Technology Offers a Way to Practice Critical Skills

How many of us are thoroughly, truly prepared to manage shoulder dystocia, to use forceps, or to perform a vaginal breech delivery?

It is not a silly question to ask ourselves, since these are critical, high-risk situations and skills that most of us do not encounter as frequently as routine vaginal delivery. When we are not practicing critical skills, we tend to lose them.

The question is increasingly important, moreover, because technological advances are making obstetric simulation more feasible and affordable for a variety of different settings. Realistic, low-fidelity mannequins that take up little space in an office or an old exam room are now relatively inexpensive.

Obstetric simulation training has become a tool that we simply must take advantage of. It is not only making its way into academia, with a small but growing body of literature showing that it improves competence and performance when a real event occurs, but is also gaining acceptance among practicing physicians as a valuable means of practicing skills and preparing for obstetric emergencies, such as shoulder dystocia, breech vaginal delivery, postpartum hemorrhage, and eclampsia.

I see and hear about attending physicians who join residents in the growing number of simulation programs that exist in academic institutions because they realize that they, too, can benefit from the practice. The American College of Obstetricians and Gynecologists is watching this trend; its Task Force on Simulation is examining the role of simulation in obstetrics and ways in which practicing obstetricians can take advantage of simulation technology.

Some professional liability organizations, meanwhile, are considering giving physicians discounts on their malpractice insurance premiums if they practice simulation; Harvard-affiliated obstetricians have been offered such discounts, and Kaiser Permanente is implementing simulation programs (including birth simulation training) as part of its initiatives for quality and patient safety.

It seems only a matter of time before more health care institutions draw on obstetric simulation to help practicing physicians update and reinforce their skills, and before certifying bodies also embrace the notion. (General surgery is on the cusp of establishing simulation centers for certification and recertification.)

In the meantime, obstetricians can take it upon themselves to use available technology and prepare for the high-acuity, low-frequency emergencies that are encountered by every obstetrician at some time.

Safety, Liability

That obstetric simulation is on the radar screen—and probably on its way to becoming mainstream—makes perfect sense.

Professionals in the airline industry, the military, and the nuclear power industry are already using simulation for teaching and for maintaining and evaluating skills. Simulation is a safety-first tool in these industries, and it often utilizes evidence-based protocols.

In medicine, we make evidence-based decisions all the time, and patient safety is a huge issue. The Joint Commission on Accreditation of Healthcare Organizations recently looked at all perinatal sentinel events across the country in all types of institutions, and found that 47% were linked with staff competence issues. Among the other identified root causes were communication issues (72%), the orientation and training process (40%), and organization culture as a barrier to effective communication and teamwork (55%). Simulation could play a significant role in addressing each of these issues.

Shoulder dystocia complicates up to 2% of all vaginal deliveries, and potentially causes permanent brachial plexus injury, clavicular fracture, hypoxic brain injury, and other significant long-term complications. Although we encounter shoulder dystocia infrequently, the risk for serious and permanent injury to the infant is so high that we ought to be prepared.

Similarly, approximately 3%–4% of singleton babies are in the breech position, yet only a minority of obstetricians are able to perform vaginal breech deliveries. In one recent study, only 33% of surveyed attending physicians performed vaginal breech deliveries. The rest do not do them anymore.

Although vaginal breech deliveries are discouraged, vaginal delivery is sometimes unavoidable or even preferable. (When the breech is on the perineum, for instance, it's riskier to go to cesarean delivery). We are putting our patients and ourselves at risk by not practicing and knowing how to do this with proper technique,

We do not like to talk about the litigation aspect, but we cannot hide it: Fetal injury that is related to emergencies like shoulder dystocia is a potential source of medical malpractice lawsuits and one that we can minimize by reinforcing and maintaining our skills through simulation.

Today's Simulators

Obstetricians worry about how they can do a simulation. Many think of simulators as too big, too expensive, and not lifelike. Some worry about doing a simulation in front of others and are too intimidated to try.

Some of the simulators available today are expensive. A full-body, high-fidelity obstetric simulator with all the bells and whistles—touch-screen computer technology that enables manipulation of the labor course, for instance, and varying vital signs and fetal heart rhythms—can cost up to $40,000.

