Robert Gherman, MD

The authors report no financial relationships relevant to this article.

Many senior obstetricians—you may be among them—have vivid recall of performing their first vaginal delivery as an intern or junior resident, guided by a seasoned obstetric nurse or senior resident. “See one, do one, teach one,” an unwritten motto at large teaching hospitals, aptly characterized the learning environment for many older physicians.

Regrettably, obstetric residents and fellows today face a very different situation. Restrictions on residents’ working hours, financial pressures that make attending faculty less available for supervision, and wariness prompted by malpractice litigation—all these have made such teaching cases less available. So, how can physicians-in-training acquire the skills they will need in practice? And how can experienced clinicians breathe life back into skills that they use infrequently but are nonetheless critical?

We believe the answer can be found in the educational technique of simulation, which we describe in this article.

Simulation provides opportunities for physicians to practice, gain experience, and refresh. The technique offers a credible way to augment the educational curriculum and, even in the absence of unequivocal proof, to improve patient safety and reduce the likelihood of adverse outcomes.¹ For that reason, some malpractice insurers are making simulation training part of their safety and risk reduction initiatives.

To begin our discussion, a brief history of simulation appears below.

What simulations reveal about OBs’ skills

Maslovitz and colleagues, in a study that used simulated events, investigated errors among residents and nurse-midwives that occurred while teams managed four critical obstetric events¹ :

• eclamptic seizure
  
• postpartum hemorrhage
  
• shoulder dystocia
  
• breech extraction.
  

The most common management errors found were:

• delays in transporting a bleeding patient to the operating room (82% of the time)
  
• unfamiliarity with administering prostaglandin to reverse uterine atony (82%)
  
• poor cardiopulmonary resuscitation technique (80%)
  
• inadequate documentation of shoulder dystocia (80%)
  
• delayed administration of blood products to reverse consumptive coagulopathy (66%)
  
• inappropriate avoidance of episiotomy in shoulder dystocia and breech extraction (32%).
  

 

Managing eclampsia

Thompson’s study of eclampsia simulation drills² identified three major problems in handling this emergency:

• difficulty summoning senior staff
  
• multiple protocols for managing eclampsia, without a clear first-line anticonvulsant
  
• significant time lost gathering items required to manage seizures.
  

Based on what was observed in simulations, Thompson recommended 1) creating so-called eclampsia boxes that contain all necessary equipment and 2) establishing a liaison with the pharmacy to ensure consistency in supplies of magnesium sulfate.

Shoulder dystocia

The 5th Report on Confidential Enquiries into Maternal Deaths in the United Kingdom found that, in 66% of neonatal deaths following shoulder dystocia, “different management could have reasonably been expected to have altered the outcome.”³

Using a standardized shoulder dystocia simulation, Deering and colleagues reported significantly higher scores for residents who were trained in the scenario, including in the timeliness of their intervention, performance of maneuvers, and overall performance.⁴

Crofts, Draycott, and various colleagues developed a training mannequin for hospital staff that included a force-monitoring system comprised of a strain gauge mounted on both clavicles. After training, they found a reduction in 1) head-to-body delivery duration and 2) maximum applied delivery force after training, although these reductions did not reach statistical significance.^5,6

Where do you begin?

Starting a simulation program can be challenging: Significant financial hurdles may exist, and teamwork and communication issues can be major barriers to yielding improvements in practice. What’s the first step?

Find backing. Garner support for your project ( TABLE 1 ). It’s imperative to involve administrative leadership early.⁷ One champion cannot sustain a program of this magnitude.

Assemble a multidisciplinary team. Include obstetricians, gynecologists, anesthesiologists, neonatologists, and other members of the perinatal or surgical team. All will be needed to create complex interdisciplinary drills or simulations.

Build consensus. Determine the scope, goals, and objectives of the project. Define measurable outcomes.

Outline a budget. Make a realistic assessment of the resources available to fund the curriculum you design.

TABLE 1

Opening questions about a simulation training program

How do you get started?
Garner support Build consensus Define outcomes Create a budget
What are the key components?
Skills inventory Necessary competencies Stated objectives Adult learning principles Performance measures Debriefing Feedback

Know how adults learn

A simulation designed to raise the skill level of professionals—be they residents, nurses, or attending physicians—must recognize the special characteristics of adult learners. Unlike school children, adult learners are self-directed; they bring real-life experience to the table, are motivated primarily by a need to know, have individual learning styles, and deserve to be treated with respect.

A simulation curriculum should incorporate so-called crew resource management skills—a style of open cockpit communication of proven worth in improving airline safety.⁸ Those crew skills should promote best practices in closed-loop communication (such as the readback/hearback system⁹ ), information sharing, assertiveness, adaptability, and leadership skills—all elements of successful simulation. Means of coordinating, allocating, and monitoring team resources should be built into the curriculum ( TABLE 1 ).

Find the time

A practical rule to follow when designing a simulation goes by the acronym ARRON—As Reasonably Realistic as Objectively Needed.¹⁰

The team leader should match the task to:

• time allotted
  
• baseline level of medical knowledge of the trainee (resident, nurse-midwife, experienced attending)
  
• budget.
  

A major hurdle, especially in a community hospital, is to schedule sessions at a time when as many providers as possible can attend. Taking time off for training is particularly difficult for office-based providers; a workable schedule must take their needs into consideration—possibly with evening or weekend sessions.

Multiple nursing shifts may necessitate repeating a simulation several times. Consider having a so-called stand-down declared, in which all nonemergency cases are delayed (if hospital administration is amenable). Alternatively, the hospital may allot time for a simulation exercise during a slot for a weekly educational lecture or monthly department meeting.

What equipment is needed?

A community hospital can develop a simulation program that is focused on its educational and safety needs. For example, a broad range of birth simulators is available ( TABLE 2 ). The features and capabilities of each model vary with cost (we do not recommend any particular simulator). The ideal childbirth simulator has yet to be defined, but existing modalities can be adapted to meet specific needs of a target audience. A standard obstetric birthing pelvis equipped with an inflatable uterus for simulating uterine atony, for example, can be modified and made to bleed from the model’s cervical os to simulate postpartum hemorrhage.¹¹ Commercial models (mannequins) are not always necessary for OB simulation; task trainers (devices that allow repeated practice of individual skills) and standardized patients (persons trained to portray patient scenarios) can also be used.

 

Most hospitals do not have an extensive simulation center. Several state-of-the-art facilities exist in the United States, including:

• The Uniformed Services University of the Health Sciences, Bethesda, Md.
  
• the Center for Medical Simulation, Cambridge, Mass.
  
• the International Academy for Clinical Simulation and Research, Miami, Fla.
  

The Society for Simulation in Healthcare maintains a list (at www.ssih.org/public) of institutions that host a simulation center.

TABLE 2

What are the commercially available childbirth simulators?
Models are listed in ascending order by price

Manufacturer	Model	Price	Features
Childbirth Graphics	• Vinyl Pelvic Model set	$ 188.50	Accommodates cloth fetal model’s head
	• Abdominal Palpation Model	486.70	Fetal head with palpable anterior and posterior fontanels; fetal body flexes for demonstration of all presentations; movable gel packs to simulate amniotic fluid
Gaumard Scientific	• Advanced Childbirth Simulator	500.00	Removable diaphragm end plate for manual positioning of fetus
Simulaids	• Obstetrical mannequin	547.00	Includes disposable umbilical cords and powder to make simulated blood
	• Forceps/vacuum delivery OB mannequin	651.00	Used in Advanced Life Support in Obstetrics training programs; soft vinyl pelvis replicates the resistance encountered in an operative vaginal delivery
Nasco	• Life/form birthing station simulator	720.00	Shows relationship between fetal head and ischial spines
Gaumard Scientific	• Obstetric Susie	995.00	Adaptive birth canal to demonstrate shoulder dystocia; ability to practice manipulation of breech
3B Scientific	• Standard Childbirth Simulator	1,336.00	Covered belly cavity; removable vulva and fetus at 40 weeks gestation
Gaumard Scientific	• NOELLE S552 Birthing Torso	1,750.00	Automatic birthing system that rotates baby as it moves through birth canal
Gaumard Scientidfic	• NOELLE S551 Birthing Simulator	2,795.00	Inflatable airway with chest rise, IV arm for meds/fluids, vulval inserts for suturing practice
Limbs & Things	• PROMPT Birthing Simulator: Standard	3,600.00	Movable legs (semirecumbent, lithotomy position, McRoberts maneuver, all fours)
	• PROMPT Birthing Simulator: Force Monitoring	6,100.00	Electronic strain gauge allows for measurement of force applied to baby as it is delivered
Gaumard Scientific	• NOELLE S555 Birthing Simulator	11,995.00	PEDI Blue full-term newborn included; nine prepackaged scenarios
	• NOELLE S560 Birthing Simulator	15,995.00	Testing stations include ALS, NRP, and obstetrics; virtual instruments used to monitor the mother include heart rate, blood pressure, pulse oxygenation, and electrocardiogram
	• NOELLE S565 Birthing Simulator	19,995.00	Computer interactive; instructor controls delivery as well as fetal monitor
Koken	• Full-body pregnancy simulator	28,518.00	Model made of lifelike materials for realistic practice
Gaumard Scientific	• NOELLE S575 Birthing Simulator	34,995.00	Wireless, tetherless, and fully responsive; built-in scenarios for crash C-section, postpartum hemorrhage, shoulder dystocia, placenta previa, and operative vaginal delivery

What topics should be covered by simulation?

