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Simulation in Obstetrics

Satin, Andrew J., MD

doi: 10.1097/AOG.0000000000002682
Contents: Medical Education: Clinical Expert Series
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Simulation in obstetrics is a widely accepted and valuable tool that benefits all levels of learners from medical students to maternal–fetal medicine subspecialists. What began as an adjunct to medical education now has a rapidly expanding role in acquisition of new and innovative procedures, team and unit training, and safety and quality initiatives. The number of obstetric simulation peer-reviewed reports has increased exponentially in recent years, yet only a small percentage of reports primarily addresses clinical outcomes. Studies link simulation to a reduction in neonatal brachial plexus injury, maternal trauma related to forceps delivery, response to postpartum hemorrhage, efficiency in performing emergent cesarean delivery, and neonatal mortality. Simulation is a required component in accredited obstetrics and gynecology residency training programs. Obstetric simulation has a role in the certification of physicians, and simulation hands-on courses may be used to meet maintenance of certification requirements. As simulation platforms are validated, they are likely to be incorporated into the certification process as a means of assessing technical and communication skills. Accrediting, certifying, professional, quality, and safety organizations have invested in simulation committees, interest groups, curricula, and continuing medical education courses. Support for research, including large multicenter trials, are needed to inform further implementation. Research and development should lead to lower costs and improved simulators. As the public, government, licensing, and credentialing institutions explore means of improving patient safety, expansion of simulation in obstetrics is inevitable.

Simulation benefits all levels of obstetric learners, and its effects on improving patient outcomes, quality and safety, and accreditation and certification are growing.

Department of Gynecology and Obstetrics, Johns Hopkins Medicine, Baltimore, Maryland.

Corresponding author: Andrew J. Satin, MD, Department of Gynecology and Obstetrics, 600 N Wolfe Street, Phipps 264, Baltimore, MD 21287-1264; email: asatin2@jhmi.edu.

Financial Disclosure The author did not report any potential conflicts of interest.

The author is an employee of Johns Hopkins University and a Director and President-Elect of the American Board of Obstetrics and Gynecology.

The opinions expressed are those of the author and not that of the organizations he serves.

Continuing medical education for this article is available at http://links.lww.com/AOG/B104.

The author has indicated that he has met the journal's requirements for authorship.

Received November 13, 2017. Received in revised form February 10, 2018. Accepted February 15, 2018.

Simulation in obstetrics now permeates all levels of training from medical students to highly subspecialized maternal–fetal medicine and fetal therapists. Although obstetric simulation incorporating high-fidelity birthing, critical care, and ultrasound simulators may feel like a new phenomenon, its roots in academic medicine in the United States were seeded in the late 1800s. At the June 1898 meeting of the Association of American Medical Colleges, J. Whitridge Williams of Johns Hopkins presented a paper titled “Teaching Obstetrics” in which he identified simulation as an important element in obstetric teaching.1 As deliveries moved into hospitals in the 1900s, obstetric trainees were exposed to a large and diverse group of patients and the need for simulation appeared to wane. Toward the end of the 20th century, interest in simulation returned, driven by contemporary changes in medical education and concerns for patient safety. In 2003, a Current Commentary published in Obstetrics & Gynecology called attention to a potential role for medical simulation in obstetrics and gynecology.2 The authors were all military physicians. We witnessed firsthand how the military effectively used aviation simulators and war games as an integral part of military training and ultimately how simulation contributed to mission success. At the time, we faced multiple challenges in getting our medical students and residents adequate experience to get ready for independent practice. Simulation offers educators the opportunity to teach, test, and prepare for the challenges in clinical practice. It allows trainees to learn new techniques without harming patients. Simulation permits us to train and gain experience in the management of rare life-threatening conditions. Simulation exercises enhance both safety and predictability. Simulation is now widely accepted as a valuable tool in training in obstetrics.