These expensive models are often purchased by academic institutions that are interested in simulation for a multitude of purposes, including team training, but such models are not necessary to simulate at least several obstetric emergencies, including vaginal breech delivery, shoulder dystocia, and the use of forceps.

For these situations, low-fidelity simulators—which may be just a model of the pelvis through which a model baby can be manually pushed—are perfectly fine. They can be purchased for $2,000-$3,000, stored in a closet, and placed in an extra exam room where physicians can practice, either with a mentor or expert or by themselves.

Nothing is as real as a true patient or a real-life situation, of course, but many of these mannequins are surprisingly lifelike, with features like an anatomically correct bony pelvis, a stretchable perineum, and a silicone pelvic-floor musculature. A mannequin's cervix, for instance, really feels like a cervix.

When I was in resident training, I practiced using the forceps on a high-fidelity mannequin. This gave me an opportunity to practice all the necessary maneuvers and to know whether I performed all critical tasks, from inserting the posterior blade first, for instance, to holding the left blade of the forceps with my left hand while using my right hand as a guide.

Later, when I was in a real and urgent situation requiring forceps, I knew just what to do. It worked like clockwork. Simulation on a low-fidelity mannequin, if that was what my institution had had, would have been just as beneficial.

Simulation also provides opportunities to create protocols. In the middle of a forceps delivery simulation, for instance, you may realize that “this needs to be done all the time just like this.” Alternatively, you may think, “Let's not do it this way next time.”

Similarly, simulation affords us opportunities to practice and fine-tune communication and teamwork.

Improved Competence

I recently oversaw a resident who had previously done simulation training with high-fidelity mannequins as part of her curriculum at the Washington Hospital Center, and was now in a real and difficult delivery involving shoulder dystocia.

She performed the recommended initial maneuvers—like placing the patient in the McRobert's position and applying suprapubic pressure—but without success. She then immediately proceeded, without any prompting, to deliver the posterior arm, which relieved the shoulder dystocia. Afterward, the resident told me that “if I hadn't done the shoulder dystocia simulation lab, I would not have known to do that.” I hear such stories often.

Studies are beginning to document the effects of obstetric simulation training on competence and performance.

In a study published several years ago, for instance, residents at Georgetown University in Washington and the Uniformed Services University of Health Sciences in Bethesda, Md., were randomized to receive training on shoulder dystocia management using a high-fidelity obstetric simulator or to receive no special training. Each resident was subsequently tested without prior notice in another simulation scenario.

Those who had practiced shoulder dystocia management on mannequins completed more critical tasks and had significantly higher scores on timeliness of their interactions, proper performance of maneuvers, and overall performance (Obstet. Gynecol. 2004:103;1224–8).

Although not randomized, another more recent study at Georgetown University showed that high-fidelity simulation training improved resident performance of vaginal breech delivery. Residents were more likely after simulation training to perform critical maneuvers correctly and to deliver in a safe manner than they were before the training (Obstet. Gynecol. 2006:107;86–9).

Research from the University of Bristol (England) is also yielding interesting results. Investigators there have reported, for instance, that obstetric emergency training courses using simulation were associated with a significant reduction in low 5-minute APGAR scores and lower rates of hypoxic-ischemic encephalopathy (BJOG 2006;113:177–82).

Another study of shoulder dystocia has shown that, whereas training with high-fidelity mannequins provides additional benefits, training with low-fidelity mannequins is also effective in improving management of the obstetric situation by obstetricians and midwives (Obstet. Gynecol. 2006;108:1477–85).

A study from the Bristol investigators in which participants were tested on a standardized simulation before a simulation workshop, and then at 3 weeks, 6 months, and 12 months afterward, shows that improved performance appears to be sustained. Those who were proficient 3 weeks after the training retained their skills at the later dates. The researchers concluded that annual training may be adequate for some physicians, whereas others may need more frequent practice (Obstet. Gynecol. 2007;110:1069–74).

Soon-to-be-published research that we have recently completed at Georgetown University and the Washington Hospital Center similarly indicates that obstetricians generally should strive for continuing simulation training at least once a year. Residents in our study who were initially taught on the simulator scored higher when tested a year later than did residents who received no simulation training. Overall, however, everyone's scores declined.

