Technology Offers a Way to Practice Critical Skills

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).