A simulation curriculum may begin with low-frequency, high-acuity events, such as shoulder dystocia, postpartum hemorrhage, breech delivery,¹² and maternal cardiorespiratory arrest ( TABLE 3 ).

Some birth simulators included prepackaged clinical scenarios ( TABLE 2 ). We recommend that you conduct prescenario and postscenario didactic teaching seminars on the specific topic of the simulation. These seminars should touch on the major aspects of care and specifically address risk components.

TABLE 3

What are possible scenarios in an OB simulation curriculum?

Amniotic fluid embolism Breech delivery Eclampsia Episiotomy/procto-episiotomy repair Maternal cardiac arrest Operative vaginal delivery Postpartum hemorrhage Shoulder dystocia Trauma in pregnancy Umbilical cord prolapse Vaginal birth after C-section/uterine rupture

Debriefing is key

Real learning occurs during postscenario debriefing, during which participants explain, analyze, and synthesize information on their actions and emotional state during the simulation (or a real event). The objective? To improve performance in similar situations.¹³

In a debriefing, teammates gather to discuss:

• their assumptions, actions, and feelings
  
• matters of teamwork and communication
  
• availability of needed equipment or other resources.
  

After-action reviews. Debriefing has its origins in 1) so-called after-action reviews that are part of military protocol—that is, preflight and postflight discussions aimed at diminishing airplane crashes—and 2) studies of organizational behavior and psychology. Gaba is credited for leading the first “critical medical event management” debriefing in the late 1980s.¹⁴ Debriefing can be self- or team-directed or led by a skilled facilitator; the team can address routine or critical events.

Good judgment. Ideally, a trained instructor or facilitator leads a debriefing session, encouraging group feedback and reflection on clinical practice and team behavior. Debriefing with good judgment is an approach that values the expert opinion of the instructor and the unique perspective of each participant. It allows the instructor to match teaching objectives with trainee concerns by understanding the assumptions and beliefs that drive participants’ actions.¹³

Debriefing can identify deficiencies in practice and documentation, and can promote best practices for teamwork among physicians, nurses, and support staff. ¹⁵ Objective and subjective performance can be assessed by reviewing videotaped simulations [Editor’s note: Watch a video of a C-section simulation in the OBG Management Video Library (www.obgmanagement.com)], participant or third-party performance evaluations, and pre- and postsession testing.

Vulnerabilities. Simulation can expose interpersonal and intrapersonal vulnerabilities. To hear criticism from colleagues about behavior and technical performance can be difficult, whether participants are inexperienced students or professional colleagues who work together in a high-stress perinatal environment.

 

In a debriefing with good judgment, the leader ensures an atmosphere of safety, in which teammates can speak up freely and must be mutually respectful and accountable to each other. Suggestions that arise from a debriefing session should be viewed as an opportunity for improvement, not a time to assign blame or impose penalties.

After the session is over

The steps you take after debriefing are the most important of all ( TABLE 4 ). To have a real impact, a simulation program must include mechanisms for assessing and documenting measurable outcomes, staff satisfaction, and improvements in patient safety. Ongoing feedback to, and from, the staff—by way of newsletters, announcements, grand rounds, and social gatherings—is crucial. Last, assessment and feedback must be used to inform regular updates of the simulation program.

TABLE 4

What ongoing program elements are needed?

Documented assessment Ongoing feedback Periodic program updates

What simulation does best

According to a “root cause” analysis by the Joint Commission on Accreditation of Healthcare Organizations, most (72%) cases of perinatal death and permanent disability can be traced to problems with organizational culture and communication among caregivers.¹⁶ These are precisely the kind of issues that simulation training is best suited to confront: Simulation allows participants to identify system-based issues and staff responses that are inadequate for managing critical clinical events.

The impact of simulation training programs can be assessed by monitoring trends in key maternal and neonatal outcomes.¹⁷ A downward trend in adverse events (e.g., low Apgar score for term newborns, maternal or neonatal birth-related injury), for example, would underscore the value of simulation in improving patient safety and quality of care.

Liability insurance. Professional liability carriers are beginning to incorporate simulation training into patient safety and risk-reduction initiatives. Harvard University’s medical malpractice insurer, Controlled Risk Insurance Company/Risk Management Foundation, established a voluntary incentive program in 2003 that provides a 10% premium credit to providers of OB services who complete risk-reduction activities that include simulation-based and didactic team training. A downward trend in obstetrical claims in association with this incentive program was recently noted.¹⁸

Resident and continuing medical education. The Council on Resident Education in Obstetrics and Gynecology featured simulation at its annual meeting in 2007 as a credible way to augment the curriculum for resident education.¹⁹ Simulation is also being used to train OBs who need to learn new skills and procedures, refresh infrequently needed skills (cesarean-hysterectomy, laparoscopy), or reenter the workplace after an extended absence.²⁰

What does the future hold?

Simulation provides a safe environment, in which mistakes are tolerated without harming patients and appropriate responses can be learned and practiced.²¹ Benefits of the technique are acknowledged in England, where annual skill drills, using simulation, are recommended by the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists.

In the United States, the use of OB simulation in residency and postresidency training programs is growing. This change is likely to trigger the introduction of simulation into board certification and credentialing procedures.

Work is needed to validate and standardize simulation-based scenarios. Studies will need to show that simulation improves clinicians’ and teams’ performance not only on simulators but in practice. Despite these hurdles, it is reasonable to conclude that respect for patients and a desire to learn without doing harm will expand and diversify the role of simulation in OB training and practice.

The authors report no financial relationships relevant to this article.

Many senior obstetricians—you may be among them—have vivid recall of performing their first vaginal delivery as an intern or junior resident, guided by a seasoned obstetric nurse or senior resident. “See one, do one, teach one,” an unwritten motto at large teaching hospitals, aptly characterized the learning environment for many older physicians.

Regrettably, obstetric residents and fellows today face a very different situation. Restrictions on residents’ working hours, financial pressures that make attending faculty less available for supervision, and wariness prompted by malpractice litigation—all these have made such teaching cases less available. So, how can physicians-in-training acquire the skills they will need in practice? And how can experienced clinicians breathe life back into skills that they use infrequently but are nonetheless critical?

We believe the answer can be found in the educational technique of simulation, which we describe in this article.

Simulation provides opportunities for physicians to practice, gain experience, and refresh. The technique offers a credible way to augment the educational curriculum and, even in the absence of unequivocal proof, to improve patient safety and reduce the likelihood of adverse outcomes.¹ For that reason, some malpractice insurers are making simulation training part of their safety and risk reduction initiatives.

To begin our discussion, a brief history of simulation appears below.

What simulations reveal about OBs’ skills

Maslovitz and colleagues, in a study that used simulated events, investigated errors among residents and nurse-midwives that occurred while teams managed four critical obstetric events¹ :

• eclamptic seizure
  
• postpartum hemorrhage
  
• shoulder dystocia
  
• breech extraction.
  

The most common management errors found were:

• delays in transporting a bleeding patient to the operating room (82% of the time)
  
• unfamiliarity with administering prostaglandin to reverse uterine atony (82%)
  
• poor cardiopulmonary resuscitation technique (80%)
  
• inadequate documentation of shoulder dystocia (80%)
  
• delayed administration of blood products to reverse consumptive coagulopathy (66%)
  
• inappropriate avoidance of episiotomy in shoulder dystocia and breech extraction (32%).
  

 

Managing eclampsia

Thompson’s study of eclampsia simulation drills² identified three major problems in handling this emergency:

• difficulty summoning senior staff
  
• multiple protocols for managing eclampsia, without a clear first-line anticonvulsant
  
• significant time lost gathering items required to manage seizures.
  

Based on what was observed in simulations, Thompson recommended 1) creating so-called eclampsia boxes that contain all necessary equipment and 2) establishing a liaison with the pharmacy to ensure consistency in supplies of magnesium sulfate.

Shoulder dystocia

The 5th Report on Confidential Enquiries into Maternal Deaths in the United Kingdom found that, in 66% of neonatal deaths following shoulder dystocia, “different management could have reasonably been expected to have altered the outcome.”³

Using a standardized shoulder dystocia simulation, Deering and colleagues reported significantly higher scores for residents who were trained in the scenario, including in the timeliness of their intervention, performance of maneuvers, and overall performance.⁴

Crofts, Draycott, and various colleagues developed a training mannequin for hospital staff that included a force-monitoring system comprised of a strain gauge mounted on both clavicles. After training, they found a reduction in 1) head-to-body delivery duration and 2) maximum applied delivery force after training, although these reductions did not reach statistical significance.^5,6

Where do you begin?

Starting a simulation program can be challenging: Significant financial hurdles may exist, and teamwork and communication issues can be major barriers to yielding improvements in practice. What’s the first step?

Find backing. Garner support for your project ( TABLE 1 ). It’s imperative to involve administrative leadership early.⁷ One champion cannot sustain a program of this magnitude.

Assemble a multidisciplinary team. Include obstetricians, gynecologists, anesthesiologists, neonatologists, and other members of the perinatal or surgical team. All will be needed to create complex interdisciplinary drills or simulations.

