Clinical Review

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

Author and Disclosure Information

Perinatal teams can practice handling emergencies without endangering patients or risking litigation. Hospitals and insurers are taking notice.



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.

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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%).
A brief history of simulation, in and outside medicine

Simulation has roots in prehistoric times, when it facilitated acquisition of hunting skills and prepared people for tribal games or warfare.1 The ancient Greeks used simulation to illustrate philosophical concepts and help students understand them.2 Today, simulation techniques are used in various industries and disciplines, especially when real-world training is too dangerous or expensive, or impossible.3

Safety in the air. The airline industry is known for incorporating simulation techniques into training programs for pilots and flight crews. The first airplane simulator was built in 1910, after the first fatal airplane crash in 1908.4 The need to train pilots during World War I and World War II greatly increased the use of flight simulators.

Beginning in the early 1980s, the airline industry began to use a range of risk-reduction activities designed to make commercial flying safer. Airlines established standard operating protocols and checklists, required pilots to participate in simulation-based training, and scheduled periodic skills and behavioral assessments. These changes in procedures, along with technological advances, led to a substantial decline in aircraft flight errors over the two decades that followed.

In labor and delivery. Obstetric simulators designed to illustrate the process of childbirth and teach midwives how to manage complications have been dated to the 1600s.1 Early childbirth simulators were typically made of basket and leather fragments in the shape of a female pelvis, accompanied by a dead fetus or doll. Later, such devices were made of wood, glass, fabric, or plastic. Their use and evolution continued through the 19th and 20th centuries.5

Computerized simulator technology was introduced during the 1960s, and widespread adoption across medical specialties began in the 1980s.6,7 Gaba and DeAnda were among the first to adapt simulation training for healthcare providers during the late 1980s.7

Since then, simulation training has become increasingly common in the fields of anesthesia, general surgery, and emergency medicine. Residents use simulation to train for difficult airway intubation, central venous access, adult and pediatric trauma resuscitation, and such complex surgical procedures as laparoscopic cholecystectomy. Reports of human patient simulation to reenact some or all aspects of routine and critical obstetrical events began to appear in the specialty’s journals in the late 1990s.8,9


1. Wilson A. The Bomb and the Computer: Wargaming from Ancient Chinese Mapboard to Atomic Computer. New York: Delacorte Press; 1968.

2. Buck GH. Development of simulators in medical education. Gesnerus. 1991;48 Pt 1:7-28.

3. McGuire CH. Simulation: its essential nature and characteristics. In: Tekian A, McGuire CH, McGaghie WC, et al, eds. Innovative Simulations for Assessing Professional Competence: From Paper and Pencil to Virtual Reality. Chicago: University of Illinois at Chicago, Department of Medical Education; 1999.

4. Haward DM. The Sanders teacher. Flight. 1910;52(50):1006-1007.

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

6. Denson JS, Abrahamson S. A computer controlled patient simulator. JAMA. 1969;208:504-508.

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

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

9. Knox GE, Simpson KR, Garite TJ. High reliability perinatal units: an approach to the prevention of patient injury and medical malpractice claims. J Healthc Risk Manag. 1999;19(2):24-32.


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