Simulation in obstetrics applies to the training of medical students, residents, maternal–fetal medicine fellows, and physicians in practice. If we do it, we can simulate it. Critics suggest that simulation is merely a reactionary response of training programs struggling with small clinical volumes. Although there may be no substitute for experience with real patients, simulation serves as an adjunct to education and patient safety initiatives. The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) have included hands-on simulation courses at their annual clinical meetings. The American Board of Obstetrics and Gynecology (ABOG) has set criteria for the use of these courses to meet maintenance of certification requirements and introduced simulation into its certifying examination. Thus, what began as an adjunct to medical education in obstetrics has grown to permeate every level of training, has been used to learn new and innovative techniques, has been incorporated into team and unit training, and has an expanding role in accreditation and certification. Outlined subsequently is an attempt to review the status of simulation in obstetrics including an overview of the published literature; the effects of simulation on clinical outcomes; the role of simulation in obstetric training and assessment; simulation development; and future roles for obstetric simulation in accreditation and certification.

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OVERVIEW OF THE LITERATURE

An enormous number of articles describing and studying obstetric simulation has been published. Nevertheless, the published evidence of simulation to positively influence all areas of obstetrics including training, research, and clinical outcomes can be construed as a mixed bag. On the one hand, a PubMed search using the words “simulation” and “obstetrics” yields 1,113 English-language articles. This is a small but significant number compared with a PubMed search using the term “medical simulation,” which yields more than 43,000 articles. There has been a marked increase in obstetric publications during the past few years (Fig. 1). There is little doubt that simulation permeates and improves many aspects of education and task performance in obstetrics, yet only a handful of these articles consists of randomized clinical trials studying the effects of simulation on patient outcomes. It is unfortunate that up until now the proliferation in articles has largely been limited in focus on education and not on direct improvement of clinical outcomes. Numerous studies describe simulation exercises for various levels of training, and a large number of reports describes the effects of simulation training on performance as measured on the corresponding simulator or simulation. Categorizing the more than 1,000 articles mentioned previously, simulation articles can be divided into the following categories: clinical outcomes; education, including medical students, residents, fellows, and continuing medical education for practicing physicians; assessment; simulation product development or comparisons; simulation science including the ideal location of exercises and implementation of programs; specific clinical situations; teamwork training; and certification.

Fig. 1

Fig. 1

A refined PubMed search with the words “simulation” and “obstetrics” confined to the title or abstract revealed 285 English-language articles. Review of each of these citations revealed 103 articles in which the focus of the report was principally on an obstetric topic. Reports were excluded if they addressed primarily gynecologic topics, including first-trimester imaging or bleeding; anesthesia management; or health care economics. Shown in Table 1 is a description of the focus or primary objective of simulation publications. A plurality of articles address the effect of simulation on performance as measured in the simulation (24%). Typically, the participant was tested within the simulation, practiced, and retested. Twenty percent of articles addressed the effect of obstetric simulation on the participants' confidence or attitude in addressing clinical situations. Only 8% focused on simulation's direct effect on actual clinical outcomes. Also, shown in Table 1 is a breakdown of these articles' study designs. A plurality of these articles were cohort studies (27%) assessing skills before and after simulation training. Twenty-five percent were commentary or review articles. Only 8% were randomized trials. These include trials that speak to clinical outcomes and randomization of learners to simulation compared with alternative learning techniques. Nearly half of obstetric simulation articles focus on learners at multiple levels (Table 1), although more articles solely involve residents (18%) and medical students (16%) than fellows (6%) or attendings (4%). A search of the MedEdPortal, associated with the Association of American Medical Colleges' Journal of Teaching and Learning, using the words “obstetrics” and “simulation,” lists 37 additional articles focused on education.

Table 1

Table 1

A search of the Cochrane Library using the word “simulation” revealed 13 reviews and three protocols. None of the reviews specifically focuses on simulation for obstetric conditions. The Library includes a review of formal resuscitation training programs to reduce mortality and morbidity in newborns. Currently many, if not most, residents complete resuscitation courses such as Basic Life Support, Advanced Cardiac Life Support, Neonatal Advanced Life Support, and Pediatric Advanced Life Support. These standardized formal resuscitation training courses are a form of simulation courses. Many hospitals require such courses as part of the credentialing and privileging process. Thus, although there is a mounting body of published work, only a small percentage of published reports primarily addresses clinical outcomes, many show improvements in a simulated environment, and simulation is the focus of many reviews and commentaries.

