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.
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.
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.