Obstetric simulation is part of our future. New physicians of the future will enter practice having done simulation training in a variety of high-acuity, low-frequency scenarios—rather than learning solely through lectures and impromptu teaching after events have occurred—and those of us already in practice will likely find that working occasionally with low-fidelity mannequins enables us to provide better, safer patient care while reducing our liability risk.

Dr. Marsha Solomon, chief resident at the Washington Hospital Center, is shown performing a simulated forceps delivery in the photo at left. In the photo at right, Dr. Solomon performs a simulated breech vaginal delivery. Photos courtesy Dr. Tamika C. Auguste

Obstetric Simulation

Do you think that you would like to have your next airplane flight piloted by someone who has not flown a plane in several years or who has little experience in landing?

Pilots are among the professionals who gain their greatest experience and expertise through the development of skills using various simulation technologies.

Simulation training is common in the aviation industry, as it is in aeronautics and in some branches of engineering, which makes this question significantly less worrisome and less relevant than if simulation were not common.

Medicine in general—and obstetrics in particular—has been practiced worldwide using the apprenticeship model, in which residents and interns work with attending physicians to learn the art of medicine.

While caring for patients with various disorders and in various scenarios, physicians-in-training work alongside the more senior practitioners, taking on progressive amounts of responsibility. Experience is gained accordingly.

This approach has been very successful over the years, and will remain so. It may be enhanced, however, as the simulation approach is slowly integrated into medicine and into obstetrics training.

The use of simulation training in medicine makes intuitive sense. The acquisition of the greatest possible skill or expertise—or the enhancement of skills if there is a hiatus in practice—makes sense from quality-of-care and patient-safety perspectives, and also because of the litigious environment in which we live and practice.

The question, “How would you like to have your baby delivered by an obstetrician who has not used forceps or managed shoulder dystocia in over a year?” is a valid one for patients who realize that less-common delivery scenarios are unpredictable.

This month's Master Class will focus on the utility, practicability, and application of simulation technology in obstetrics as a means of maximizing not only the skills of the resident, but also the skills of the practicing clinician.

Our guest author, Dr. Tamika C. Auguste, is the director of obstetric simulation at Washington Hospital Center and assistant professor of obstetrics/gynecology at Georgetown University in Washington. She speaks in various forums on the issue of simulation for both residents and practicing physicians, and is fast becoming a young leader and expert from whom we can expect to hear more in the future.

Key Points on Simulation

1. Simulation can be used to practice classic obstetric skills and high-risk, low-frequency obstetric emergencies.

2. Simulation is not only for those in academic medicine but also for those in private practice.

3. Low-fidelity simulators can be just as useful as high-fidelity simulators.

4. Simulation is becoming the norm in residency training programs.

How many of us are thoroughly, truly prepared to manage shoulder dystocia, to use forceps, or to perform a vaginal breech delivery?

It is not a silly question to ask ourselves, since these are critical, high-risk situations and skills that most of us do not encounter as frequently as routine vaginal delivery. When we are not practicing critical skills, we tend to lose them.

The question is increasingly important, moreover, because technological advances are making obstetric simulation more feasible and affordable for a variety of different settings. Realistic, low-fidelity mannequins that take up little space in an office or an old exam room are now relatively inexpensive.

Obstetric simulation training has become a tool that we simply must take advantage of. It is not only making its way into academia, with a small but growing body of literature showing that it improves competence and performance when a real event occurs, but is also gaining acceptance among practicing physicians as a valuable means of practicing skills and preparing for obstetric emergencies, such as shoulder dystocia, breech vaginal delivery, postpartum hemorrhage, and eclampsia.

I see and hear about attending physicians who join residents in the growing number of simulation programs that exist in academic institutions because they realize that they, too, can benefit from the practice. The American College of Obstetricians and Gynecologists is watching this trend; its Task Force on Simulation is examining the role of simulation in obstetrics and ways in which practicing obstetricians can take advantage of simulation technology.

