducted with a convenience sample of SBAs in rural Rwanda. Two separate groups of SBAs underwent initial simulation training with pre- and immediate post-testing. Group A had training in February 2013. Group B had training in February 2014. Simulation drills to assess skill retention were conducted in September 2015 for both groups. Participants were scored on communication, evaluation, and management skills. Median scores were calculated and the Wilcoxon signed-rank sum test compared the pre-training, post-training, and retention scores. RESULTS: 68% (13/19) of SBAs in Group A and 53% (8/15) SBAs in Group B were available for the skill-retention evaluation. There were no demographic, experiential, or educational differences between groups. After training, both groups showed immediate improvement in almost all the areas evaluated. At 2 years, Group A showed significant falls in their scores in three of the areas evaluated while group B at 1 year demonstrated a decline in only one of the areas evaluated. CONCLUSION: Simulation training is an effective method for acquisition of SVD and PPH skills in low resource settings. Most skills were retained 1 year after the initial training, but lost after 2 years, which suggests that training should be conducted on a yearly basis.

THE OBSTETRICS, GYNECOLOGY AND PERINATOLOGY SIMULATION TRAINING CENTER OF VOLGOGRAD STATE MEDICAL UNIVERSITY: A CONTRIBUTION TO THE SOLUTION OF PROBLEMS OF REGIONAL HEALTHCARE

This article contains the description of basic overall results of three year activity (2014-2017) of the Obstetrics, Gynecology and Perinatology Simulation Training Center of Volgograd State Medical University and its contribution to the solution of problems of regional healthcare and the prospective ways of its effective using.

Improving students’ ability to perform a standardized foetal biometry plane using ultrasound simulators

ObjectiveThe objective of this study is to assess progress made in the ultrasound (US) measurement of femur length (FL) by students after one hour of training on US obstetric simulators. Materials and methodsMedical residents and midwives registered for the 2016 French national foetal US diploma were invited to a 1-hour US training course with simulators. The time to acquire the FL plane with changing foetal presentation was prospectively measured before and after the training. Every image was recorded, and quality criteria were assessed. ResultsThirty new learners trained in foetal US were evaluated. The time needed to measure the FL was significantly shorter in the post-test versus the pre-test (86s versus 125, P=0.015). The quality criteria were statistically similar before and after training regarding the angle to horizontal (10.0° versus 9.6°, P=0.84) and FL (31.3mm versus 32.0mm, P=0.15). ConclusionThe time needed to obtain the FL plane was reduced by 30% after a 1-hour US simulation training session.

Impact of Video Coaching on Gynecologic Resident Laparoscopic Suturing: A Randomized Controlled Trial

Study ObjectiveTo determine if the addition of video coaching to an obstetrics and gynecology resident laparoscopic simulation curriculum improves acquisition of suturing skills. DesignRandomized controlled trial (Canadian Task Force classification I). SettingAcademic teaching hospital with a residency program in obstetrics and gynecology. PatientsTwenty obstetrics and gynecology residents undergoing a 4-week laparoscopic simulation curriculum were video recorded weekly performing a suturing task on a validated vaginal cuff model. InterventionsResidents were randomized to standard simulation curriculum or standard curriculum plus weekly video coaching by an expert laparoscopic surgeon. Primary outcome measure was comparison of weekly Global Operative Assessment of Laparoscopic Skills plus Vaginal Cuff Metrics (GOALS+) scores of the suturing task. Measurements and Main ResultsBaseline GOALS+ scores did not differ across training groups (p = .406), although “senior” (postgraduate years 3 and 4) residents initially had significantly higher GOALS+ scores than “junior” (postgraduate years 1 and 2) residents (p < .001). GOALS+ scores significantly improved from week 1 to week 2 in the intervention group compared with the control group (p < .05). Junior coached residents had significantly higher GOALS+ scores at week 2 (mean, 28.06; standard deviation, 3.10) compared with the junior control residents (mean, 20.75; standard deviation, 6.38; p < .04). Over the 4-week period all residents showed significant improvement (p = .005), with novice residents improving more than experienced residents (p = .001). The junior coached residents exhibited a significant difference between weeks 1 and 2 when compared with the junior residents undergoing the standard curriculum. ConclusionVideo coaching during laparoscopic simulation training has the greatest impact early in junior learners' skill acquisition, thus providing another tool for simulation training curricula.