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SIMULATION AND CLINICAL OUTCOMES

Shown in Table 2 are obstetric conditions with evidence of improved clinical outcomes associated with simulation.

Table 2

Table 2

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Shoulder Dystocia

The best evidence for simulation in obstetrics is in the implementation of simulation training for the management of shoulder dystocia leading to a reduction in brachial plexus injuries in newborns. In 2008, Draycott et al3 compared the management of and neonatal injury associated with shoulder dystocia before and after mandatory shoulder dystocia simulation training. This retrospective, observational study compared the management and neonatal outcome of births complicated by shoulder dystocia before and after the introduction of annual shoulder dystocia training. All training was performed on a hemipelvis mannequin. Training covered risk factors, recognition, and demonstration of maneuvers on the simulator. The training consisted of a stepwise approach to management that included calling for help, McRoberts' position, suprapubic pressure, and internal maneuvers (delivery of the posterior arm or rotation of the fetal shoulders). This initial report covered more than 39,000 births over a 9-year period. The management of shoulder dystocia and associated injuries was compared pretraining and posttraining using clinical records. Clinical management improved with training. Importantly there was a significant reduction in neonatal injury after a shoulder dystocia (30/324 [9.3%] vs 6/262 [2.3%]; relative risk 0.25, CI 0.11–0.57).

The same group updated their data with a 12-year follow-up and the effect of simulation training was even more profound. Physicians and midwives in their system attend an annual 30-minute practical session on shoulder dystocia management. Using a mannequin with the skin pulled back and an anterior shoulder impacted on a bony pelvis, they learn “do not pull hard, do not pull quickly, and do not pull down.” Individuals practice McRoberts' maneuver, suprapubic pressure, delivery of the posterior arm, and internal rotation.4 They then participate in team simulation. Additionally, the simulation training includes instruction on proper documentation. There were significant benefits to long-term embedded training programs with improvement in management of shoulder dystocia and reduction in brachial plexus injuries. Twelve years after the introduction of training, fetal morbidity associated with shoulder dystocia was extremely low. There were no cases of permanent brachial plexus injury in the last 4 years of the follow-up involving more than 17,000 vaginal births.4 Thus, when it comes to shoulder dystocia, the literature describes clear benefit for simulation training and an algorithmic approach for the improvement of clinical outcomes.

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Forceps Delivery

Another example of simulation training influencing clinical outcomes is simulation training for forceps-assisted vaginal delivery and reduction in maternal perineal trauma. The group from Northwestern University designed a curriculum for training residents in the use of Simpson forceps.5 Central to this curriculum was simulation training on a birth mannequin. Residents continued simulation practice until they achieved mastery-level performance. This program was credited with a 26% reduction in third- and fourth-degree lacerations while concomitantly increasing the use of forceps delivery.

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Decision to Delivery for Emergency Cesarean

Teamwork and communication is accepted as a critical element of patient safety. The Department of Defense evaluated the effect of teamwork training on adverse maternal and neonatal outcomes in 15 hospitals.6 Although there were no statistically significant differences between groups in individual maternal and neonatal outcomes, there was a reduction in time from the decision to proceed with immediate cesarean delivery to the time of incision from 33 to 21 minutes. In an interventional before-and-after study in Denmark, a multidisciplinary team training program focused on emergency cesarean delivery, including full-scale simulations resulted in a statistically significant reduction in the decision-to-delivery interval (24.8 vs 27.3 minutes) and an increase in the number of deliveries within 30 minutes (88% vs 74%, P=.017).7 Importantly, this was reported as decision to delivery as opposed to decision to incision.

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Postpartum Hemorrhage

A simulation-based training program in a low-resource setting was associated with a 38% reduction (2.1–1.3%) in postpartum hemorrhage. An educational intervention, which included a half-day simulation session, was performed in Tanzania. This reduction in hemorrhage was associated with an increase in performance of basic delivery skills and the use oxytocin. The authors emphasized the clinical importance of these findings in a region with a high prevalence of anemia and a lack of blood banking.8 An interprofessional postpartum simulation training program in Norway focused on prevention, identification, treatment, communication, and leadership.9 This retrospective study found an association with simulation training and a reduction in the rate of red blood cell transfusion (12% vs 21%, P<.01), curettages (6.0% vs 11%, P<.01), and uterine artery embolization (0.2% vs 1.9%, P=.01). Although the authors recognize the potential for confounding variables, they suggest that simulation led to an increase in competence among health care professionals resulting in improved clinical outcomes.