Build consensus. Determine the scope, goals, and objectives of the project. Define measurable outcomes.

Outline a budget. Make a realistic assessment of the resources available to fund the curriculum you design.

TABLE 1

Opening questions about a simulation training program

How do you get started?
Garner support Build consensus Define outcomes Create a budget
What are the key components?
Skills inventory Necessary competencies Stated objectives Adult learning principles Performance measures Debriefing Feedback

Know how adults learn

A simulation designed to raise the skill level of professionals—be they residents, nurses, or attending physicians—must recognize the special characteristics of adult learners. Unlike school children, adult learners are self-directed; they bring real-life experience to the table, are motivated primarily by a need to know, have individual learning styles, and deserve to be treated with respect.

A simulation curriculum should incorporate so-called crew resource management skills—a style of open cockpit communication of proven worth in improving airline safety.⁸ Those crew skills should promote best practices in closed-loop communication (such as the readback/hearback system⁹ ), information sharing, assertiveness, adaptability, and leadership skills—all elements of successful simulation. Means of coordinating, allocating, and monitoring team resources should be built into the curriculum ( TABLE 1 ).

Find the time

A practical rule to follow when designing a simulation goes by the acronym ARRON—As Reasonably Realistic as Objectively Needed.¹⁰

The team leader should match the task to:

• time allotted
  
• baseline level of medical knowledge of the trainee (resident, nurse-midwife, experienced attending)
  
• budget.
  

A major hurdle, especially in a community hospital, is to schedule sessions at a time when as many providers as possible can attend. Taking time off for training is particularly difficult for office-based providers; a workable schedule must take their needs into consideration—possibly with evening or weekend sessions.

Multiple nursing shifts may necessitate repeating a simulation several times. Consider having a so-called stand-down declared, in which all nonemergency cases are delayed (if hospital administration is amenable). Alternatively, the hospital may allot time for a simulation exercise during a slot for a weekly educational lecture or monthly department meeting.

What equipment is needed?

A community hospital can develop a simulation program that is focused on its educational and safety needs. For example, a broad range of birth simulators is available ( TABLE 2 ). The features and capabilities of each model vary with cost (we do not recommend any particular simulator). The ideal childbirth simulator has yet to be defined, but existing modalities can be adapted to meet specific needs of a target audience. A standard obstetric birthing pelvis equipped with an inflatable uterus for simulating uterine atony, for example, can be modified and made to bleed from the model’s cervical os to simulate postpartum hemorrhage.¹¹ Commercial models (mannequins) are not always necessary for OB simulation; task trainers (devices that allow repeated practice of individual skills) and standardized patients (persons trained to portray patient scenarios) can also be used.

 

Most hospitals do not have an extensive simulation center. Several state-of-the-art facilities exist in the United States, including:

• The Uniformed Services University of the Health Sciences, Bethesda, Md.
  
• the Center for Medical Simulation, Cambridge, Mass.
  
• the International Academy for Clinical Simulation and Research, Miami, Fla.
  

The Society for Simulation in Healthcare maintains a list (at www.ssih.org/public) of institutions that host a simulation center.

TABLE 2

What are the commercially available childbirth simulators?
Models are listed in ascending order by price

Manufacturer	Model	Price	Features
Childbirth Graphics	• Vinyl Pelvic Model set	$ 188.50	Accommodates cloth fetal model’s head
	• Abdominal Palpation Model	486.70	Fetal head with palpable anterior and posterior fontanels; fetal body flexes for demonstration of all presentations; movable gel packs to simulate amniotic fluid
Gaumard Scientific	• Advanced Childbirth Simulator	500.00	Removable diaphragm end plate for manual positioning of fetus
Simulaids	• Obstetrical mannequin	547.00	Includes disposable umbilical cords and powder to make simulated blood
	• Forceps/vacuum delivery OB mannequin	651.00	Used in Advanced Life Support in Obstetrics training programs; soft vinyl pelvis replicates the resistance encountered in an operative vaginal delivery
Nasco	• Life/form birthing station simulator	720.00	Shows relationship between fetal head and ischial spines
Gaumard Scientific	• Obstetric Susie	995.00	Adaptive birth canal to demonstrate shoulder dystocia; ability to practice manipulation of breech
3B Scientific	• Standard Childbirth Simulator	1,336.00	Covered belly cavity; removable vulva and fetus at 40 weeks gestation
Gaumard Scientific	• NOELLE S552 Birthing Torso	1,750.00	Automatic birthing system that rotates baby as it moves through birth canal
Gaumard Scientidfic	• NOELLE S551 Birthing Simulator	2,795.00	Inflatable airway with chest rise, IV arm for meds/fluids, vulval inserts for suturing practice
Limbs & Things	• PROMPT Birthing Simulator: Standard	3,600.00	Movable legs (semirecumbent, lithotomy position, McRoberts maneuver, all fours)
	• PROMPT Birthing Simulator: Force Monitoring	6,100.00	Electronic strain gauge allows for measurement of force applied to baby as it is delivered
Gaumard Scientific	• NOELLE S555 Birthing Simulator	11,995.00	PEDI Blue full-term newborn included; nine prepackaged scenarios
	• NOELLE S560 Birthing Simulator	15,995.00	Testing stations include ALS, NRP, and obstetrics; virtual instruments used to monitor the mother include heart rate, blood pressure, pulse oxygenation, and electrocardiogram
	• NOELLE S565 Birthing Simulator	19,995.00	Computer interactive; instructor controls delivery as well as fetal monitor
Koken	• Full-body pregnancy simulator	28,518.00	Model made of lifelike materials for realistic practice
Gaumard Scientific	• NOELLE S575 Birthing Simulator	34,995.00	Wireless, tetherless, and fully responsive; built-in scenarios for crash C-section, postpartum hemorrhage, shoulder dystocia, placenta previa, and operative vaginal delivery

What topics should be covered by simulation?

A simulation curriculum may begin with low-frequency, high-acuity events, such as shoulder dystocia, postpartum hemorrhage, breech delivery,¹² and maternal cardiorespiratory arrest ( TABLE 3 ).

Some birth simulators included prepackaged clinical scenarios ( TABLE 2 ). We recommend that you conduct prescenario and postscenario didactic teaching seminars on the specific topic of the simulation. These seminars should touch on the major aspects of care and specifically address risk components.

TABLE 3

What are possible scenarios in an OB simulation curriculum?

Amniotic fluid embolism Breech delivery Eclampsia Episiotomy/procto-episiotomy repair Maternal cardiac arrest Operative vaginal delivery Postpartum hemorrhage Shoulder dystocia Trauma in pregnancy Umbilical cord prolapse Vaginal birth after C-section/uterine rupture

Debriefing is key

Real learning occurs during postscenario debriefing, during which participants explain, analyze, and synthesize information on their actions and emotional state during the simulation (or a real event). The objective? To improve performance in similar situations.¹³

In a debriefing, teammates gather to discuss:

• their assumptions, actions, and feelings
  
• matters of teamwork and communication
  
• availability of needed equipment or other resources.
  

After-action reviews. Debriefing has its origins in 1) so-called after-action reviews that are part of military protocol—that is, preflight and postflight discussions aimed at diminishing airplane crashes—and 2) studies of organizational behavior and psychology. Gaba is credited for leading the first “critical medical event management” debriefing in the late 1980s.¹⁴ Debriefing can be self- or team-directed or led by a skilled facilitator; the team can address routine or critical events.

Good judgment. Ideally, a trained instructor or facilitator leads a debriefing session, encouraging group feedback and reflection on clinical practice and team behavior. Debriefing with good judgment is an approach that values the expert opinion of the instructor and the unique perspective of each participant. It allows the instructor to match teaching objectives with trainee concerns by understanding the assumptions and beliefs that drive participants’ actions.¹³

Debriefing can identify deficiencies in practice and documentation, and can promote best practices for teamwork among physicians, nurses, and support staff. ¹⁵ Objective and subjective performance can be assessed by reviewing videotaped simulations [Editor’s note: Watch a video of a C-section simulation in the OBG Management Video Library (www.obgmanagement.com)], participant or third-party performance evaluations, and pre- and postsession testing.

Vulnerabilities. Simulation can expose interpersonal and intrapersonal vulnerabilities. To hear criticism from colleagues about behavior and technical performance can be difficult, whether participants are inexperienced students or professional colleagues who work together in a high-stress perinatal environment.

 

In a debriefing with good judgment, the leader ensures an atmosphere of safety, in which teammates can speak up freely and must be mutually respectful and accountable to each other. Suggestions that arise from a debriefing session should be viewed as an opportunity for improvement, not a time to assign blame or impose penalties.

After the session is over

The steps you take after debriefing are the most important of all ( TABLE 4 ). To have a real impact, a simulation program must include mechanisms for assessing and documenting measurable outcomes, staff satisfaction, and improvements in patient safety. Ongoing feedback to, and from, the staff—by way of newsletters, announcements, grand rounds, and social gatherings—is crucial. Last, assessment and feedback must be used to inform regular updates of the simulation program.

TABLE 4

What ongoing program elements are needed?

Documented assessment Ongoing feedback Periodic program updates

What simulation does best

According to a “root cause” analysis by the Joint Commission on Accreditation of Healthcare Organizations, most (72%) cases of perinatal death and permanent disability can be traced to problems with organizational culture and communication among caregivers.¹⁶ These are precisely the kind of issues that simulation training is best suited to confront: Simulation allows participants to identify system-based issues and staff responses that are inadequate for managing critical clinical events.

