The Use of Simulation to Teach Clinical Skills in Obstetrics

doi:10.1053/j.semperi.2011.01.005

Seminars in Perinatology

Volume 35, Issue 2, April 2011, Pages 68-73

https://doi.org/10.1053/j.semperi.2011.01.005 Get rights and content

Obstetrical practice demands sensitivity, clinical skill, and acumen. Obstetrical emergencies are rare occurrences and are most appropriately dealt with by experienced staff. Simulation provides an opportunity to gain this experience without patient risk and furthermore builds confidence and satisfaction amongst learners. There is an abundance of evidence to show the effectiveness of simulation training. Simulation has been demonstrated to reduce errors, increase knowledge, skills, communication and team working, and improve perinatal outcomes. Further research to measure the effect of training to identify what works, where and at what cost is needed. We explore the evidence for the use of simulation-based training across a broad range of obstetrical emergencies, promote collaboration amongst disciplines and discuss the formal introduction of simulation training into a curriculum. Reducing preventable harm in obstetrics is a priority for families and society at large and this article endeavors to highlight the role that simulation has to play.

Section snippets

Objective Evidence of the Effect of Simulation

There have now been several studies in which the authors evaluated the effectiveness of simulation training in obstetrical emergencies. Training can occur in a variety of settings and incorporate practical training to improve knowledge and clinical skills and training as part of a team to develop team working ability, communication and attitudes. This article discusses the use of simulation-based training across a broad range of obstetrical emergencies.

Simulation Training in Rural Environments

Simulation training is not solely confined to the developed world. The introduction of training with the Essential Newborn Care course, a 3-day course based in a hospital setting in 6 countries (Argentina, Democratic Republic of the Congo, Guatemala, India, Pakistan, and Zambia) showed a significant improvement in the reduction of stillbirth. The outcomes of 57,643 infants were studied where the rate of stillbirth fell from 23 per 1000 to 15.9 per 1000. Those involved included specialists and

Simulation as Part of Institutional Risk Management

The Society of Obstetricians and Gynaecologists of Canada has developed a multidisciplinary 1-day course, “Managing Obstetric Risks Efficiently” (MOREOB), in an attempt to address the high litigation and culture of blame focus of the specialty. This program has been disseminated to 126 hospitals, overall dealing with 48% of the births in Canada. A review of its impact in 2007 has shown knowledge enhancement in all disciplines and in all practice environments, with a significant reduction in

Common Themes for Effectiveness

It is clear that simulation training is an essential part of progress to improve outcomes, however creating the ideal and most effective program that encompasses all aspects of clinical approach, team working and communication is a challenge. In 1 UK center in-house training for the management of shoulder dystocia was associated with an increased adverse outcomes, including perinatal asphyxia and brachial plexus injuries, those exact sequelae that the training was introduced to prevent. The

Patient Perception

Obstetrical emergency situations occur in the presence of a conscious patient with close relatives where the safety of a much loved and anticipated baby is at stake. These events are often recounted to friends and family and remembered forever. Training in communication both to the patient and among team members is important to ensure that the needs of the mother and birth partner are also considered.

Simulation training can build confidence in the learners' ability to perform tasks in an

The Future

There is no doubt that simulation training can contribute to improve maternal and neonatal outcomes. Obstetrical emergencies are thankfully rare; however, the reduced working hours of junior doctors further contributes to the lack of exposure to real life emergency training. In addition, the sensitive nature of obstetrics demands trust, empathy, and reassurance and simulation can aid in building confidence and satisfaction amongst learners. Simulation is thus a foundation for training. There is