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Neonatal Resuscitation

A Cochrane Library review sought to determine whether standardized programs in neonatal resuscitation improve neonatal outcomes.10 The authors identified five trials comparing standardized neonatal programs with no standardized programs. They conclude that standardized neonatal resuscitation programs (compared with basic newborn care) results in reductions of early neonatal and 28-day mortality. These trials, however, are mainly limited to developing countries.

Thus, an enormous number of reports describing and studying simulation in obstetrics exists. Although few address the actual effects of simulation on clinical outcomes, simulation has had a positive influence on brachial plexus injuries resulting from shoulder dystocia, maternal trauma with forceps, management of postpartum hemorrhage, timeliness of emergent cesarean delivery, and neonatal resuscitation (Table 2). Based on the growing number of simulation reports, the positive effect of simulation on more or more clinical outcomes seems inevitable.

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SIMULATION IN OBSTETRICS EDUCATION

Medical Students

Simulation in obstetrics has its roots in medical student education. At the beginning of the 21st century, medical schools began building simulation centers in response to decreased access to patients for teaching. Obstetric simulation is now part of nearly all U.S. medical schools' obstetric training. Shown in Box 1 is the list of simulation topics for medical students often cited in the literature. Additionally, a number of programs have simulation courses either just before medical students leave school or boot camps just before starting internship programs. These programs have a strong simulation emphasis on basic and surgical skills. Most reported medical student simulation programs include skills needed to manage labor and delivery. Typically, these accounts either address the students' attitude or confidence in performing particular skills or measure performance on a simulation exercise before and after learning or practicing on a simulator. Simply stated, students feel better prepared and perform better on simulation exercises with practice. There exist little data addressing students' skills with real patients. Jude et al11 compared third-year students who practiced vaginal delivery skills on a mannequin with those who simply attended a lecture. Students who practiced deliveries on a simulator were more likely to believe they could perform a vaginal delivery independently or with minimal supervision. The “Labor Games” describes a series of low-fidelity, low-cost simulations including cervical examinations, knot-tying, suturing, fetal heart rate interpretation, estimated blood loss, amniotomy, and estimated fetal weight.12 Using residents as teachers, students rotate through the seven stations. Postassessment shows improved self-perception in all skills. Students training in a simulation laboratory are more comfortable with fundal height measurement, fetal scalp electrode placement, Leopold maneuvers, artificial rupture of membranes, and intrauterine catheter placement.13 A study of 113 medical students randomized to simulation or classic teaching reveals simulation students perform higher on their oral and written examinations.14 Nitsche and coworkers assigned third-year students to receive or not receive simulation training on cervical examinations. Cervical examination simulation training improved accuracy in dilation and effacement when tested on simulators. Further analysis found that it took 100 repetitions for students to achieve competence.15 The same group concluded that it took two to three simulation training sessions for students to obtain minimal competence in vaginal delivery skills.16

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Common Obstetric Simulation Curricula Grouped by Learner Cited Here...

Medical Students

  • Fundal height
  • EFW
  • Leopold maneuvers
  • Labor and delivery skills
  • Estimation of blood loss
  • Suturing, knot-tying

Residents

  • Operative vaginal delivery
  • Breech delivery
  • Twin delivery
  • Shoulder dystocia
  • 3rd- and 4th-degree laceration
  • Postpartum hemorrhage
  • Eclampsia
  • Team-based drills
  • MFM Fellows
  • Critical care obstetrics
  • Invasive in utero procedures
  • Ultrasonography

CME Courses

  • Obstetric emergencies
  • Critical care obstetrics
  • Team-based emergencies
  • New procedures
  • Ultrasonography
  • Invasive in utero procedures

EFW, estimated fetal weight; MFM, maternal–fetal medicine; CME, continuing medical education.