The impact of simulation training programs can be assessed by monitoring trends in key maternal and neonatal outcomes.¹⁷ A downward trend in adverse events (e.g., low Apgar score for term newborns, maternal or neonatal birth-related injury), for example, would underscore the value of simulation in improving patient safety and quality of care.

Liability insurance. Professional liability carriers are beginning to incorporate simulation training into patient safety and risk-reduction initiatives. Harvard University’s medical malpractice insurer, Controlled Risk Insurance Company/Risk Management Foundation, established a voluntary incentive program in 2003 that provides a 10% premium credit to providers of OB services who complete risk-reduction activities that include simulation-based and didactic team training. A downward trend in obstetrical claims in association with this incentive program was recently noted.¹⁸

Resident and continuing medical education. The Council on Resident Education in Obstetrics and Gynecology featured simulation at its annual meeting in 2007 as a credible way to augment the curriculum for resident education.¹⁹ Simulation is also being used to train OBs who need to learn new skills and procedures, refresh infrequently needed skills (cesarean-hysterectomy, laparoscopy), or reenter the workplace after an extended absence.²⁰

What does the future hold?

Simulation provides a safe environment, in which mistakes are tolerated without harming patients and appropriate responses can be learned and practiced.²¹ Benefits of the technique are acknowledged in England, where annual skill drills, using simulation, are recommended by the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists.

In the United States, the use of OB simulation in residency and postresidency training programs is growing. This change is likely to trigger the introduction of simulation into board certification and credentialing procedures.

Work is needed to validate and standardize simulation-based scenarios. Studies will need to show that simulation improves clinicians’ and teams’ performance not only on simulators but in practice. Despite these hurdles, it is reasonable to conclude that respect for patients and a desire to learn without doing harm will expand and diversify the role of simulation in OB training and practice.

The authors report no financial relationships relevant to this article.

Many senior obstetricians—you may be among them—have vivid recall of performing their first vaginal delivery as an intern or junior resident, guided by a seasoned obstetric nurse or senior resident. “See one, do one, teach one,” an unwritten motto at large teaching hospitals, aptly characterized the learning environment for many older physicians.

Regrettably, obstetric residents and fellows today face a very different situation. Restrictions on residents’ working hours, financial pressures that make attending faculty less available for supervision, and wariness prompted by malpractice litigation—all these have made such teaching cases less available. So, how can physicians-in-training acquire the skills they will need in practice? And how can experienced clinicians breathe life back into skills that they use infrequently but are nonetheless critical?

We believe the answer can be found in the educational technique of simulation, which we describe in this article.

Simulation provides opportunities for physicians to practice, gain experience, and refresh. The technique offers a credible way to augment the educational curriculum and, even in the absence of unequivocal proof, to improve patient safety and reduce the likelihood of adverse outcomes.¹ For that reason, some malpractice insurers are making simulation training part of their safety and risk reduction initiatives.

To begin our discussion, a brief history of simulation appears below.

What simulations reveal about OBs’ skills

Maslovitz and colleagues, in a study that used simulated events, investigated errors among residents and nurse-midwives that occurred while teams managed four critical obstetric events¹ :

• eclamptic seizure
  
• postpartum hemorrhage
  
• shoulder dystocia
  
• breech extraction.
  

The most common management errors found were:

• delays in transporting a bleeding patient to the operating room (82% of the time)
  
• unfamiliarity with administering prostaglandin to reverse uterine atony (82%)
  
• poor cardiopulmonary resuscitation technique (80%)
  
• inadequate documentation of shoulder dystocia (80%)
  
• delayed administration of blood products to reverse consumptive coagulopathy (66%)
  
• inappropriate avoidance of episiotomy in shoulder dystocia and breech extraction (32%).
  

 

Managing eclampsia

Thompson’s study of eclampsia simulation drills² identified three major problems in handling this emergency:

• difficulty summoning senior staff
  
• multiple protocols for managing eclampsia, without a clear first-line anticonvulsant
  
• significant time lost gathering items required to manage seizures.
  

Based on what was observed in simulations, Thompson recommended 1) creating so-called eclampsia boxes that contain all necessary equipment and 2) establishing a liaison with the pharmacy to ensure consistency in supplies of magnesium sulfate.

Shoulder dystocia

The 5th Report on Confidential Enquiries into Maternal Deaths in the United Kingdom found that, in 66% of neonatal deaths following shoulder dystocia, “different management could have reasonably been expected to have altered the outcome.”³

Using a standardized shoulder dystocia simulation, Deering and colleagues reported significantly higher scores for residents who were trained in the scenario, including in the timeliness of their intervention, performance of maneuvers, and overall performance.⁴

Crofts, Draycott, and various colleagues developed a training mannequin for hospital staff that included a force-monitoring system comprised of a strain gauge mounted on both clavicles. After training, they found a reduction in 1) head-to-body delivery duration and 2) maximum applied delivery force after training, although these reductions did not reach statistical significance.^5,6

Where do you begin?

Starting a simulation program can be challenging: Significant financial hurdles may exist, and teamwork and communication issues can be major barriers to yielding improvements in practice. What’s the first step?

Find backing. Garner support for your project ( TABLE 1 ). It’s imperative to involve administrative leadership early.⁷ One champion cannot sustain a program of this magnitude.

Assemble a multidisciplinary team. Include obstetricians, gynecologists, anesthesiologists, neonatologists, and other members of the perinatal or surgical team. All will be needed to create complex interdisciplinary drills or simulations.

Build consensus. Determine the scope, goals, and objectives of the project. Define measurable outcomes.

Outline a budget. Make a realistic assessment of the resources available to fund the curriculum you design.

TABLE 1

Opening questions about a simulation training program

How do you get started?
Garner support Build consensus Define outcomes Create a budget
What are the key components?
Skills inventory Necessary competencies Stated objectives Adult learning principles Performance measures Debriefing Feedback

Know how adults learn

A simulation designed to raise the skill level of professionals—be they residents, nurses, or attending physicians—must recognize the special characteristics of adult learners. Unlike school children, adult learners are self-directed; they bring real-life experience to the table, are motivated primarily by a need to know, have individual learning styles, and deserve to be treated with respect.

A simulation curriculum should incorporate so-called crew resource management skills—a style of open cockpit communication of proven worth in improving airline safety.⁸ Those crew skills should promote best practices in closed-loop communication (such as the readback/hearback system⁹ ), information sharing, assertiveness, adaptability, and leadership skills—all elements of successful simulation. Means of coordinating, allocating, and monitoring team resources should be built into the curriculum ( TABLE 1 ).

Find the time

A practical rule to follow when designing a simulation goes by the acronym ARRON—As Reasonably Realistic as Objectively Needed.¹⁰

The team leader should match the task to:

• time allotted
  
• baseline level of medical knowledge of the trainee (resident, nurse-midwife, experienced attending)
  
• budget.
  

A major hurdle, especially in a community hospital, is to schedule sessions at a time when as many providers as possible can attend. Taking time off for training is particularly difficult for office-based providers; a workable schedule must take their needs into consideration—possibly with evening or weekend sessions.

Multiple nursing shifts may necessitate repeating a simulation several times. Consider having a so-called stand-down declared, in which all nonemergency cases are delayed (if hospital administration is amenable). Alternatively, the hospital may allot time for a simulation exercise during a slot for a weekly educational lecture or monthly department meeting.

What equipment is needed?

A community hospital can develop a simulation program that is focused on its educational and safety needs. For example, a broad range of birth simulators is available ( TABLE 2 ). The features and capabilities of each model vary with cost (we do not recommend any particular simulator). The ideal childbirth simulator has yet to be defined, but existing modalities can be adapted to meet specific needs of a target audience. A standard obstetric birthing pelvis equipped with an inflatable uterus for simulating uterine atony, for example, can be modified and made to bleed from the model’s cervical os to simulate postpartum hemorrhage.¹¹ Commercial models (mannequins) are not always necessary for OB simulation; task trainers (devices that allow repeated practice of individual skills) and standardized patients (persons trained to portray patient scenarios) can also be used.

 

Most hospitals do not have an extensive simulation center. Several state-of-the-art facilities exist in the United States, including:

• The Uniformed Services University of the Health Sciences, Bethesda, Md.
  
• the Center for Medical Simulation, Cambridge, Mass.
  
• the International Academy for Clinical Simulation and Research, Miami, Fla.
  

The Society for Simulation in Healthcare maintains a list (at www.ssih.org/public) of institutions that host a simulation center.