Some professional liability organizations, meanwhile, are considering giving physicians discounts on their malpractice insurance premiums if they practice simulation; Harvard-affiliated obstetricians have been offered such discounts, and Kaiser Permanente is implementing simulation programs (including birth simulation training) as part of its initiatives for quality and patient safety.

It seems only a matter of time before more health care institutions draw on obstetric simulation to help practicing physicians update and reinforce their skills, and before certifying bodies also embrace the notion. (General surgery is on the cusp of establishing simulation centers for certification and recertification.)

In the meantime, obstetricians can take it upon themselves to use available technology and prepare for the high-acuity, low-frequency emergencies that are encountered by every obstetrician at some time.

Safety, Liability

That obstetric simulation is on the radar screen—and probably on its way to becoming mainstream—makes perfect sense.

Professionals in the airline industry, the military, and the nuclear power industry are already using simulation for teaching and for maintaining and evaluating skills. Simulation is a safety-first tool in these industries, and it often utilizes evidence-based protocols.

In medicine, we make evidence-based decisions all the time, and patient safety is a huge issue. The Joint Commission on Accreditation of Healthcare Organizations recently looked at all perinatal sentinel events across the country in all types of institutions, and found that 47% were linked with staff competence issues. Among the other identified root causes were communication issues (72%), the orientation and training process (40%), and organization culture as a barrier to effective communication and teamwork (55%). Simulation could play a significant role in addressing each of these issues.

Shoulder dystocia complicates up to 2% of all vaginal deliveries, and potentially causes permanent brachial plexus injury, clavicular fracture, hypoxic brain injury, and other significant long-term complications. Although we encounter shoulder dystocia infrequently, the risk for serious and permanent injury to the infant is so high that we ought to be prepared.

Similarly, approximately 3%–4% of singleton babies are in the breech position, yet only a minority of obstetricians are able to perform vaginal breech deliveries. In one recent study, only 33% of surveyed attending physicians performed vaginal breech deliveries. The rest do not do them anymore.

Although vaginal breech deliveries are discouraged, vaginal delivery is sometimes unavoidable or even preferable. (When the breech is on the perineum, for instance, it's riskier to go to cesarean delivery). We are putting our patients and ourselves at risk by not practicing and knowing how to do this with proper technique,

We do not like to talk about the litigation aspect, but we cannot hide it: Fetal injury that is related to emergencies like shoulder dystocia is a potential source of medical malpractice lawsuits and one that we can minimize by reinforcing and maintaining our skills through simulation.

Today's Simulators

Obstetricians worry about how they can do a simulation. Many think of simulators as too big, too expensive, and not lifelike. Some worry about doing a simulation in front of others and are too intimidated to try.

Some of the simulators available today are expensive. A full-body, high-fidelity obstetric simulator with all the bells and whistles—touch-screen computer technology that enables manipulation of the labor course, for instance, and varying vital signs and fetal heart rhythms—can cost up to $40,000.

These expensive models are often purchased by academic institutions that are interested in simulation for a multitude of purposes, including team training, but such models are not necessary to simulate at least several obstetric emergencies, including vaginal breech delivery, shoulder dystocia, and the use of forceps.

For these situations, low-fidelity simulators—which may be just a model of the pelvis through which a model baby can be manually pushed—are perfectly fine. They can be purchased for $2,000-$3,000, stored in a closet, and placed in an extra exam room where physicians can practice, either with a mentor or expert or by themselves.

Nothing is as real as a true patient or a real-life situation, of course, but many of these mannequins are surprisingly lifelike, with features like an anatomically correct bony pelvis, a stretchable perineum, and a silicone pelvic-floor musculature. A mannequin's cervix, for instance, really feels like a cervix.

When I was in resident training, I practiced using the forceps on a high-fidelity mannequin. This gave me an opportunity to practice all the necessary maneuvers and to know whether I performed all critical tasks, from inserting the posterior blade first, for instance, to holding the left blade of the forceps with my left hand while using my right hand as a guide.

Later, when I was in a real and urgent situation requiring forceps, I knew just what to do. It worked like clockwork. Simulation on a low-fidelity mannequin, if that was what my institution had had, would have been just as beneficial.

Simulation also provides opportunities to create protocols. In the middle of a forceps delivery simulation, for instance, you may realize that “this needs to be done all the time just like this.” Alternatively, you may think, “Let's not do it this way next time.”