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A preliminary quantification of the clinical gesture during vacuum assisted delivery on a training dummy
2023, Clinical Biomechanics
The vacuum assisted delivery represents, in France, the most used operative vaginal delivery technique. The purpose was to provide a preliminar quantification of the operator's hand kinematics while performing a vacuum assisted delivery.
A group of 21 participants composed of 12 trainees and 9 obstetricians were recorded performing a vacuum assisted delivery on a training dummy, the matching fetal presentation was a left occiput anterior position.
The mean movement was composed of a first phase corresponding to a descendant pull, followed by an ascendant finish of the gesture. No significative difference were found between the trainees and the obstetricians' mean gesture.
This is the first quantification of the clinical gesture associated with the vacuum assisted delivery.
Simulation of the peri-mortem caesarean; beyond the «know-how»
2021, Educacion Medica
Introducción La simulación clínica ha sido uno de los principales avances en la didáctica para la formación de profesionales de la salud. Diferentes autores identifican la necesidad del fortalecimiento de las habilidades en el recurso humano, entendidas estas como la transferencia del conocimiento en escenarios reales o simulados; además, muestran a través de la evidencia científica y desde una postura crítica la necesidad de avanzar más allá de la capacidad.
Valorar el desarrollo de pensamiento crítico a partir de la simulación clínica de la cesárea perimortem en cada una de sus etapas (diagnóstico, intervención y reflexión).
Estudio cualitativo comprensivo. Se diseña una rúbrica y se aplica a un equipo de respuesta de un hospital de tercer nivel de la ciudad de Manizales (Colombia), con el fin de valorar el desarrollo del pensamiento crítico. A partir de la observación y el uso del debriefing, se identificaron los niveles bajo, medio y alto de la competencia del equipo (23 personas del equipo de salud).
Se identifica que el nivel de pensamiento crítico se encuentra entre «alto» y «medio» en el diagnóstico, la intervención y la reflexión. Los participantes resaltan la importancia de la simulación clínica para mejorar las habilidades en la atención, más allá de saber el protocolo.
The clinical simulation has become one of the main advances in didactics for training health professionals. The necessity to strengthen skills of health providers has been identified from different perspectives. Skills have been understood as the transfer of knowledge in real or simulated scenarios. Furthermore, using the scientific evidence, they show the necessity to move beyond capacity.
To assess the development of critical thinking based on clinical simulation of a peri-mortem caesarean section in each of its stages (diagnosis, intervention, and debriefing).
A comprehensive qualitative study carried out with a pilot scenario designed and applied to a response team of a high complexity hospital in the city of Manizales, Colombia. Different levels of technical competences were identified based on the evaluation of the scenario and the use of debriefing (23 people of the health team).
The level of critical thinking was identified as between «high» and «medium» in the diagnosis, intervention, and reflection. The participants emphasised the importance of clinical simulation to improve the skills in care, beyond knowing the protocol.
Using briefing, simulation and debriefing to improve human and system performance
2019, Seminars in Perinatology
Citation Excerpt :
The same research group found in a retrospective multicenter cohort observational study of 19,460 neonates that 1) the incidence of newborns with 5-min Apgar scores of 6 or lower decreased from 86.6 to 44.6 per 10,000 births (p < .001), and 2) hypoxic ischemic encephalopathy (HIE) decreased from 27.3 to 13.6 per 10,000 births (p < .032) over a five-year period following the introduction of a simulation-based training program in the management of shoulder dystocia, postpartum hemorrhage, eclampsia, twin delivery, breech presentation, and maternal and neonatal resuscitation.33 This work subsequently has been replicated by other investigators.34–38 While the type of data described previously may not meet the gold standard for pharmaceutical or medical device testing, it is important to note that no other industry in which the risk to human life is high would forego using simulation-based training while it awaits the definitive prospective, randomized, controlled, multicenter, sufficiently powered trial.39
Safety, effectiveness and efficiency are keys to performance in all high-risk industries; healthcare is no exception, and neonatal-perinatal medicine is one of the highest risk subspecialties within healthcare. Briefing, simulation and debriefing are methods used by professionals in high-risk industries to reduce the overall risk to life and enhance the safety of the human beings involved in receiving and delivering the services provided by those industries. Although relatively new to neonatal-perinatal medicine, briefing, simulation and debriefing are being practiced with increasing frequency and have become embedded in training exercises such as the Neonatal Resuscitation Program (NRP) of the American Academy of Pediatrics (AAP). This chapter will define these terms and offer examples as to how they are used in high-risk activities including neonatal-perinatal medicine.
Effect of an in-situ simulation workshop on home birth practice in Australia
2019, Women and Birth
Citation Excerpt :
In situ simulation refers to “a team based simulation that occurs in the actual health care units involving actual team members within their own working environment”.11 We have previously described an in situ simulated home birth training workshop using a modification of the Practical Obstetric Multi-Professional Training program.5,9,12 The interprofessional team commences with the presence of the attending midwife accompanied by another support midwife.13
Interprofessional training programs for obstetric emergencies have been introduced for up-skilling birth unit staff in hospitals but not frequently used in training midwives and paramedicine staff for home birth emergency.
Practical Obstetric Multiprofessional Training (PROMPT) has previously been described in the home birth setting using in-situ simulation training of home births for midwifery and paramedicine staff.
The aim of this study was to evaluate the benefit of the home birth simulation in clinical practice and to explore how the simulation program prepared the midwives for a birth-related emergency in a publicly funded home birth program.
Midwives conducting home births, the midwifery educator and the simulated woman in labour (n = 9) attended an interview that explored how the midwives’ learning through simulation affected their home birth clinical practice. The simulated woman and the facilitator who conducted the simulation for more than six years were also interviewed to comment on the observed change in performance in simulation. The interview transcripts were thematically analysed.
The themes that were identified and agreed upon, were applying learning to clinical practice, learning in teams, valuing realism, facilitating simulation based education and managing variation.
In-situ nature of simulation with home birth midwives and paramedical staff facilitated learning transfer and team-based approach to practice. The careful simulation design provided a breadth of experience in emergencies.
Applying learning to prepare for clinical emergency situations changed the midwives’ approach in managing home births. This provided evidence for a change in behaviour (Level 3 Kirkpatrick’s framework) and transfer of learning, leading to changed protocols (Level 4a Kirkpatrick’s framework).
Mobile obstetric and neonatal simulation based skills training in India
2019, Midwifery
Citation Excerpt :
This form of teaching is particularly relevant for professionals involved in managing an emergency situation, where training may be delivered either in a simulation centre or taught as “in situ” simulation to mimic the clinical setting (Rosen et al., 2012; Sørensen et al., 2015; Kumar et al., 2016). These training sessions have been found to improve learning (Crofts et al., 2007), clinical practice and patient outcomes (Draycott et al., 2015; Cass et al., 2011; Draycott and Crofts, 2006). An example of interprofessional simulation is obstetric based training to improve maternal and neonatal outcomes (Bergh et al., 2015).
The developing world has a significantly high risk of women and babies dying during childbirth. Interprofessional simulation training has improved birth practices and outcomes by impacting clinical and non-technical skills like communication, teamwork, leadership and effective use of resources. While these programs have become a training requirement in many high-income countries, they have not been widely introduced in the low-income, low-resource settings.
To explore the use of a structured obstetric and neonatal emergency simulation training program in India.
The aim was to identify the challenges faced by birthing staff in their clinical practice and the key messages learnt from the simulation programs that are applicable to their clinical practices.
Mobile interprofessional obstetric and neonatal workshops were piloted in three locations (metropolitan, primary rural and secondary hospitals) of India for medical and midwifery staff, and students. Using a pre-post workshop survey design, participants were asked to describe their role and challenges in their birth practice and the key learning acquired by the program.
Eight workshops were conducted across three sites involving a total of 150 participants. Participants at all sites described maintaining safety of women and babies as their key role. Their main challenge was lack of availability of medical back up, resources, structured training and poor compliance from women. The key learning was gaining knowledge and procedural skills, non-technical skills, a systematic approach to obstetric and neonatal emergencies and learning in teams through simulation.
Mobile obstetric and neonatal simulation training workshops were useful for medical and midwifery staff, and students in different health settings in India and may have a role as a routine training tool for health professionals involved in childbirth.
Managing major obstetric haemorrhage: Pharmacotherapy and transfusion
2017, Best Practice and Research: Clinical Anaesthesiology
Major obstetric haemorrhage is a leading cause of maternal mortality. A prescriptive approach to early recognition and management is critical to improving outcomes. Uterine atony is the primary cause of post-partum haemorrhage. First-line prevention and treatment include the administration of uterine tonic agents; other conservative measures include uterine cavity tamponade and uterine compression sutures. Interventional radiology procedures have been used for both prophylaxis and treatment, but a hysterectomy may be necessary if conservative measures fail. Assessment of anaemia and coagulation status is an important aspect of the management of haemorrhage. Hypofibrinogenaemia is a predictor of severe haemorrhage. Early and empiric use of fixed transfusion red blood cell:plasma:platelet ratios is controversial and may not be justified for all causes of haemorrhage. Cell salvage may be used safely in obstetric haemorrhage. Goal-directed therapy using point-of-care testing (e.g. thromboelastography) has not been well studied but holds promise for individualising resuscitation measures.