TABLE 2

What are the commercially available childbirth simulators?
Models are listed in ascending order by price

Manufacturer	Model	Price	Features
Childbirth Graphics	• Vinyl Pelvic Model set	$ 188.50	Accommodates cloth fetal model’s head
	• Abdominal Palpation Model	486.70	Fetal head with palpable anterior and posterior fontanels; fetal body flexes for demonstration of all presentations; movable gel packs to simulate amniotic fluid
Gaumard Scientific	• Advanced Childbirth Simulator	500.00	Removable diaphragm end plate for manual positioning of fetus
Simulaids	• Obstetrical mannequin	547.00	Includes disposable umbilical cords and powder to make simulated blood
	• Forceps/vacuum delivery OB mannequin	651.00	Used in Advanced Life Support in Obstetrics training programs; soft vinyl pelvis replicates the resistance encountered in an operative vaginal delivery
Nasco	• Life/form birthing station simulator	720.00	Shows relationship between fetal head and ischial spines
Gaumard Scientific	• Obstetric Susie	995.00	Adaptive birth canal to demonstrate shoulder dystocia; ability to practice manipulation of breech
3B Scientific	• Standard Childbirth Simulator	1,336.00	Covered belly cavity; removable vulva and fetus at 40 weeks gestation
Gaumard Scientific	• NOELLE S552 Birthing Torso	1,750.00	Automatic birthing system that rotates baby as it moves through birth canal
Gaumard Scientidfic	• NOELLE S551 Birthing Simulator	2,795.00	Inflatable airway with chest rise, IV arm for meds/fluids, vulval inserts for suturing practice
Limbs & Things	• PROMPT Birthing Simulator: Standard	3,600.00	Movable legs (semirecumbent, lithotomy position, McRoberts maneuver, all fours)
	• PROMPT Birthing Simulator: Force Monitoring	6,100.00	Electronic strain gauge allows for measurement of force applied to baby as it is delivered
Gaumard Scientific	• NOELLE S555 Birthing Simulator	11,995.00	PEDI Blue full-term newborn included; nine prepackaged scenarios
	• NOELLE S560 Birthing Simulator	15,995.00	Testing stations include ALS, NRP, and obstetrics; virtual instruments used to monitor the mother include heart rate, blood pressure, pulse oxygenation, and electrocardiogram
	• NOELLE S565 Birthing Simulator	19,995.00	Computer interactive; instructor controls delivery as well as fetal monitor
Koken	• Full-body pregnancy simulator	28,518.00	Model made of lifelike materials for realistic practice
Gaumard Scientific	• NOELLE S575 Birthing Simulator	34,995.00	Wireless, tetherless, and fully responsive; built-in scenarios for crash C-section, postpartum hemorrhage, shoulder dystocia, placenta previa, and operative vaginal delivery

What topics should be covered by simulation?

A simulation curriculum may begin with low-frequency, high-acuity events, such as shoulder dystocia, postpartum hemorrhage, breech delivery,¹² and maternal cardiorespiratory arrest ( TABLE 3 ).

Some birth simulators included prepackaged clinical scenarios ( TABLE 2 ). We recommend that you conduct prescenario and postscenario didactic teaching seminars on the specific topic of the simulation. These seminars should touch on the major aspects of care and specifically address risk components.

TABLE 3

What are possible scenarios in an OB simulation curriculum?

Amniotic fluid embolism Breech delivery Eclampsia Episiotomy/procto-episiotomy repair Maternal cardiac arrest Operative vaginal delivery Postpartum hemorrhage Shoulder dystocia Trauma in pregnancy Umbilical cord prolapse Vaginal birth after C-section/uterine rupture

Debriefing is key

Real learning occurs during postscenario debriefing, during which participants explain, analyze, and synthesize information on their actions and emotional state during the simulation (or a real event). The objective? To improve performance in similar situations.¹³

In a debriefing, teammates gather to discuss:

• their assumptions, actions, and feelings
  
• matters of teamwork and communication
  
• availability of needed equipment or other resources.
  

After-action reviews. Debriefing has its origins in 1) so-called after-action reviews that are part of military protocol—that is, preflight and postflight discussions aimed at diminishing airplane crashes—and 2) studies of organizational behavior and psychology. Gaba is credited for leading the first “critical medical event management” debriefing in the late 1980s.¹⁴ Debriefing can be self- or team-directed or led by a skilled facilitator; the team can address routine or critical events.

Good judgment. Ideally, a trained instructor or facilitator leads a debriefing session, encouraging group feedback and reflection on clinical practice and team behavior. Debriefing with good judgment is an approach that values the expert opinion of the instructor and the unique perspective of each participant. It allows the instructor to match teaching objectives with trainee concerns by understanding the assumptions and beliefs that drive participants’ actions.¹³

Debriefing can identify deficiencies in practice and documentation, and can promote best practices for teamwork among physicians, nurses, and support staff. ¹⁵ Objective and subjective performance can be assessed by reviewing videotaped simulations [Editor’s note: Watch a video of a C-section simulation in the OBG Management Video Library (www.obgmanagement.com)], participant or third-party performance evaluations, and pre- and postsession testing.

Vulnerabilities. Simulation can expose interpersonal and intrapersonal vulnerabilities. To hear criticism from colleagues about behavior and technical performance can be difficult, whether participants are inexperienced students or professional colleagues who work together in a high-stress perinatal environment.

 

In a debriefing with good judgment, the leader ensures an atmosphere of safety, in which teammates can speak up freely and must be mutually respectful and accountable to each other. Suggestions that arise from a debriefing session should be viewed as an opportunity for improvement, not a time to assign blame or impose penalties.

After the session is over

The steps you take after debriefing are the most important of all ( TABLE 4 ). To have a real impact, a simulation program must include mechanisms for assessing and documenting measurable outcomes, staff satisfaction, and improvements in patient safety. Ongoing feedback to, and from, the staff—by way of newsletters, announcements, grand rounds, and social gatherings—is crucial. Last, assessment and feedback must be used to inform regular updates of the simulation program.

TABLE 4

What ongoing program elements are needed?

Documented assessment Ongoing feedback Periodic program updates

What simulation does best

According to a “root cause” analysis by the Joint Commission on Accreditation of Healthcare Organizations, most (72%) cases of perinatal death and permanent disability can be traced to problems with organizational culture and communication among caregivers.¹⁶ These are precisely the kind of issues that simulation training is best suited to confront: Simulation allows participants to identify system-based issues and staff responses that are inadequate for managing critical clinical events.

The impact of simulation training programs can be assessed by monitoring trends in key maternal and neonatal outcomes.¹⁷ A downward trend in adverse events (e.g., low Apgar score for term newborns, maternal or neonatal birth-related injury), for example, would underscore the value of simulation in improving patient safety and quality of care.

Liability insurance. Professional liability carriers are beginning to incorporate simulation training into patient safety and risk-reduction initiatives. Harvard University’s medical malpractice insurer, Controlled Risk Insurance Company/Risk Management Foundation, established a voluntary incentive program in 2003 that provides a 10% premium credit to providers of OB services who complete risk-reduction activities that include simulation-based and didactic team training. A downward trend in obstetrical claims in association with this incentive program was recently noted.¹⁸

Resident and continuing medical education. The Council on Resident Education in Obstetrics and Gynecology featured simulation at its annual meeting in 2007 as a credible way to augment the curriculum for resident education.¹⁹ Simulation is also being used to train OBs who need to learn new skills and procedures, refresh infrequently needed skills (cesarean-hysterectomy, laparoscopy), or reenter the workplace after an extended absence.²⁰

What does the future hold?

Simulation provides a safe environment, in which mistakes are tolerated without harming patients and appropriate responses can be learned and practiced.²¹ Benefits of the technique are acknowledged in England, where annual skill drills, using simulation, are recommended by the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists.

In the United States, the use of OB simulation in residency and postresidency training programs is growing. This change is likely to trigger the introduction of simulation into board certification and credentialing procedures.

Work is needed to validate and standardize simulation-based scenarios. Studies will need to show that simulation improves clinicians’ and teams’ performance not only on simulators but in practice. Despite these hurdles, it is reasonable to conclude that respect for patients and a desire to learn without doing harm will expand and diversify the role of simulation in OB training and practice.

<huc>A</huc> No, unless the vacuum extraction involves shoulder dystocia, high fetal birth weight, or application of fundal pressure. Shoulder dystocia is by far the most significant risk factor for brachial plexus palsy in this context.

Expert commentary

This excellent study provides indirect scientific evidence that shoulder dystocia is the prominent risk factor for brachial plexus palsy in the setting of vacuum extraction, with an odds ratio (OR) of 16.0 (95% confidence interval [CI] 8.9–28.7). Other independent factors include fetal birth weight of 3,999 g or more (OR 7.1; 95% CI 4.8–10.5) and application of fundal pressure (OR 1.6; 95% CI 1.1–2.3). However, 81% of the infants with brachial plexus palsy did not experience shoulder dystocia during vacuum extraction. This finding is in accord with recent studies of obstetric brachial plexus palsy.¹

Duration of vacuum extraction plays a role. The authors determined that 5 minutes of vacuum extraction carries an estimated risk of brachial plexus palsy of 0.8%, whereas 25 minutes carries a risk close to 4%.

Longstanding enigma

Ever since the 1978 landmark study by Benedetti and Gabbe,² the association between operative vaginal delivery and shoulder dystocia has aroused interest. Even today, clinical questions persist when an infant experiences brachial plexus palsy in the setting of operative vaginal delivery. Did the application of the vacuum or forceps cause the neonatal injury? Was the shoulder dystocia a direct consequence of the vacuum or forceps? Given the marked decrease in forceps usage and increasing reliance on vacuum extraction, this research article is timely and clinically relevant.