Thus, many reports focused on medical students describe the use of inexpensive models to gain skills. The notion of balance of cost compared with realism pervades simulation development at all levels of training. Macedonia et al2 used the term ARRON rule (as reasonably realistic as objectively needed) for guiding the development of simulation scenarios. DeStephano et al17 found that lower cost, low-technology birth simulators were as effective as expensive high-fidelity birthing mannequins for teaching students vaginal delivery. Importantly, the examples cited previously also highlight the concept of evaluating technical skills. The evaluation of technical skills is an area of great importance for more advanced health care providers with potential to have a role in certification, licensing, and credentialing. Thus, simulation in obstetrics is deeply rooted in medical student education. The Association of Professors of Gynecology and Obstetrics through their Undergraduate Medical Education Committee publishes The Basic Clinical Skills Curriculum Teaching Modules. This guide includes low-fidelity simulations for teaching basic clinical and surgical skills (www.apgo.org/educational-resources).

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Residents

Residency training needs drove the acceptance of simulation in our specialty and subspecialties. It is during residency that simulation has its most robust application. Nearly every procedure necessary to learn during residency has been addressed through simulation. Through its Surgical Skills Task Force and Simulation Working Group, ACOG describes simulation scenarios for several obstetric procedures (https://www.acog.org/-/media/Departments/Simulation-Consortium/Simulations-Consortium-Toolkit051818-2.pdf?dmc=i&ts-20180521T1306463525). The Simulation Working Group was also instrumental in developing the Emergencies in Clinical Obstetrics Course, which focuses on simulations for shoulder dystocia, postpartum hemorrhage, umbilical cord prolapse, and breech vaginal delivery. The decline in hands-on experience in specific procedures is well known across all surgical specialties. In obstetrics, the spectrum of skills required is wide and includes antepartum and intrapartum emergencies and postpartum complications. Numerous reports address the use of simulation in residency to allow trainees to rehearse and learn from mistakes without harming patients. Commonly reported topics in residency include operative vaginal delivery, breech delivery, twin delivery, management of shoulder dystocia, third- and fourth-degree laceration repair, management of eclampsia, and hemorrhage.

Simulation topics for residency training evolved as actual clinical experience with a specific procedure declined. The Royal College of Obstetricians and Gynaecologists developed a specific birth simulation training course, ROBuST, focused on operative vaginal delivery including manual rotation, vacuum, and forceps delivery.18 Macedonia described use of a hemipelvis and doll for teaching residents low-forceps deliveries.2 Recognized experts have called for the use of simulation to teach forceps, because it can enhance residents' understanding of mechanical principles and therefore should precede clinical work.19,20 The Northwestern group cited previously not only showed a reduction in maternal perineal trauma with introduction of a resident forceps simulation program, but they describe in detail the development of a simulation-based curriculum for forceps-assisted vaginal delivery and the method for implementation of this curriculum into training.5 Vaginal delivery of the breech fetus is now mostly limited to unplanned rapid deliveries as well as breech extraction of the second twin. The lack of breech deliveries available for training obstetric residents combined with the potential for birth injury resulting from an incorrect delivery technique led to development of simulation training in these areas. Deering21 reported that simulation improved resident performance in the management of a vaginal breech delivery. The design of this study is consistent with the design of many simulation studies in that residents improve their performance on the simulations. Easter et al22 describe a simulation for twin vaginal birth including breech extraction of the second twin. Personal comfort with performing breech extraction on a nonvertex second twin improved from 5.5% to 66.7% (P<.01) after simulation. This study design is also common because it addresses attitudes or comfort of trainees with a specific clinical topic after simulation training.

