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Review Article

Training Cesarean Section

A Scoping Review

Zetner, Diana B. MD; Petersen, Iben MBBS; Konge, Lars MD, PhD; Thinggaard, Ebbe MD, PhD

Author Information
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: August 2019 - Volume 14 - Issue 4 - p 264-270
doi: 10.1097/SIH.0000000000000367

Abstract

Cesarean section is an essential and lifesaving procedure. Trainees in obstetrics and gynecology are therefore required to be able to perform cesarean section early in their speciality training.1

Traditionally, surgical skills have been taught by the apprenticeship model where residents first observe and then perform the procedure under supervision of a more experienced senior doctor.2,3 The apprenticeship model has been criticized because the method lacks structure and objective assessment of competencies.4 Studies indicate that residents do not feel that they are adequately trained in performing medical procedures.5,6 Inadequate knowledge, experience, and supervision may lead to errors and threaten patient safety.4 In addition, there has been an increasing focus on training of nontechnical skills. Nontechnical skills are particularly important in an emergency cesarean section because poor teamwork and communication may delay delivery.7 Therefore, it has been argued that teaching of clinical skills should integrate educational strategies such as simulation-based training.4 This allows for training in a safe and controlled environment.4 Simulation-based training can improve trainees' surgical skills, prepare trainees for learning in the operating room thereby shortening the learning curve,8–11 and improve nontechnical skills.12

The integrating of simulation-based training in obstetrics raises new questions to be answered, such as how, where, and when to use this training method compared with other training strategies. This study aims to review the existing literature on educational strategies in training of cesarean section, to explore how cesarean section is trained, and to identify areas that need further investigation.

METHODS

This review is a scoping review following the methodology of Arksey and O'Mally13 and further developed by Levac et al.14 A scoping approach relies on the iterative, integrative, and flexible process of synthesizing the literature,15 following a framework, which include six steps, to ensure a flexible but still systematic approach.13,14 The six steps are as follows: identifying the research question, searching for relevant studies, selecting studies, charting the data, collating, summarizing, reporting the results, and consulting with stakeholders (optional). The research questions in scoping reviews are in general broad, and the scoping approach is well suited for reporting the extent, range, and nature of research activity and to determine gaps in the literature. Scoping reviews differ from both systematic and narrative reviews, because scoping reviews typically do not assess the quality of included studies and because an analytical reinterpretation of the literature is required.13,14

We reported the review according to the STructured apprOach to the Reporting In healthcare education of Evidence Synthesis (STORIES) statement.16 The STORIES statement is a set of criteria for reporting evidence synthesis in healthcare education. Reporting of evidence synthesis in medical education is complex, because there have been a paradigm shift from studies investigating “whether” an educational intervention is effective to studies asking questions such as “how,” “why,” “when,” and “for whom.” To reflect this, a panel of 19 experts agreed on the STORIES statement that consists of 25 questions that focus on the context of the synthesis rather than the methodology.16

A thematic approach was used to synthesize primary evidence. The goal of the thematic analysis is to identify and analyze patterns (themes) in the data set.17 Detailed notes of study design, methods, participants, and results were made on all included studies. Data were analyzed noting every possible pattern/theme related to educational strategies, and the studies was reread to ensure that no pattern/themes were missed. All potential key words in the literature were highlighted and reviewed by two authors. Examples on thematic data extraction are shown in Table 1.

TABLE 1
TABLE 1:
Examples of the Thematic Analysis

The research group identified inclusion criteria as studies describing and/or evaluating training programs and educational strategies in performing cesarean section or studies reporting on simulation models used for training cesarean section. Studies reporting on training programs were required to include doctors or medical students as participants, to include a description of the training method used, and to include practical training of cesarean section (eg, demonstration, hands-on-training, case-scenario-training, training in the operating room, simulation-based training, etc.). Studies written in English were included. Exclusion criteria were identified as studies in which training was limited to a discussion of the procedure, to personnel that do not perform surgery, to postoperative care, or studies limited to nontraining interventions to lower the cesarean section rate.

Key words were identified and a search string was created (see Table, Supplemental Digital Content 1, https://links.lww.com/SIH/A417, which shows all key words and the search string). A systematic search was carried out in the following databases: PubMed/MEDLINE, EMBASE, ERIC, Web of Science, and Cochrane library (CENTRAL) (December 27, 2017). Two researchers independently screened titles and abstracts and read full-text articles to identify records relevant for inclusion and data extraction. Disagreement was resolved by consensus or by a third reviewer. The literature search also included a “snowball search” to identify relevant literature through references in the included studies and relevant review articles obtained. Furthermore, literature from relevant Web sites, such as Royal College of Obstetricians and Gynaecologists, the American College of Obstetrics and Gynecologists, International Federation of Gynecology and Obstetrics, The European Board & College of Gynecology and Obstetrics, and Danish Society of Obstetrics and Gynecology was obtained. Authors were contacted by e-mail if further information was needed to decide for inclusion. Ethical approval was not sought for this article, because we were not collecting data from any individuals but reviewing existing research studies.