Strength in numbers: 13,716 vacuum deliveries

In Sweden since 1973, all deliveries have been recorded in the Medical Birth Registry of the National Board of Health and Welfare. Using this registry, Mollberg and colleagues were able to study 13,716 deliveries involving vacuum extraction, 153 of which resulted in brachial plexus palsy. The strength of this study lies in its immense power, which yielded insight into the approximate incidence (1.1%) of brachial plexus palsy in the setting of vacuum extraction.

Some medical records were incomplete

This study had a relatively high exclusion rate of 32%, since charts were analyzed only if they possessed a completed instrumental delivery protocol. As a result, Mollberg and colleagues were able to evaluate only a limited number of factors that could potentially be tied to brachial plexus palsy: shoulder dystocia, fetal birth weight, fundal pressure, number of tractions, duration of vacuum application, parity, vacuum silicone cup, epidural anesthesia, and fetal station.

No details on fundal pressure. A surprising percentage (58%) of infants with brachial plexus palsy had fundal pressure applied. Unfortunately, no indication was given as to whether this fundal pressure was used to assist with maternal expulsive efforts, to aid with placement of the vacuum extractor, or as a maneuver to alleviate shoulder dystocia.

Prolonged second stage defined differently from ACOG standard. This study defined a prolonged second stage as longer than 60 minutes in parous women and longer than 120 minutes in nulliparous women, whereas the American College of Obstetricians and Gynecologists defines it in multiparous women as longer than 2 hours with or 1 hour without regional anesthesia, and in nulliparous women as longer than 3 hours with or 2 hours without regional anesthesia.

Another weakness: Some vacuum extractions may have been midpelvic, given that cases with the fetal vertex at the level of the ischial spine were allowed.

Take-home message: Don’t retire the vacuum extractor

There is no reason obstetricians should stop using the vacuum extractor for fear of brachial plexus palsy. However, they should continue to:

• minimize the duration of application,
• monitor the rate of fetal descent and,
• as always, employ sound clinical judgment.³

The author reports no financial relationships relevant to this article.

<huc>A</huc> No, unless the vacuum extraction involves shoulder dystocia, high fetal birth weight, or application of fundal pressure. Shoulder dystocia is by far the most significant risk factor for brachial plexus palsy in this context.

Expert commentary

This excellent study provides indirect scientific evidence that shoulder dystocia is the prominent risk factor for brachial plexus palsy in the setting of vacuum extraction, with an odds ratio (OR) of 16.0 (95% confidence interval [CI] 8.9–28.7). Other independent factors include fetal birth weight of 3,999 g or more (OR 7.1; 95% CI 4.8–10.5) and application of fundal pressure (OR 1.6; 95% CI 1.1–2.3). However, 81% of the infants with brachial plexus palsy did not experience shoulder dystocia during vacuum extraction. This finding is in accord with recent studies of obstetric brachial plexus palsy.¹

Duration of vacuum extraction plays a role. The authors determined that 5 minutes of vacuum extraction carries an estimated risk of brachial plexus palsy of 0.8%, whereas 25 minutes carries a risk close to 4%.

Longstanding enigma

Ever since the 1978 landmark study by Benedetti and Gabbe,² the association between operative vaginal delivery and shoulder dystocia has aroused interest. Even today, clinical questions persist when an infant experiences brachial plexus palsy in the setting of operative vaginal delivery. Did the application of the vacuum or forceps cause the neonatal injury? Was the shoulder dystocia a direct consequence of the vacuum or forceps? Given the marked decrease in forceps usage and increasing reliance on vacuum extraction, this research article is timely and clinically relevant.

Strength in numbers: 13,716 vacuum deliveries

In Sweden since 1973, all deliveries have been recorded in the Medical Birth Registry of the National Board of Health and Welfare. Using this registry, Mollberg and colleagues were able to study 13,716 deliveries involving vacuum extraction, 153 of which resulted in brachial plexus palsy. The strength of this study lies in its immense power, which yielded insight into the approximate incidence (1.1%) of brachial plexus palsy in the setting of vacuum extraction.

Some medical records were incomplete

This study had a relatively high exclusion rate of 32%, since charts were analyzed only if they possessed a completed instrumental delivery protocol. As a result, Mollberg and colleagues were able to evaluate only a limited number of factors that could potentially be tied to brachial plexus palsy: shoulder dystocia, fetal birth weight, fundal pressure, number of tractions, duration of vacuum application, parity, vacuum silicone cup, epidural anesthesia, and fetal station.

No details on fundal pressure. A surprising percentage (58%) of infants with brachial plexus palsy had fundal pressure applied. Unfortunately, no indication was given as to whether this fundal pressure was used to assist with maternal expulsive efforts, to aid with placement of the vacuum extractor, or as a maneuver to alleviate shoulder dystocia.

Prolonged second stage defined differently from ACOG standard. This study defined a prolonged second stage as longer than 60 minutes in parous women and longer than 120 minutes in nulliparous women, whereas the American College of Obstetricians and Gynecologists defines it in multiparous women as longer than 2 hours with or 1 hour without regional anesthesia, and in nulliparous women as longer than 3 hours with or 2 hours without regional anesthesia.

Another weakness: Some vacuum extractions may have been midpelvic, given that cases with the fetal vertex at the level of the ischial spine were allowed.

Take-home message: Don’t retire the vacuum extractor

There is no reason obstetricians should stop using the vacuum extractor for fear of brachial plexus palsy. However, they should continue to:

• minimize the duration of application,
• monitor the rate of fetal descent and,
• as always, employ sound clinical judgment.³

The author reports no financial relationships relevant to this article.

<huc>A</huc> No, unless the vacuum extraction involves shoulder dystocia, high fetal birth weight, or application of fundal pressure. Shoulder dystocia is by far the most significant risk factor for brachial plexus palsy in this context.

Expert commentary

This excellent study provides indirect scientific evidence that shoulder dystocia is the prominent risk factor for brachial plexus palsy in the setting of vacuum extraction, with an odds ratio (OR) of 16.0 (95% confidence interval [CI] 8.9–28.7). Other independent factors include fetal birth weight of 3,999 g or more (OR 7.1; 95% CI 4.8–10.5) and application of fundal pressure (OR 1.6; 95% CI 1.1–2.3). However, 81% of the infants with brachial plexus palsy did not experience shoulder dystocia during vacuum extraction. This finding is in accord with recent studies of obstetric brachial plexus palsy.¹

Duration of vacuum extraction plays a role. The authors determined that 5 minutes of vacuum extraction carries an estimated risk of brachial plexus palsy of 0.8%, whereas 25 minutes carries a risk close to 4%.

Longstanding enigma

Ever since the 1978 landmark study by Benedetti and Gabbe,² the association between operative vaginal delivery and shoulder dystocia has aroused interest. Even today, clinical questions persist when an infant experiences brachial plexus palsy in the setting of operative vaginal delivery. Did the application of the vacuum or forceps cause the neonatal injury? Was the shoulder dystocia a direct consequence of the vacuum or forceps? Given the marked decrease in forceps usage and increasing reliance on vacuum extraction, this research article is timely and clinically relevant.

Strength in numbers: 13,716 vacuum deliveries

In Sweden since 1973, all deliveries have been recorded in the Medical Birth Registry of the National Board of Health and Welfare. Using this registry, Mollberg and colleagues were able to study 13,716 deliveries involving vacuum extraction, 153 of which resulted in brachial plexus palsy. The strength of this study lies in its immense power, which yielded insight into the approximate incidence (1.1%) of brachial plexus palsy in the setting of vacuum extraction.

Some medical records were incomplete

This study had a relatively high exclusion rate of 32%, since charts were analyzed only if they possessed a completed instrumental delivery protocol. As a result, Mollberg and colleagues were able to evaluate only a limited number of factors that could potentially be tied to brachial plexus palsy: shoulder dystocia, fetal birth weight, fundal pressure, number of tractions, duration of vacuum application, parity, vacuum silicone cup, epidural anesthesia, and fetal station.

No details on fundal pressure. A surprising percentage (58%) of infants with brachial plexus palsy had fundal pressure applied. Unfortunately, no indication was given as to whether this fundal pressure was used to assist with maternal expulsive efforts, to aid with placement of the vacuum extractor, or as a maneuver to alleviate shoulder dystocia.

Prolonged second stage defined differently from ACOG standard. This study defined a prolonged second stage as longer than 60 minutes in parous women and longer than 120 minutes in nulliparous women, whereas the American College of Obstetricians and Gynecologists defines it in multiparous women as longer than 2 hours with or 1 hour without regional anesthesia, and in nulliparous women as longer than 3 hours with or 2 hours without regional anesthesia.

Another weakness: Some vacuum extractions may have been midpelvic, given that cases with the fetal vertex at the level of the ischial spine were allowed.

Take-home message: Don’t retire the vacuum extractor

There is no reason obstetricians should stop using the vacuum extractor for fear of brachial plexus palsy. However, they should continue to:

• minimize the duration of application,
• monitor the rate of fetal descent and,
• as always, employ sound clinical judgment.³

The author reports no financial relationships relevant to this article.

This procedure does not change the actual dimensions of the maternal pelvis.

A lthough shoulder dystocia occurs in less than 1% of all births, it can lead to serious injury of the infant and mother. Potential fetal complications include death, permanent neurologic impairment, brachial plexus injury, and Erb’s palsy, while the mother may suffer vaginal and cervical lacerations, significant blood loss, or uterine rupture.

