Clinical Review

How simulation can train, and refresh, physicians for critical OB events

OBG Manag. 2008 September;20(9):42-54

References

1. Maslovitz S, Barkai G, Lessing JB, Ziv A, Many A. Recurrent obstetric management mistakes identified by simulation. Obstet Gynecol. 2007;109:1295-1300.

2. Thompson S, Neal S, Clark V. Clinical risk management in obstetrics: eclampsia drills. Qual Saf Health Care. 2004;13(2):127-129.

3. Hope P, Breslin S, Lamont L, et al. Fatal shoulder dystocia: a review of 56 cases reported to the Confidential Enquiry into Stillbirths and Deaths in Infancy. Br J Obstet Gynaecol. 1998;105:1256-1261.

4. Deering S, Poggi S, Macedonia C, Gherman R, Satin AJ. Improving resident competency in the management of shoulder dystocia with simulation training. Obstet Gynecol. 2004;103:1224-1228.

5. Crofts JF, Attilakos G, Read M, Sibanda T, Draycott TJ. Shoulder dystocia training using a new birth training mannequin. BJOG. 2005;112:997-999.

6. Crofts JF, Bartlett C, Ellis D, Hunt LP, Fox R, Draycott TJ. Training for shoulder dystocia: a trial of simulation using low-fidelity and high-fidelity mannequins. Obstet Gynecol. 2006;108:1477-1485.

7. Friedrich M. Practice makes perfect: risk free training with patient simulators. JAMA. 2002;288:2808-2812.

8. Pizzi L, Goldfarb N, Nash DB. Crew Resource Management and Its Application in Medicine. In Making Healthcare Safer: A Critical Analysis of Patient Safety Policies. Evidence Report/Technology Assessment # 43. AHRQ Publication No. 01-E058, July 2001. AHRQ. Rockville, MD. www.ahrq.gov/clinic/ptsafety/

9. Brown JP. Closing the communication loop: using readback/hearback to support patient safety. Jt Comm J Qual Saf. 2004;30:460-464.

10. Macedonia CR, Gherman RB, Satin AJ. Simulation laboratories for training in obstetrics and gynecology. Obstet Gynecol. 2003;102:388-392.

11. Gardner R. Simulation and simulator technology in obstetrics: past, present and future. Expert Rev Obstet Gynecol. 2007;2:775-790.

12. Deering S, Brown J, Hodor J, Satin AJ. Simulation training and resident performance of singleton vaginal breech delivery. Obstet Gynecol. 2006;107:86-89.

13. Rudolph JW, Simon R, Rivard P, Dufresne RL, Raemer DB. There’s no such thing as “non-judgmental debriefing: a theory and method for debriefing with good judgment. Simul Healthc. 2006;1(1):49-55.

14. Gaba DM, DeAnda A. A comprehensive anesthesia simulator environment: re-creating the operating room for research and training. Anesthesiology. 1988;69:387-394.

15. Deering S, Poggi S, Hodor J, Macedonia C, Satin AJ. Evaluation of residents’ delivery notes after a simulated shoulder dystocia. Obstet Gynecol. 2004;104:667-670.

16. Joint Commission on Accreditation of Healthcare Organizations. Sentinel event alert. 31 July 2004.

17. Draycott T, Sibanda T, Owen L, et al. Does training in obstetric emergencies improve neonatal outcome? BJOG. 2006;113:177-182.

18. McCarthy J, Cooper JB. Malpractice insurance carrier provides premium incentive for simulation based training and believes it’s made a difference. Anesth Patient Saf Found Newsl. 2007;22(1):17.-

19. CREOG and APGO Annual Meeting 2007. Innovations in medical education: achieving your potential. March 7-10, 2007. Salt Lake City, Utah.

20. Allen R. Update of AMA’s initiative to transform medical education (ITME). Section on medical schools interim meeting. November 10, 2007. Available at: http://www.ama-assn.org/amal/pub/upload/mm/44/i07highlights.pdf.

21. Vozenilek J, Huff JS, Reznek M, Gordon JA. See one, do one, teach one: advanced technology in medical education. Acad Emerg Med. 2004;11:1149-1154.

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
Childbirth Graphics	• 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
Simulaids	• 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)
Limbs & Things	• 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

CONTACT INFORMATION

3B Scientific
www.3bscientific.com

Childbirth Graphics
1-800-299-3366
www.childbirthgraphics.com

Gaumard Scientific
1-800-882-6655
www.gaumard.com

Koken
www.kokenmpc.co.jp/english

Limbs & Things
1-866-GOLIMBS
www.golimbs.com

Nasco
1-800-558-9595
www.enasco.com

Simulaids
1-800-431-4310
www.simulaids.com

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.