RESULTS

We identified 5001 records through the selected databases and four records through other sources. After removing duplicates 3550 remained and were screened by abstract and title, identifying 136 studies for full-text screening. Reading full text resulted in inclusion of 28 records, which were analyzed (Fig. 1). Of the 28 articles included, the two researchers initially agreed on inclusion of all but one. This study was discussed with a third reviewer, resulting in consensus on inclusion of the study among all three researchers.

FIGURE 1
FIGURE 1:
Identification, screening, and selection of records.

Study Characteristics

Twelve studies reported on specialty specific training19,21–31: obstetrics and gynecology (n = 9), family medicine (n = 1), maternal fetal medicine (n = 1), and general practitioners (n = 1). Another 11 studies approached training through interdisciplinary training where doctors trained together with nurses, midwifes, and/or other staff involved in labor and delivery (n = 117,12,18,20,32–40) or where doctors from different specialities trained together such as obstetricians and anesthesiologists (n = 241,42). We identified one study exploring validity evidence for a simulator25 and one descriptive study of a cesarean section simulator (Table 2)43 (see Table, Supplemental Digital Content 2, https://links.lww.com/SIH/A418, which provides a brief description of training methods used in included studies and the related themes).

TABLE 2
TABLE 2:
Study Characteristics

Thematic Analysis

Themes were identified through a thematic analysis of the literature.17 In the initial process of analyzing data, 31 key words on educational strategies were identified. Two researchers discussed each key word and key words covering similar topics were grouped into 13 educational concepts. The key words and concepts were reviewed, and six themes and nine subthemes were identified (see Table, Supplemental Digital Content 3, https://links.lww.com/SIH/A419, which outlines the exact process of identifying concepts, themes, and subthemes). Our thematic analysis revealed the following training strategies: simulation-based training (subthemes: team training, in situ training, technical training), simulators (subthemes: high-fidelity simulators, low-fidelity simulators), clinical training, e-learning or videos, classroom-based learning (subthemes: lectures, small groups), and assessment (subthemes: assessment of programs/interventions, assessment of learners) (Table 3).

TABLE 3
TABLE 3:
Overview of Themes and Subthemes

We also explored whether cesarean section was trained using one or more training methods. Eleven studies described simulation-based training of cesarean section without combination of other training methods,7,18,21,25,30,32,38–41,43 whereas 12 studies described training as a combination of simulation-based training with lectures, e-learning, and/or clinical training.12,20,22,23,27,28,33–37,42 Four studies combined clinical training with lectures, videos, and/or e-learning,23,24,29,31 whereas only one study described clinical, supervised training in the operating room as the only training method.19

DISCUSSION

We performed a scoping review using a thematic approach to identify educational strategies in training cesarean section. Most 28 studies, included in this review, reported on simulation-based training (n = 23) with a major focus on team-based training (n = 17). Reporting on clinical training programs was sparse (n = 7), and clinical training was commonly combined with other training strategies (n = 6). We identified only a few studies providing a more detailed description of training of surgical skills in relation to cesarean section (n = 4).

Simulation-Based Training

Team Training

Simulation-based training is a common way of training teamwork and communication skills in obstetrics. Simulation-based team training of obstetric emergencies may improve efficiency and reduce errors.44 Most studies that reported on team-based training of cesarean section used an interdisciplinary approach. This included doctors from obstetrics and gynecology, anesthesiology, midwives, nurses, and other staff.7,12,18,20,32–41 Programs were most commonly comprehensive and not limited to cesarean section, but included multiple obstetric emergency scenarios.12,21,27,32,34,35,38,42 Training was often followed by debriefing sessions addressing nontechnical skills such as teamwork and communicational skills.12,18,20,21,34,35,38,40 Studies on interdisciplinary simulation-based training reported on decreased time from diagnosis to operating room entry,35,39 time to delivery,7,39 and increased proportions of cesarean section achieved within a recommended time frame.12,20 Barriers to implementing team-based training are that team training requires a great amount of coordination of staff, and combined with the expense of high-fidelity simulators and actors, this approach is expensive. Educational level and training needs should be taken into consideration when planning a team-based simulation program.