Several techniques can be administered to safely dislodge the infant’s shoulder, including the Woods-screw, Rubin, Gaskin (“all-fours”), and McRoberts maneuvers. I prefer the Mc-Roberts maneuver because it involves only maternal manipulation while allowing the fetal shoulder to rotate into the oblique diameter.

Success rates. McRoberts is not only technically simple to employ, but has been found to alleviate 39% to 42% of shoulder dystocias when used alone.¹ The addition of suprapubic pressure and/or proctoepisiotomy increases success rates to between 54% and 58%.^1,2 In patients with diabetes, however, success rates are not higher.¹ This is most likely due to the fact that infants of mothers with diabetes tend to have higher birthweights than infants of gravidas without the disease.

Prophylaxis. To date, no clinical studies have evaluated birth outcomes after the prophylactic employment of the McRoberts maneuver, even though the procedure is commonplace. Since McRoberts has many potential benefits (Table 1), it is reasonable to consider its prophylactic use in suspected fetal macrosomia or when concern for shoulder dystocia exists. The maneuver also may be useful in managing an entrapped fetal head during a vaginal breech delivery.³

Mechanism of action. Contrary to popular belief, the McRoberts maneuver does not change the actual dimensions of the maternal pelvis. In a recently published x-ray pelvimetry analysis, we found no significant changes in the anterior-posterior and transverse diameters of the pelvic inlet, midpelvis, and pelvic outlet.⁴ Nor did the obstetric, true, and diagonal conjugates increase when McRoberts was applied. Our analysis thus confirms Gonik’s hypothesis that McRoberts relieves shoulder dystocia via marked cephalad rotation of the symphysis pubis and flattening of the sacrum.⁵

The maneuver also may work by converting voluntary maternal expulsive effort, independent of uterine contractions, into enhanced intrauterine pressure. Buhimschi and colleagues found that McRoberts not only increased the intrauterine pressure during the second stage of labor by 97%, but also increased the amplitude of uterine contractions.⁶ Further, they calculated that McRoberts added 31 N of pushing force when employed during delivery.

Technical considerations. The technique is performed by flexing the mother’s thighs toward her shoulders while she is lying on her back. No specific degree of elevation or flexion of the patient’s legs has been defined for the McRoberts maneuver. Recent obstetric textbooks simply state that McRoberts is performed by “hyperflexing” or “sharply flexing” the maternal legs on the abdomen.^7,8

The overwhelming majority of patients can assume the proper position for the McRoberts maneuver with little difficulty. Women may be instructed to grasp the posterior aspect of their thighs and pull themselves into position, with family members or health-care professionals providing any assistance necessary. The obstetrician also may choose to flex both of the patient’s legs.

Problems may occur when moving an obese patient or a woman who has undergone a dense epidural motor blockade. Further, patients with pelvic fractures, spinal-cord injuries, severe degenerative joint disorders (osteoarthritis or rheumatoid arthritis), or neuromuscular disorders may have trouble assuming a dorsal lithotomy position, making the McRoberts maneuver difficult or impossible to perform.

Additional maneuvers. My colleagues and I have found that the need for additional maneuvers after McRoberts has been performed is correlated to fetal birthweights, length of the active phase of labor, and length of the second stage of labor.¹ In these circumstances, additional maneuvers including suprapubic pressure, fetal rotational maneuvers (Woods or Rubin), extraction of the posterior fetal arm, and proctoepisiotomy may be employed. I recommend that the patient undergo the McRoberts maneuver while these ancillary techniques are performed. Since these techniques involve direct fetal manipulation, they should not be hindered by McRoberts.

Neonatal injury. The McRoberts maneuver does not remove the inherent risk of neonatal bone or nerve injury associated with shoulder dystocia. Even among patients who undergo McRoberts only, approximately 10.2% of infants will have brachial plexus injuries.¹

 

With increased fetal bisacromial diameters, a condition that occurs in infants of mothers with diabetes, the protective effects of McRoberts appear to be reduced while the incidence of brachial plexus palsy is increased.¹ Even so, objective testing indicates that the McRoberts maneuver may reduce fetal-shoulder extraction forces and brachial plexus stretching.⁹

Complications. Care should be taken to avoid prolonged or overly aggressive application of the McRoberts maneuver, as the fibrocartilaginous articular surfaces of the symphysis pubis and surrounding ligaments may be unduly stretched. In addition, when the maternal thighs are markedly flexed and abducted, pressure from the overlying inguinal ligament may lead to femoral nerve injury.

My colleagues and I have experienced 2 cases in which significant maternal morbidity was associated with the McRoberts maneuver. In one, a patient who was maintained in McRoberts throughout her 2-hour, 11-minute second stage of labor suffered a 5-cm symphyseal separation, dislocation of the sacroiliac joint, and transient lateral femoral cutaneous neuropathy. These abnormalities required closed reduction of the left hemi-pelvis, followed by an open reduction and internal fixation of the symphysis pubis 2 weeks after failing conservative treatment.¹⁰ A previous report described similar pelvic findings following an exaggerated McRoberts maneuver for suspected fetal macrosomia.¹¹

The long view. In 1991, a survey of 108 major teaching institutions in the United States found that only 64% were familiar with the McRoberts maneuver and only 40% taught the maneuver to house staff.¹² Yet, William A. McRoberts, Jr, MD, practiced his maneuver with great success for more than 40 years at Hermann Hospital and the University of Texas Medical School in Houston.¹³ As we continue into the new millennium, I believe it is important to teach residents to initially employ the McRoberts maneuver whenever shoulder dystocia occurs.

TABLE 1

Potential mechanical benefits of the McRoberts maneuver

Anterior fetal shoulder elevation Fetal spine flexion Pushing of posterior fetal shoulder over the sacrum Straightening of maternal lordosis Removal of sacral promontory as point of obstruction Removal of weight-bearing force from the sacrum Pelvic inlet opened to maximum Pelvic inlet brought perpendicular to maximum expulsive force

The author reports no financial relationship with any companies whose products are mentioned in this article.

This procedure does not change the actual dimensions of the maternal pelvis.

A lthough shoulder dystocia occurs in less than 1% of all births, it can lead to serious injury of the infant and mother. Potential fetal complications include death, permanent neurologic impairment, brachial plexus injury, and Erb’s palsy, while the mother may suffer vaginal and cervical lacerations, significant blood loss, or uterine rupture.

Several techniques can be administered to safely dislodge the infant’s shoulder, including the Woods-screw, Rubin, Gaskin (“all-fours”), and McRoberts maneuvers. I prefer the Mc-Roberts maneuver because it involves only maternal manipulation while allowing the fetal shoulder to rotate into the oblique diameter.

Success rates. McRoberts is not only technically simple to employ, but has been found to alleviate 39% to 42% of shoulder dystocias when used alone.¹ The addition of suprapubic pressure and/or proctoepisiotomy increases success rates to between 54% and 58%.^1,2 In patients with diabetes, however, success rates are not higher.¹ This is most likely due to the fact that infants of mothers with diabetes tend to have higher birthweights than infants of gravidas without the disease.

Prophylaxis. To date, no clinical studies have evaluated birth outcomes after the prophylactic employment of the McRoberts maneuver, even though the procedure is commonplace. Since McRoberts has many potential benefits (Table 1), it is reasonable to consider its prophylactic use in suspected fetal macrosomia or when concern for shoulder dystocia exists. The maneuver also may be useful in managing an entrapped fetal head during a vaginal breech delivery.³

Mechanism of action. Contrary to popular belief, the McRoberts maneuver does not change the actual dimensions of the maternal pelvis. In a recently published x-ray pelvimetry analysis, we found no significant changes in the anterior-posterior and transverse diameters of the pelvic inlet, midpelvis, and pelvic outlet.⁴ Nor did the obstetric, true, and diagonal conjugates increase when McRoberts was applied. Our analysis thus confirms Gonik’s hypothesis that McRoberts relieves shoulder dystocia via marked cephalad rotation of the symphysis pubis and flattening of the sacrum.⁵

The maneuver also may work by converting voluntary maternal expulsive effort, independent of uterine contractions, into enhanced intrauterine pressure. Buhimschi and colleagues found that McRoberts not only increased the intrauterine pressure during the second stage of labor by 97%, but also increased the amplitude of uterine contractions.⁶ Further, they calculated that McRoberts added 31 N of pushing force when employed during delivery.

Technical considerations. The technique is performed by flexing the mother’s thighs toward her shoulders while she is lying on her back. No specific degree of elevation or flexion of the patient’s legs has been defined for the McRoberts maneuver. Recent obstetric textbooks simply state that McRoberts is performed by “hyperflexing” or “sharply flexing” the maternal legs on the abdomen.^7,8

The overwhelming majority of patients can assume the proper position for the McRoberts maneuver with little difficulty. Women may be instructed to grasp the posterior aspect of their thighs and pull themselves into position, with family members or health-care professionals providing any assistance necessary. The obstetrician also may choose to flex both of the patient’s legs.

Problems may occur when moving an obese patient or a woman who has undergone a dense epidural motor blockade. Further, patients with pelvic fractures, spinal-cord injuries, severe degenerative joint disorders (osteoarthritis or rheumatoid arthritis), or neuromuscular disorders may have trouble assuming a dorsal lithotomy position, making the McRoberts maneuver difficult or impossible to perform.