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Fellows and Attendings

Although simulation in obstetrics has its origins with undergraduate and resident education, team training and safety initiatives drive inclusion of attending physicians. The Society for Maternal-Fetal Medicine's simulation committee focuses on two clinical realms: invasive fetal procedures and clinical care obstetrics.23 Simulation courses are now a regular addition to the SMFM Annual Pregnancy Meeting. In 2014–2015, SMFM supported the development of critical care obstetric simulation scenarios, which serve as the foundation for critical care simulation courses sponsored by the Society. The development of a video library of critical care simulation scenarios was supported by SMFM, developed by Johns Hopkins, and titled JH C2ODE. These simulation scenarios include the management of numerous critical care conditions including pulmonary embolism, maternal cardiac arrest, hypertensive emergencies, eclampsia, severe sepsis with shock, pulmonary edema with acute respiratory distress syndrome, hemodynamic monitoring and mechanical ventilation through the ARDS net protocol, myocardial infarction, diabetic ketoacidosis, amniotic fluid embolism, Advanced Cardiac Life Support in pregnancy, massive hemorrhage, and perimortem cesarean delivery. An example of these critical care simulation exercises for amniotic fluid embolism, massive transfusion protocol, and cesarean delivery is available at www.hopkinsmedicine.org/gynecology_obstetrics/education/.

The training of maternal–fetal medicine fellows faces similar challenges as resident and student education. As noninvasive screening for aneuploidy became available, the number of invasive needle procedures for fetal diagnosis decreased. Thus, simulation fills a training need. Nitsche and Brost24 reported on a series of simulations using a small animal model and ultrasonography to practice invasive in utero needle procedures including amniocentesis, percutaneous umbilical blood sampling, or bladder stenting. Commercial and homegrown simulators exist for intrauterine transfusion and chorionic villus sampling. These simulations in critical care and invasive fetal diagnostic procedures benefit both fellows and attendings, are included in continuing medical education programs, and are incorporated in ABOG maintenance of certification programs. Simulation now has a role in individualized medicine and surgical rehearsal in obstetrics. Miller et al25 describe a process in preparation for minimally invasive in utero spina bifida repair. Three-dimensional ultrasound image acquisition leads to a three-dimensional printer-generated model of the specific fetal lesion, which is then placed in a homegrown simulator, and the procedure is rehearsed before the actual surgery (Fig. 2).

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SIMULATION PRODUCT DEVELOPMENT AND COMPARISON

Nearly one fourth of publications (Table 1) primarily focus on simulators or simulation design. The results of product development and simulation comparative studies are dependent on the level of learners and the specific skills or outcomes that are being evaluated. High-fidelity simulators may be beneficial for critical care education and skills. In an attempt to invoke the ARRON rule cited previously, MCIC, a risk-retention collaborative of five academic health systems, compared multiple commercial simulator platforms before rolling out a mandated shoulder dystocia simulation training curriculum. They ultimately chose a relatively low-fidelity platform.26 A randomized trial involving medical students and vaginal delivery did not show a marked advantage for a high-fidelity product.27 Similar conclusions were drawn for residents participating in a postpartum hemorrhage drill.17 The use of a beef tongue model to teach residents third- and fourth-degree laceration repair is widespread. Descriptive reports on how to modify and improve the model are increasing and may be accompanied by video links to add descriptive detail and support for adult learners (http://links.lww.com/AOG/A924).28 The key to any simulation design is to customize to the learners and what you want them to learn. Furthermore, simulation design varies when used for teaching as opposed to evaluation and assessment.

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LOCATION OF SIMULATIONS

A number of reports attempt to address the relative advantages of performing simulations in freestanding state-of-the-art simulation centers or in situ where obstetric care occurs. Simulation centers allow institutions to consolidate very costly simulation resources such as high-fidelity mannequins, realistic operating rooms, and anesthesia and critical care equipment. Simulation centers are separate from clinical areas and most often are in buildings physically separate from hospitals and birthing centers. Centers may facilitate interdisciplinary and multilevel training and provide a core of technical support. Both ACOG and the Society for Simulation in Healthcare have developed criteria to recognize unique standards for simulation centers and the conduct of simulation. Centers allow participants to focus on the tasks and not be distracted by the real-time needs of their clinical units. In an interventional study with training in a simulation center, multidisciplinary team training reduces the decision-to-delivery interval for emergency cesarean delivery.7 Alternatively, the logistics of going to a simulation center may be a barrier to attendance and may not optimize team performance for a specific condition on a specific unit. A randomized trial comparing training for eclampsia management in a simulation center compared with local hospitals showed no additional improvement by training in a simulation center.29 The trend in the literature is to show an advantage to simulation in either setting with no universal advantage for location. The lack of clarity may simply be function of the heterogeneity of groups and outcomes studied.