In situ Training

In situ simulation is a method where simulation-based training is carried out in the actual care unit, meaning that it is performed where the participants normally work and have their daily routines.45,46 In addition to training staff, in situ training can be used to identify barriers and threats to patient safety and provide solutions for these.18,38,39,45,46 Hamman et al38 performed 40 in situ simulations and identified that staff was undereducated in callout policies and had difficulties finding needed medicine and equipment. Identification of threats and consequences was used to improve system solutions such as cesarean section boxes.

Although the setting, in which simulations are carried out may not influence learning outcomes of individuals or teams,45 in situ simulations may be more accepted by participants, because studies indicate that trainees perceive this type of simulation as more authentic.34,45 Furthermore, in situ simulation may be easier to implement because of increased accessibility, making it easier to coordinate team-based training. Nonetheless, the hospital departments are required to have access to simulators, patient actors, mannequins, and well-educated instructors in simulation. Other challenges are the high rate of cancellations of in situ simulations, eg, due to a heavy load of patients.45

Technical Training

We found the literature lacking in studies reporting on training of surgical skills specifically in relation to cesarean section. Twelve studies included in this review described simulation-based training of technical skills.7,12,21–23,25,27,28,30,40,42,43 In these studies, technical training was most commonly aimed at a more general level, such as life support, or lacked a more detailed description of surgical skill training. One study reported on limitations of the mannequin to perform surgical training.18 Training of surgical skills in relation to cesarean section was only described in detail in four studies.23,25,28,43 One study did a lecture and demonstration followed by supervised training on a cesarean section simulator; the effect of training was measured using self-assessment.28 Studies on self-assessment show that trainees' perceptions of own skills may be highly inaccurate,47 indicating the need for feedback, especially when training residents. Another study described using an online module combined with supervised clinical training. Feedback on trainees' surgical skills was given through the online module.23 Two studies aimed at exploring validity evidence or describing a simulator for training of surgical skills.25,43

More studies on training of surgical skills in cesarean section are warranted. It is recommended that studies evaluating the effect of surgical training should include objective measurements.

Simulators

A common classification of simulators is the division into low- and high-fidelity simulators, resembling the complexity and to some extent the realism of the simulator.48 We found that high-fidelity simulators are widely used in training of cesarean section (n = 1412,18,21,22,25,28,30,32–35,38,40,41), whereas the uses of low-fidelity simulators were only reported in two studies.22,43

High-fidelity simulators provide a more realistic simulation scenario compared with low-fidelity simulators, but they are often expensive. Training surgical skills in cesarean section require cutting in the simulator, and exchangeable modules are therefore needed. Limitations of the simulators and the cost of exchangeable modules may result in many educators not training the surgical steps in cesarean section. This may explain why we identified only a few studies focusing on training of surgical skills.

Low-fidelity simulators on the other hand have the advantage of being simple, often low-cost simulators, making them more accessible. Deganus43 described a cesarean section simulator that can be easily made without advanced equipment and at a low cost. Low-fidelity, low-cost simulators may provide a reasonable training method for training surgical skills for cesarean section, although they do not provide the same possibilities to train complex scenarios as the high-fidelity simulators.

Another possibility is to modify a high-fidelity simulator. Adam et al21 provided a detailed description of a modification of a high-fidelity simulator. The study group used flank steak and foam to simulate the fascia, muscle layers, and subcutaneous fat when training cesarean section.21 We identified only one study that reported on validity evidence for a cesarean section simulator.25 Therefore, further studies exploring validity evidence for cesarean section surgical skills simulators are warranted.

Clinical Training

We identified seven studies reporting on clinical training in cesarean section.19,23,24,29,31,36,37 Clinical training was described as on-the-job, hands-on training,36,37 eg, by using the apprenticeship model in which residents observed and acquired surgical skills during supervised surgery.19,23,24,29,31 However, clinical training programs were poorly described in general. Two studies reported on a minimum number of cesarean sections residents were expected to perform during clinical training.29,31 Only one study reported a detailed training curriculum.29 Trainees were expected to demonstrate knowledge of the procedure and surgical competence in the operating room before they could proceed training and ultimately perform cesarean section independently.29 A challenge is that clinical training may lack structure,4 because the residents are taught by different educators with different preferences. Because clinical training is a common way of teaching surgical skills,3 studies reporting on clinical training may be underrepresented in the literature compared with studies exploring new training methods, such as simulation-based training. To ensure patient safety and adequate supervision, studies looking into the quality and efficiency of clinical training of cesarean section are warranted.