Additional maneuvers. My colleagues and I have found that the need for additional maneuvers after McRoberts has been performed is correlated to fetal birthweights, length of the active phase of labor, and length of the second stage of labor.¹ In these circumstances, additional maneuvers including suprapubic pressure, fetal rotational maneuvers (Woods or Rubin), extraction of the posterior fetal arm, and proctoepisiotomy may be employed. I recommend that the patient undergo the McRoberts maneuver while these ancillary techniques are performed. Since these techniques involve direct fetal manipulation, they should not be hindered by McRoberts.

Neonatal injury. The McRoberts maneuver does not remove the inherent risk of neonatal bone or nerve injury associated with shoulder dystocia. Even among patients who undergo McRoberts only, approximately 10.2% of infants will have brachial plexus injuries.¹

 

With increased fetal bisacromial diameters, a condition that occurs in infants of mothers with diabetes, the protective effects of McRoberts appear to be reduced while the incidence of brachial plexus palsy is increased.¹ Even so, objective testing indicates that the McRoberts maneuver may reduce fetal-shoulder extraction forces and brachial plexus stretching.⁹

Complications. Care should be taken to avoid prolonged or overly aggressive application of the McRoberts maneuver, as the fibrocartilaginous articular surfaces of the symphysis pubis and surrounding ligaments may be unduly stretched. In addition, when the maternal thighs are markedly flexed and abducted, pressure from the overlying inguinal ligament may lead to femoral nerve injury.

My colleagues and I have experienced 2 cases in which significant maternal morbidity was associated with the McRoberts maneuver. In one, a patient who was maintained in McRoberts throughout her 2-hour, 11-minute second stage of labor suffered a 5-cm symphyseal separation, dislocation of the sacroiliac joint, and transient lateral femoral cutaneous neuropathy. These abnormalities required closed reduction of the left hemi-pelvis, followed by an open reduction and internal fixation of the symphysis pubis 2 weeks after failing conservative treatment.¹⁰ A previous report described similar pelvic findings following an exaggerated McRoberts maneuver for suspected fetal macrosomia.¹¹

The long view. In 1991, a survey of 108 major teaching institutions in the United States found that only 64% were familiar with the McRoberts maneuver and only 40% taught the maneuver to house staff.¹² Yet, William A. McRoberts, Jr, MD, practiced his maneuver with great success for more than 40 years at Hermann Hospital and the University of Texas Medical School in Houston.¹³ As we continue into the new millennium, I believe it is important to teach residents to initially employ the McRoberts maneuver whenever shoulder dystocia occurs.

TABLE 1

Potential mechanical benefits of the McRoberts maneuver

Anterior fetal shoulder elevation Fetal spine flexion Pushing of posterior fetal shoulder over the sacrum Straightening of maternal lordosis Removal of sacral promontory as point of obstruction Removal of weight-bearing force from the sacrum Pelvic inlet opened to maximum Pelvic inlet brought perpendicular to maximum expulsive force

The author reports no financial relationship with any companies whose products are mentioned in this article.

This procedure does not change the actual dimensions of the maternal pelvis.

A lthough shoulder dystocia occurs in less than 1% of all births, it can lead to serious injury of the infant and mother. Potential fetal complications include death, permanent neurologic impairment, brachial plexus injury, and Erb’s palsy, while the mother may suffer vaginal and cervical lacerations, significant blood loss, or uterine rupture.

Several techniques can be administered to safely dislodge the infant’s shoulder, including the Woods-screw, Rubin, Gaskin (“all-fours”), and McRoberts maneuvers. I prefer the Mc-Roberts maneuver because it involves only maternal manipulation while allowing the fetal shoulder to rotate into the oblique diameter.

Success rates. McRoberts is not only technically simple to employ, but has been found to alleviate 39% to 42% of shoulder dystocias when used alone.¹ The addition of suprapubic pressure and/or proctoepisiotomy increases success rates to between 54% and 58%.^1,2 In patients with diabetes, however, success rates are not higher.¹ This is most likely due to the fact that infants of mothers with diabetes tend to have higher birthweights than infants of gravidas without the disease.

Prophylaxis. To date, no clinical studies have evaluated birth outcomes after the prophylactic employment of the McRoberts maneuver, even though the procedure is commonplace. Since McRoberts has many potential benefits (Table 1), it is reasonable to consider its prophylactic use in suspected fetal macrosomia or when concern for shoulder dystocia exists. The maneuver also may be useful in managing an entrapped fetal head during a vaginal breech delivery.³

Mechanism of action. Contrary to popular belief, the McRoberts maneuver does not change the actual dimensions of the maternal pelvis. In a recently published x-ray pelvimetry analysis, we found no significant changes in the anterior-posterior and transverse diameters of the pelvic inlet, midpelvis, and pelvic outlet.⁴ Nor did the obstetric, true, and diagonal conjugates increase when McRoberts was applied. Our analysis thus confirms Gonik’s hypothesis that McRoberts relieves shoulder dystocia via marked cephalad rotation of the symphysis pubis and flattening of the sacrum.⁵

The maneuver also may work by converting voluntary maternal expulsive effort, independent of uterine contractions, into enhanced intrauterine pressure. Buhimschi and colleagues found that McRoberts not only increased the intrauterine pressure during the second stage of labor by 97%, but also increased the amplitude of uterine contractions.⁶ Further, they calculated that McRoberts added 31 N of pushing force when employed during delivery.

Technical considerations. The technique is performed by flexing the mother’s thighs toward her shoulders while she is lying on her back. No specific degree of elevation or flexion of the patient’s legs has been defined for the McRoberts maneuver. Recent obstetric textbooks simply state that McRoberts is performed by “hyperflexing” or “sharply flexing” the maternal legs on the abdomen.^7,8

The overwhelming majority of patients can assume the proper position for the McRoberts maneuver with little difficulty. Women may be instructed to grasp the posterior aspect of their thighs and pull themselves into position, with family members or health-care professionals providing any assistance necessary. The obstetrician also may choose to flex both of the patient’s legs.

Problems may occur when moving an obese patient or a woman who has undergone a dense epidural motor blockade. Further, patients with pelvic fractures, spinal-cord injuries, severe degenerative joint disorders (osteoarthritis or rheumatoid arthritis), or neuromuscular disorders may have trouble assuming a dorsal lithotomy position, making the McRoberts maneuver difficult or impossible to perform.

Additional maneuvers. My colleagues and I have found that the need for additional maneuvers after McRoberts has been performed is correlated to fetal birthweights, length of the active phase of labor, and length of the second stage of labor.¹ In these circumstances, additional maneuvers including suprapubic pressure, fetal rotational maneuvers (Woods or Rubin), extraction of the posterior fetal arm, and proctoepisiotomy may be employed. I recommend that the patient undergo the McRoberts maneuver while these ancillary techniques are performed. Since these techniques involve direct fetal manipulation, they should not be hindered by McRoberts.

Neonatal injury. The McRoberts maneuver does not remove the inherent risk of neonatal bone or nerve injury associated with shoulder dystocia. Even among patients who undergo McRoberts only, approximately 10.2% of infants will have brachial plexus injuries.¹

 

With increased fetal bisacromial diameters, a condition that occurs in infants of mothers with diabetes, the protective effects of McRoberts appear to be reduced while the incidence of brachial plexus palsy is increased.¹ Even so, objective testing indicates that the McRoberts maneuver may reduce fetal-shoulder extraction forces and brachial plexus stretching.⁹

Complications. Care should be taken to avoid prolonged or overly aggressive application of the McRoberts maneuver, as the fibrocartilaginous articular surfaces of the symphysis pubis and surrounding ligaments may be unduly stretched. In addition, when the maternal thighs are markedly flexed and abducted, pressure from the overlying inguinal ligament may lead to femoral nerve injury.

My colleagues and I have experienced 2 cases in which significant maternal morbidity was associated with the McRoberts maneuver. In one, a patient who was maintained in McRoberts throughout her 2-hour, 11-minute second stage of labor suffered a 5-cm symphyseal separation, dislocation of the sacroiliac joint, and transient lateral femoral cutaneous neuropathy. These abnormalities required closed reduction of the left hemi-pelvis, followed by an open reduction and internal fixation of the symphysis pubis 2 weeks after failing conservative treatment.¹⁰ A previous report described similar pelvic findings following an exaggerated McRoberts maneuver for suspected fetal macrosomia.¹¹

The long view. In 1991, a survey of 108 major teaching institutions in the United States found that only 64% were familiar with the McRoberts maneuver and only 40% taught the maneuver to house staff.¹² Yet, William A. McRoberts, Jr, MD, practiced his maneuver with great success for more than 40 years at Hermann Hospital and the University of Texas Medical School in Houston.¹³ As we continue into the new millennium, I believe it is important to teach residents to initially employ the McRoberts maneuver whenever shoulder dystocia occurs.

TABLE 1

Potential mechanical benefits of the McRoberts maneuver

Anterior fetal shoulder elevation Fetal spine flexion Pushing of posterior fetal shoulder over the sacrum Straightening of maternal lordosis Removal of sacral promontory as point of obstruction Removal of weight-bearing force from the sacrum Pelvic inlet opened to maximum Pelvic inlet brought perpendicular to maximum expulsive force

The author reports no financial relationship with any companies whose products are mentioned in this article.