Similarly, simulation affords us opportunities to practice and fine-tune communication and teamwork.

Improved Competence

I recently oversaw a resident who had previously done simulation training with high-fidelity mannequins as part of her curriculum at the Washington Hospital Center, and was now in a real and difficult delivery involving shoulder dystocia.

She performed the recommended initial maneuvers—like placing the patient in the McRobert's position and applying suprapubic pressure—but without success. She then immediately proceeded, without any prompting, to deliver the posterior arm, which relieved the shoulder dystocia. Afterward, the resident told me that “if I hadn't done the shoulder dystocia simulation lab, I would not have known to do that.” I hear such stories often.

Studies are beginning to document the effects of obstetric simulation training on competence and performance.

In a study published several years ago, for instance, residents at Georgetown University in Washington and the Uniformed Services University of Health Sciences in Bethesda, Md., were randomized to receive training on shoulder dystocia management using a high-fidelity obstetric simulator or to receive no special training. Each resident was subsequently tested without prior notice in another simulation scenario.

Those who had practiced shoulder dystocia management on mannequins completed more critical tasks and had significantly higher scores on timeliness of their interactions, proper performance of maneuvers, and overall performance (Obstet. Gynecol. 2004:103;1224–8).

Although not randomized, another more recent study at Georgetown University showed that high-fidelity simulation training improved resident performance of vaginal breech delivery. Residents were more likely after simulation training to perform critical maneuvers correctly and to deliver in a safe manner than they were before the training (Obstet. Gynecol. 2006:107;86–9).

Research from the University of Bristol (England) is also yielding interesting results. Investigators there have reported, for instance, that obstetric emergency training courses using simulation were associated with a significant reduction in low 5-minute APGAR scores and lower rates of hypoxic-ischemic encephalopathy (BJOG 2006;113:177–82).

Another study of shoulder dystocia has shown that, whereas training with high-fidelity mannequins provides additional benefits, training with low-fidelity mannequins is also effective in improving management of the obstetric situation by obstetricians and midwives (Obstet. Gynecol. 2006;108:1477–85).

A study from the Bristol investigators in which participants were tested on a standardized simulation before a simulation workshop, and then at 3 weeks, 6 months, and 12 months afterward, shows that improved performance appears to be sustained. Those who were proficient 3 weeks after the training retained their skills at the later dates. The researchers concluded that annual training may be adequate for some physicians, whereas others may need more frequent practice (Obstet. Gynecol. 2007;110:1069–74).

Soon-to-be-published research that we have recently completed at Georgetown University and the Washington Hospital Center similarly indicates that obstetricians generally should strive for continuing simulation training at least once a year. Residents in our study who were initially taught on the simulator scored higher when tested a year later than did residents who received no simulation training. Overall, however, everyone's scores declined.

Obstetric simulation is part of our future. New physicians of the future will enter practice having done simulation training in a variety of high-acuity, low-frequency scenarios—rather than learning solely through lectures and impromptu teaching after events have occurred—and those of us already in practice will likely find that working occasionally with low-fidelity mannequins enables us to provide better, safer patient care while reducing our liability risk.

Dr. Marsha Solomon, chief resident at the Washington Hospital Center, is shown performing a simulated forceps delivery in the photo at left. In the photo at right, Dr. Solomon performs a simulated breech vaginal delivery. Photos courtesy Dr. Tamika C. Auguste

Obstetric Simulation

Do you think that you would like to have your next airplane flight piloted by someone who has not flown a plane in several years or who has little experience in landing?

Pilots are among the professionals who gain their greatest experience and expertise through the development of skills using various simulation technologies.

Simulation training is common in the aviation industry, as it is in aeronautics and in some branches of engineering, which makes this question significantly less worrisome and less relevant than if simulation were not common.

Medicine in general—and obstetrics in particular—has been practiced worldwide using the apprenticeship model, in which residents and interns work with attending physicians to learn the art of medicine.

While caring for patients with various disorders and in various scenarios, physicians-in-training work alongside the more senior practitioners, taking on progressive amounts of responsibility. Experience is gained accordingly.