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TEAMWORK AND DRILLS

Teamwork and communication failures contribute to a majority of sentinel events in obstetrics. Labor and delivery units are an environment where emergencies are expected. The American College of Obstetricians and Gynecologists asserts that a protocol with standardized interventions and onsite drills will improve care given in an emergency.30 Simulation is a common method for training obstetric teams. By simulating emergencies, teams can learn and practice required interventions, improve efficiency, and reveal and ultimately reduce errors. In a randomized controlled trial, team training focused on shoulder dystocia and perimortem cesarean delivery; simulation improved team performance and technical skills.31 A team-based simulation curricula including eclampsia, postpartum hemorrhage, shoulder dystocia, and breech extraction was used to identify common mistakes in management and ultimately served to modify and improve training.32 In an analysis of teamwork behaviors as related to eclampsia management, more efficient teams were likely to have exhibited certain team behaviors such as recognizing and verbally declaring the emergency and managing the critical task of closed loop communication.33

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LEADERSHIP ORGANIZATIONS

Accreditation and Certification

Accreditation, certification, and professional organizations have embraced the potential of simulation to serve their constituents. The Accreditation Council for Graduate Medical Education accredits sponsoring institutions and residency and fellowship programs. The Accreditation Council for Graduate Medical Education common program requirements are in place to ensure that accredited programs follow a basic set of standards in training. In their Program Requirement for Obstetrics and Gynecology, they state that obstetrics and gynecology residents must develop and ultimately demonstrate proficiency in obstetrics and gynecology procedures essential for specialty board certification.34 The Program Requirements mention the use of obstetric simulation in several areas. In the discussion of the educational program and curriculum, they state that regularly scheduled didactic sessions should include simulation training. In the Frequently Asked Question section of their website, they note that simulation includes a range of options from low to high fidelity, saying that the Review Committee does not require each program to have a simulation center; however, incorporation of simulation in residency education is required. The Program Requirements go on to establish a role for simulation in the learning of communication skills. Residents must participate as team members in real or simulated interprofessional clinical patient safety activities that include analysis as well as formulation and implementation of actions. Simulation is also recognized as a way for residents to participate in the disclosure of patient safety events.

The American Board of Obstetrics and Gynecology certifies individuals in obstetrics and gynecology in the United States. They conduct tests and other procedures to test the qualifications of candidates for certification. Typically, candidates graduate from an accredited residency training program, take a qualifying examination on graduating from residency, a certifying examination after a period of independent practice, and enter a maintenance of certification process. The Board has begun to incorporate obstetric simulation as a part of the certification process, approved simulation as a means to meet the maintenance of certification requirement for improvement in medical practice, and they recognize simulation training as an innovative approach to assess a physician's technical, clinical, and teamwork skills. Approved simulation activities must provide advanced, hands-on clinical education experiences. It may integrate task trainers and varying degrees of fidelity simulators.35 Importantly, ABOG now includes a low-fidelity pelvis and doll into the general and maternal–fetal medicine certifying examinations as a means of further addressing the evaluation, diagnosis, and management of labor and delivery conditions.

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PROFESSIONAL ORGANIZATIONS

With more than 50,000 members, ACOG is obstetrics and gynecology's largest professional organization. Its embrace of simulation is well-documented. A search of their website using the words “simulation” and “obstetrics” reveals 220 references. These span a broad range of documents and activities from education to hands-on courses to safety and practice guidelines. In 2006, ACOG President Michael Mennuti asked me to present a plenary session on simulation at the Annual Clinical Meeting. This was followed by a series of presidential task forces and subsequently the ACOG Simulation Consortium. The Consortium evolved into the Simulation Working Group. The Group includes representatives from more than 20 established simulation centers in the United States. The stated purpose of the Group is the “development and implementation of unique, standardized, and validated simulations based-curriculum to improve residency education and clinical competency beyond residency” (https://www.acog.org/About-ACOG/ACOG-Departments/Simulations-Consortium). The Group's Tool Kit includes detailed descriptions of simulations for vaginal breech delivery, cesarean delivery, postpartum hemorrhage, shoulder dystocia, and laceration repair. For several years, ACOG has held hands-on simulation continuing medical education courses at its Annual Clinical and Scientific Meeting. Its publications, including Committee Opinions and patient safety materials, often cite a role for simulation in improving patient safety.