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The Use of Simulation to Teach Clinical Skills in Obstetrics

Section snippets

Objective Evidence of the Effect of Simulation

Simulation Training in Rural Environments

Simulation as Part of Institutional Risk Management

Common Themes for Effectiveness

Patient Perception

The Future

BJOG

Nurse Educ Today

Am J Obstet Gynecol

Lancet

Best Pract Res Clin Obstet Gynaecol

Best Pract Res Clin Obstet Gynaecol

Best Pract Res Clin Obstet Gynaecol

A comprehensive medical simulation education curriculum for emergency medicine residents

Ann Emerg Med

Medical simulation from an insurer's perspective

Acad Emerg Med

The King's Midwife: A History and Mystery of Madame Du Coudray

What factors are associated with neonatal injury following shoulder dystocia?

J Perinatol

Training for shoulder dystocia: A trial of simulation using low-fidelity and high-fidelity mannequins

Obstet Gynecol

Management of shoulder dystocia: Skill retention 6 and 12 months after training

Obstet Gynecol

Improving resident competency in the management of shoulder dystocia with simulation training

Obstet Gynecol

Improving shoulder dystocia management among resident and attending physicians using simulations

Am J Obstet Gynecol

Improving neonatal outcome through practical shoulder dystocia training

Obstet Gynecol

Documentation of simulated shoulder dystocia: Accurate and complete?

BJOG

Evaluation of residents' delivery notes after a simulated shoulder dystocia

Obstet Gynecol

Global burden of maternal death and disability

Br Med Bull

Use of a postpartum hemorrhage simulator for instruction and evaluation of residents

J Grad Med Ed