This approach has been very successful over the years, and will remain so. It may be enhanced, however, as the simulation approach is slowly integrated into medicine and into obstetrics training.

The use of simulation training in medicine makes intuitive sense. The acquisition of the greatest possible skill or expertise—or the enhancement of skills if there is a hiatus in practice—makes sense from quality-of-care and patient-safety perspectives, and also because of the litigious environment in which we live and practice.

The question, “How would you like to have your baby delivered by an obstetrician who has not used forceps or managed shoulder dystocia in over a year?” is a valid one for patients who realize that less-common delivery scenarios are unpredictable.

This month's Master Class will focus on the utility, practicability, and application of simulation technology in obstetrics as a means of maximizing not only the skills of the resident, but also the skills of the practicing clinician.

Our guest author, Dr. Tamika C. Auguste, is the director of obstetric simulation at Washington Hospital Center and assistant professor of obstetrics/gynecology at Georgetown University in Washington. She speaks in various forums on the issue of simulation for both residents and practicing physicians, and is fast becoming a young leader and expert from whom we can expect to hear more in the future.

Key Points on Simulation

1. Simulation can be used to practice classic obstetric skills and high-risk, low-frequency obstetric emergencies.

2. Simulation is not only for those in academic medicine but also for those in private practice.

3. Low-fidelity simulators can be just as useful as high-fidelity simulators.

4. Simulation is becoming the norm in residency training programs.

How many of us are thoroughly, truly prepared to manage shoulder dystocia, to use forceps, or to perform a vaginal breech delivery?

It is not a silly question to ask ourselves, since these are critical, high-risk situations and skills that most of us do not encounter as frequently as routine vaginal delivery. When we are not practicing critical skills, we tend to lose them.

The question is increasingly important, moreover, because technological advances are making obstetric simulation more feasible and affordable for a variety of different settings. Realistic, low-fidelity mannequins that take up little space in an office or an old exam room are now relatively inexpensive.

Obstetric simulation training has become a tool that we simply must take advantage of. It is not only making its way into academia, with a small but growing body of literature showing that it improves competence and performance when a real event occurs, but is also gaining acceptance among practicing physicians as a valuable means of practicing skills and preparing for obstetric emergencies, such as shoulder dystocia, breech vaginal delivery, postpartum hemorrhage, and eclampsia.

I see and hear about attending physicians who join residents in the growing number of simulation programs that exist in academic institutions because they realize that they, too, can benefit from the practice. The American College of Obstetricians and Gynecologists is watching this trend; its Task Force on Simulation is examining the role of simulation in obstetrics and ways in which practicing obstetricians can take advantage of simulation technology.

Some professional liability organizations, meanwhile, are considering giving physicians discounts on their malpractice insurance premiums if they practice simulation; Harvard-affiliated obstetricians have been offered such discounts, and Kaiser Permanente is implementing simulation programs (including birth simulation training) as part of its initiatives for quality and patient safety.

It seems only a matter of time before more health care institutions draw on obstetric simulation to help practicing physicians update and reinforce their skills, and before certifying bodies also embrace the notion. (General surgery is on the cusp of establishing simulation centers for certification and recertification.)

In the meantime, obstetricians can take it upon themselves to use available technology and prepare for the high-acuity, low-frequency emergencies that are encountered by every obstetrician at some time.

Safety, Liability

That obstetric simulation is on the radar screen—and probably on its way to becoming mainstream—makes perfect sense.

Professionals in the airline industry, the military, and the nuclear power industry are already using simulation for teaching and for maintaining and evaluating skills. Simulation is a safety-first tool in these industries, and it often utilizes evidence-based protocols.

In medicine, we make evidence-based decisions all the time, and patient safety is a huge issue. The Joint Commission on Accreditation of Healthcare Organizations recently looked at all perinatal sentinel events across the country in all types of institutions, and found that 47% were linked with staff competence issues. Among the other identified root causes were communication issues (72%), the orientation and training process (40%), and organization culture as a barrier to effective communication and teamwork (55%). Simulation could play a significant role in addressing each of these issues.