E-learning or Videos

E-learning is a flexible way of acquiring knowledge because it can easily be standardized and updated and allows trainees to learn at their own pace.49,50 Nonetheless, we only identified three studies reporting on the use of e-learning,23,35,42 and three studies reporting on the use of videos, but in a classroom-based setting or during debriefing sessions.24,34,40 E-learning was used to prepare trainees before simulation-based training in two studies.12,35,42 York et al23 developed an interactive computer-based simulation program for training residents' surgical skills in cesarean section. An online module provided the trainees with videos, audios, animations, self-test questions, and an evaluation tool, including personalized feedback on surgery performed in the clinic. The study group found that the module was feasible to implement. However, because the study provided no control group, the effect of e-learning in cesarean section training is still unclear.23

Classroom-Based Learning

Lectures are a common way of teaching in medical education. Of the 28 studies included in this review, 10 reported on the use of lectures in training of cesarean section.20,22,27–29,31,33–35,42 Lecture-based learning provides an opportunity to share knowledge to a large group of people, eg, as an introduction before practical sessions, or to share new knowledge.51

Another method for classroom-based learning is small groups, which activates learners' through interaction and discussion.52 We identified only one study using a small group approach for learning.22 Small group learning of cesarean section may be beneficial because learners are required to argue, share thoughts, and reflect on clinical reasoning.52 This method may therefore be beneficial in an interdisciplinary or interprofessional setting where sharing knowledge and ideas for problem solutions, across specialities and jobs, is relevant for the clinical setting.

Assessment

We identified assessment as a theme in 21 of the 28 studies included.7,12,18–23,25–30,34–37,39,40,42 Assessment can be subdivided into assessment that evaluates the training program and/or assessment evaluating learners.

Assessment to evaluate a training program or intervention was described in 18 studies.7,12,18,20,21,25–30,34–37,39,40,42 Common approaches to measure the training program or intervention were to analyze patient charts or hospital data,7,20,26,29,35,37,39,42 knowledge testing,21,27,30,34 assessment of performance using rating scales or checklists,12,18,21,27,30,34 and participant evaluation.40

Assessment of learners can be formative, providing feedback on performance to improve learning, or summative, focusing on learning outcomes, typically examining competency to progress in training.53 We identified 12 studies describing formative assessment7,12,18,20,21,23,27,29,30,34,35,40 using individualized feedback,23,27,29,30 debriefing sessions,7,12,18,20,21,34,35,40 and patient actor feedback.7,21 Three studies described a summative approach to certify cardiac life support and neonatal resuscitation22 or surgical skills in cesarean section.19,29 Summative feedback is traditionally used to ensure patient safety by determining minimum levels of competency but has been criticized because training toward passing an examination may remove the trainees' focus from their education and lifelong learning.53

We found that there was a lack of structure when assessing residents' ability to perform surgery. Of the seven studies that reported on clinical training, only three provided a description of assessment of surgical skills,19,23,29 two in which there were no objective assessment described. The use of objective rating scales for cesarean section, such as Objective Structured Assessment of Technical Skills,54 is integrated in some training programs in obstetrics.55 Another objective measure is the requirement of a certain number of cesarean sections performed before the residents are given the responsibility to perform surgery individually.56 Subjective assessment made by a more senior doctor may vary widely depending on the assessor and assessors may be biased.57 Assessment for determining competency should rely on several methods of assessment.58

Strengths and Limitations

This study provides a systematic and thorough overview of the available literature in training of cesarean section. All studies have been reviewed in detail, and relevant results have been presented. We chose a scoping method, which is is an accepted way of reporting,13,14 to allow for a broader range of outcomes and criteria for inclusion of literature. In systematic reviews, a rigid, pre-set protocol is followed. This approach may be too narrow when seeking to expose gaps in the literature. However, a limitation to the scoping method and thematic analysis is the lack of predefined criteria's for analysis of results. In addition, inclusion of various study types resulted in a great heterogeneity of the studies included, challenging the comparison of data. Finally, cesarean section training was in some cases a part of larger training programs, in which the training method was described as a whole, making data extraction for specific training of cesarean section challenging.

CONCLUSIONS

Simulation-based training provides a unique method for training in a safe and controlled environment. Thematic analysis of studies included in our scoping review indicates that simulation-based training is widely accepted and used in many obstetrics departments. Simulation-based team training improves nontechnical skills, which are important in obstetric emergencies, such as emergency cesarean section. Team training is therefore recommended. High-fidelity simulators are advanced and realistic but expensive. Low-cost low-fidelity simulators may be more suited when training surgical skills in cesarean section. The literature in training and assessment of surgical skills in cesarean section is sparse and more studies are warranted.

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Keywords:

Cesarean section; education; simulation; technical skills; nontechnical skills; obstetrics

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