Simulation in General Obstetrics and Gynecology

Obstetrical simulation dates from the Paleolithic period. Gynecologic simulation has its origins in the 1920s Link box trainers. By improving maternal-fetal outcomes, obstetric simulation secures our existence. Improved maternal-fetal outcomes create a need for gynecologic surgery and simulation. Therefore, gynecologic simulation may be an afterthought that has yet to attain a validated place in medical education and professional practice. The objectives of this review article are to assess the scope of simulation in obstetrics and gynecology, identify simulation’s strengths and weaknesses, review barriers to simulation growth in obstetrics and gynecology, and present a route forward. Google scholar and Google Internet searches phrased “simulation obstetrics gynecology”, performed on November 25, 2015 yielded 29 references from 2001 to 2015. PubMed search on December 19, 2015, terms “simulation obstetrics gynecology, found 12 relevant, non-redundant articles. Additional Google scholar hand search on December 20, 2015, and September 14, 2016 yielded 45 articles for timely topic completion. Post-Halstedian apprenticeship based medical training guarantees an ever-increasing role of simulation in obstetrics and gynecology training. Patient safety, healthcare quality, and healthcare provider credentialing concerns assure the future of medical simulation. Given positive association with neonatal outcomes, medical student interest in obstetrics, and obstetrics team building, obstetrics simulation has proven itself. Gynecologic simulation needs to address fidelity, reliability, and validity concerns to secure an enduring position in gynecologic education and professional practice.

Building Comprehensive Strategies for Obstetric Safety: Simulation Drills and Communication.

As pioneers in the field of patient safety, anesthesiologists are uniquely suited to help develop and implement safety strategies to minimize preventable harm on the labor and delivery unit. Most existing obstetric safety strategies are not comprehensive, lack input from anesthesiologists, are designed with a relatively narrow focus, or lack implementation details to allow customization for different units. This article attempts to address these gaps and build more comprehensive strategies by discussing the available evidence and multidisciplinary authors' local experience with obstetric simulation drills and optimization of team communication.

Obstetric team simulation program challenges

ObjectiveTo describe the challenges associated with the development and assessment of an obstetric emergency team simulation program. DesignThe goal was to develop a hybrid, in-situ and high fidelity obstetric emergency team simulation program that incorporated weekly simulation sessions on the labor and delivery unit, and quarterly, education protected sessions in the simulation center. All simulation sessions were video-recorded and reviewed. SettingLabor and delivery unit and simulation center. ParticipantsMedical staff covering labor and delivery, anesthesiology and obstetric residents and obstetric nurses. MeasurementsAssessments included an on-line knowledge multiple-choice questionnaire about the simulation scenarios. This was completed prior to the initial in-situ simulation session and repeated 3 months later, the Clinical Teamwork Scale with inter-rater reliability, participant confidence surveys and subjective participant satisfaction. A web-based curriculum comprising modules on communication skills, team challenges, and team obstetric emergency scenarios was also developed. Main resultsOver 4 months, only 6 labor and delivery unit in-situ sessions out of a possible 14 sessions were carried out. Four high-fidelity sessions were performed in 2 quarterly education protected meetings in the simulation center. Information technology difficulties led to the completion of only 18 pre/post web-based multiple-choice questionnaires. These test results showed no significant improvement in raw score performance from pre-test to post-test (P=.27). During Clinical Teamwork Scale live and video assessment, trained raters and program faculty were in agreement only 31% and 28% of the time, respectively (Kendall's W=.31, P<.001 and W=.28, P<.001). Participant confidence surveys overall revealed confidence significantly increased (P<.05), from pre-scenario briefing to after post-scenario debriefing. ConclusionProgram feedback indicates a high level of participant satisfaction and improved confidence yet further program refinement is required.

The Role of Ultrasound Simulation in Obstetrics and Gynecology Training: A UK Trainees' Perspective.

Ultrasonography is a core skill required by all obstetrics and gynecology trainees; however, training opportunities in clinical ultrasound are declining. Simulation ultrasound training has been proposed as a strategy to overcome this.The study aims were to determine the current availability of clinical and simulation ultrasound training in obstetrics and gynecology in the United Kingdom and to explore the trainees' perspective on the role of ultrasound simulation. All obstetrics and gynecology trainees within the East Midlands Local Education Training Board in the United Kingdom were asked to complete an anonymous web-based survey in July 2014. Of 140 trainees, 70 (50%) responded to the survey, and 69% reported rarely having dedicated clinical ultrasound sessions. Fifty percent had failed to achieve ultrasound competencies required for their stage of training, and 83% felt that the pressures of service provision limited their exposure to clinical ultrasound.Seventy-three percent of the trainees considered ultrasound simulation to be an essential component of training, and 69% agreed that it would help improve their clinical skills. Only 50% had access to an ultrasound simulator. Seventy-seven percent of the trainees thought that it would be useful to have ultrasound simulation integrated into training. Trainees are struggling to achieve minimal ultrasound competences with clinical ultrasound training alone. They believe that ultrasound simulation will shorten the learning curve and improve their clinical skills and knowledge. Despite the cost implications of simulation training, we propose that consideration is given to formal integration of ultrasound simulation into the curriculum as a possible way forward.

Designing and implementing an in-situ emergency obstetric and neonatal care (EmONC) simulation and team-training curriculum for midwife mentors to drive quality improvement in Bihar, India

Designing and implementing an in-situ emergency obstetric and neonatal care (EmONC) simulation and team-training curriculum for midwife mentors to drive quality improvement in Bihar, India