Shoulder dystocia complicates up to 2% of all vaginal deliveries, and potentially causes permanent brachial plexus injury, clavicular fracture, hypoxic brain injury, and other significant long-term complications. Although we encounter shoulder dystocia infrequently, the risk for serious and permanent injury to the infant is so high that we ought to be prepared.

Similarly, approximately 3%–4% of singleton babies are in the breech position, yet only a minority of obstetricians are able to perform vaginal breech deliveries. In one recent study, only 33% of surveyed attending physicians performed vaginal breech deliveries. The rest do not do them anymore.

Although vaginal breech deliveries are discouraged, vaginal delivery is sometimes unavoidable or even preferable. (When the breech is on the perineum, for instance, it's riskier to go to cesarean delivery). We are putting our patients and ourselves at risk by not practicing and knowing how to do this with proper technique,

We do not like to talk about the litigation aspect, but we cannot hide it: Fetal injury that is related to emergencies like shoulder dystocia is a potential source of medical malpractice lawsuits and one that we can minimize by reinforcing and maintaining our skills through simulation.

Today's Simulators

Obstetricians worry about how they can do a simulation. Many think of simulators as too big, too expensive, and not lifelike. Some worry about doing a simulation in front of others and are too intimidated to try.

Some of the simulators available today are expensive. A full-body, high-fidelity obstetric simulator with all the bells and whistles—touch-screen computer technology that enables manipulation of the labor course, for instance, and varying vital signs and fetal heart rhythms—can cost up to $40,000.

These expensive models are often purchased by academic institutions that are interested in simulation for a multitude of purposes, including team training, but such models are not necessary to simulate at least several obstetric emergencies, including vaginal breech delivery, shoulder dystocia, and the use of forceps.

For these situations, low-fidelity simulators—which may be just a model of the pelvis through which a model baby can be manually pushed—are perfectly fine. They can be purchased for $2,000-$3,000, stored in a closet, and placed in an extra exam room where physicians can practice, either with a mentor or expert or by themselves.

Nothing is as real as a true patient or a real-life situation, of course, but many of these mannequins are surprisingly lifelike, with features like an anatomically correct bony pelvis, a stretchable perineum, and a silicone pelvic-floor musculature. A mannequin's cervix, for instance, really feels like a cervix.

When I was in resident training, I practiced using the forceps on a high-fidelity mannequin. This gave me an opportunity to practice all the necessary maneuvers and to know whether I performed all critical tasks, from inserting the posterior blade first, for instance, to holding the left blade of the forceps with my left hand while using my right hand as a guide.

Later, when I was in a real and urgent situation requiring forceps, I knew just what to do. It worked like clockwork. Simulation on a low-fidelity mannequin, if that was what my institution had had, would have been just as beneficial.

Simulation also provides opportunities to create protocols. In the middle of a forceps delivery simulation, for instance, you may realize that “this needs to be done all the time just like this.” Alternatively, you may think, “Let's not do it this way next time.”

Similarly, simulation affords us opportunities to practice and fine-tune communication and teamwork.

Improved Competence

I recently oversaw a resident who had previously done simulation training with high-fidelity mannequins as part of her curriculum at the Washington Hospital Center, and was now in a real and difficult delivery involving shoulder dystocia.

She performed the recommended initial maneuvers—like placing the patient in the McRobert's position and applying suprapubic pressure—but without success. She then immediately proceeded, without any prompting, to deliver the posterior arm, which relieved the shoulder dystocia. Afterward, the resident told me that “if I hadn't done the shoulder dystocia simulation lab, I would not have known to do that.” I hear such stories often.

Studies are beginning to document the effects of obstetric simulation training on competence and performance.

In a study published several years ago, for instance, residents at Georgetown University in Washington and the Uniformed Services University of Health Sciences in Bethesda, Md., were randomized to receive training on shoulder dystocia management using a high-fidelity obstetric simulator or to receive no special training. Each resident was subsequently tested without prior notice in another simulation scenario.

Those who had practiced shoulder dystocia management on mannequins completed more critical tasks and had significantly higher scores on timeliness of their interactions, proper performance of maneuvers, and overall performance (Obstet. Gynecol. 2004:103;1224–8).