Within the past decade, SMFM established a simulation committee and special interest group. Members of this group have led hands-on continuing medical education courses at the Annual Pregnancy Meeting. These courses have focused on a series of topics including obstetric complications, critical care, and fetal diagnosis and invasive therapy. The American Institute of Ultrasound in Medicine conducts hands-on courses in ultrasonography, including fetal imaging. The Society for Simulation in Healthcare created an obstetrics and gynecology interest group that supports a web portal whereby members can post simulation content to promote transdisciplinary sharing of information and ideas. The Alliance for Innovation on Maternal Health, which is supported by multiple professional organizations and foundations, produced a series of safety bundles. Implementation of these bundles has been supported by government, safety, and quality organizations. Topics including postpartum hemorrhage and severe hypertension in pregnancy recognize simulation drills as a valuable tool in improving care. Thus, accrediting and certifying organizations and professional membership organizations all support a role for simulation in obstetrics.

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DISCUSSION

It is clear obstetric training is a lifelong process, and simulation permeates all levels of obstetric training from medical students, residents, maternal–fetal medicine fellows to practicing obstetricians and obstetric subspecialists. Regardless of level of training or experience in practice, the obligation to ensure patient safety by learning new techniques before clinical application suggests an increasing role for simulation. As the public, government, licensing, and credentialing institutions explore means of improving patient safety, expansion of simulation programs is inevitable. The American Board of Obstetrics and Gynecology has incorporated simulation into the maintenance of certification process and in the certifying examination. The goal of ensuring competency in technical skills among certification bodies suggests further expansion of simulation-based platforms as part of the board certification process. A high-fidelity obstetric ultrasound simulator was evaluated on candidates taking the French national examination for the practice of ultrasonography, and the simulator was as good an assessment measure of technical skills as performance on volunteer patients.36 The American Board of Surgery currently requires completion of a low-fidelity laparoscopic simulation course to be eligible to take their examinations. Currently, there is not a widely distributed, standardized obstetrics simulation course that has been associated with improved clinical outcomes. The American Board of Anesthesia has piloted the use of simulated and standardized patients to assess communication skills as part of their certification process. As simulation platforms unique to obstetrics and maternal–fetal medicine are validated, they are likely to be incorporated into the certification process as a means of assessing technical skills.

Another potential role for obstetric simulation is in credentialing and reentry into clinical practice. The military used laparoscopic virtual reality simulators for gynecologists on return from deployments to assist in transition back to practice. Many hospitals require demonstration of competence on a robotic simulator before granting robotic surgical privileges. In obstetrics, there are little data related to the number of simulated obstetric procedures to demonstrate competency or proficiency. It stands to reason that local credentialing decisions may now include a combination of simulation and peer review of clinical performance.

The Agency for Healthcare Research and Quality currently advocates implementing TeamSTEPPS training nationwide (http://teamstepps.ahrq.gov). As outlined previously, a strong argument for team training can be made, yet there are no trials on the effects of TeamSTEPPS training in reducing adverse obstetric outcomes. Support for large multicenter trials to determine best practices and determine where to focus simulation resources is overdue.

Simulation in obstetrics is here to stay. It is valuable and essential in obstetric education. We must be careful not to assume that all simulation programs positively affect clinical outcomes and that all programmatic interventions are cost-effective. As someone who believes in the potential of obstetric simulation to improve many clinical outcomes and describe clinical competence, we must recognize the limited data specific to clinical outcomes and competency. We should be cautious regarding widespread implementation of all things simulation and the potential for unintended consequences. We must encourage and support future simulation research focused on improving obstetric outcomes and accurate measuring health care provider competence.

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REFERENCES

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