Although not randomized, another more recent study at Georgetown University showed that high-fidelity simulation training improved resident performance of vaginal breech delivery. Residents were more likely after simulation training to perform critical maneuvers correctly and to deliver in a safe manner than they were before the training (Obstet. Gynecol. 2006:107;86–9).

Research from the University of Bristol (England) is also yielding interesting results. Investigators there have reported, for instance, that obstetric emergency training courses using simulation were associated with a significant reduction in low 5-minute APGAR scores and lower rates of hypoxic-ischemic encephalopathy (BJOG 2006;113:177–82).

Another study of shoulder dystocia has shown that, whereas training with high-fidelity mannequins provides additional benefits, training with low-fidelity mannequins is also effective in improving management of the obstetric situation by obstetricians and midwives (Obstet. Gynecol. 2006;108:1477–85).

A study from the Bristol investigators in which participants were tested on a standardized simulation before a simulation workshop, and then at 3 weeks, 6 months, and 12 months afterward, shows that improved performance appears to be sustained. Those who were proficient 3 weeks after the training retained their skills at the later dates. The researchers concluded that annual training may be adequate for some physicians, whereas others may need more frequent practice (Obstet. Gynecol. 2007;110:1069–74).

Soon-to-be-published research that we have recently completed at Georgetown University and the Washington Hospital Center similarly indicates that obstetricians generally should strive for continuing simulation training at least once a year. Residents in our study who were initially taught on the simulator scored higher when tested a year later than did residents who received no simulation training. Overall, however, everyone's scores declined.

Obstetric simulation is part of our future. New physicians of the future will enter practice having done simulation training in a variety of high-acuity, low-frequency scenarios—rather than learning solely through lectures and impromptu teaching after events have occurred—and those of us already in practice will likely find that working occasionally with low-fidelity mannequins enables us to provide better, safer patient care while reducing our liability risk.

Dr. Marsha Solomon, chief resident at the Washington Hospital Center, is shown performing a simulated forceps delivery in the photo at left. In the photo at right, Dr. Solomon performs a simulated breech vaginal delivery. Photos courtesy Dr. Tamika C. Auguste

Obstetric Simulation

Do you think that you would like to have your next airplane flight piloted by someone who has not flown a plane in several years or who has little experience in landing?

Pilots are among the professionals who gain their greatest experience and expertise through the development of skills using various simulation technologies.

Simulation training is common in the aviation industry, as it is in aeronautics and in some branches of engineering, which makes this question significantly less worrisome and less relevant than if simulation were not common.

Medicine in general—and obstetrics in particular—has been practiced worldwide using the apprenticeship model, in which residents and interns work with attending physicians to learn the art of medicine.

While caring for patients with various disorders and in various scenarios, physicians-in-training work alongside the more senior practitioners, taking on progressive amounts of responsibility. Experience is gained accordingly.

This approach has been very successful over the years, and will remain so. It may be enhanced, however, as the simulation approach is slowly integrated into medicine and into obstetrics training.

The use of simulation training in medicine makes intuitive sense. The acquisition of the greatest possible skill or expertise—or the enhancement of skills if there is a hiatus in practice—makes sense from quality-of-care and patient-safety perspectives, and also because of the litigious environment in which we live and practice.

The question, “How would you like to have your baby delivered by an obstetrician who has not used forceps or managed shoulder dystocia in over a year?” is a valid one for patients who realize that less-common delivery scenarios are unpredictable.

This month's Master Class will focus on the utility, practicability, and application of simulation technology in obstetrics as a means of maximizing not only the skills of the resident, but also the skills of the practicing clinician.

Our guest author, Dr. Tamika C. Auguste, is the director of obstetric simulation at Washington Hospital Center and assistant professor of obstetrics/gynecology at Georgetown University in Washington. She speaks in various forums on the issue of simulation for both residents and practicing physicians, and is fast becoming a young leader and expert from whom we can expect to hear more in the future.

Key Points on Simulation

1. Simulation can be used to practice classic obstetric skills and high-risk, low-frequency obstetric emergencies.

2. Simulation is not only for those in academic medicine but also for those in private practice.

3. Low-fidelity simulators can be just as useful as high-fidelity simulators.

4. Simulation is becoming the norm in residency training programs.