Emergency obstetric simulation training: How do we know where we are going, if we don't know where we have been?

Review Article

Emergency obstetric simulation training: How do we know where weare going, if we don’t know where we have been?

Katrina L. CALVERT,1 Paul M. MCGURGAN,2 Edward M. DEBENHAM,3

Frances J. GRATWICK1 and Panos MAOURIS41Department of Postgraduate Medical Education, King Edward Memorial Hospital, 2School of Women’s and Infants’ Health, TheUniversity of Western Australia, 3Department of Anaesthetics, King Edward Memorial Hospital, and 4Obstetric and GynaecologyClinical Care Unit, King Edward Memorial Hospital, Perth, Western Australia, Australia

Background: Obstetric emergencies contribute significantly to maternal morbidity and mortality. Current training in themanagement of obstetric emergencies in Australia and internationally focusses on utilising a multidisciplinary simulation-based model. Arguments for and against this type of training exist, using both economic and clinical reasoning.Aims: To identify the evidence base for the clinical impact of simulation training in obstetric emergencies and to addresssome of the concerns regarding appropriate delivery of obstetric emergency training in the Australian setting.Methods: A literature search was performed to identify research undertaken in the area of obstetric emergency training.The initial literature search using broad search terms identified 887 articles which were then reviewed and considered forinclusion if they provided original research with a specific emphasis on the impact of training on clinical outcomes.Results: Ninety-two articles were identified, comprising evidence in the following clinical situations: eclampsia, shoulderdystocia, postpartum haemorrhage, maternal collapse, cord prolapse and teamwork training. Evidence exists for a benefitin knowledge or skills gained from simulation training and for the benefit of training in small units without access to high-fidelity equipment or facilities.Conclusions: Evidence exists for a positive impact of training in obstetric emergencies, although the majority of theavailable evidence applies to evaluation at the level of participants’ confidence, knowledge or skills rather than at the levelof impact on clinical outcomes. The model of simulation-based training is an appropriate one for the Australian settingand should be further utilised in rural and remote settings.

Key words: obstetric emergency, training, simulation, interprofessional teaching.

Background

Obstetric emergencies are unpredictable and evolve rapidly.Successful management of obstetric emergencies involves acoordinated response from an ad hoc multidisciplinaryteam comprised of individuals with varying degrees ofclinical experience. Maternal mortality confidentialenquiries1 and reviews2,3 repeatedly stress the involvementof poor teamwork and communication errors in badoutcomes on obstetric emergencies. Simulation providesobstetric emergency training in a safe nonclinicalenvironment, with the aim of improving clinical outcomes.

The use of simulation in obstetric training is centuries old.Midwifery training models made of wood, leather or clothare on display in museums in South America and Europeand are thought to date back to the 16th century.4

Simulation training in obstetrics ranges from very simplesimulators such as a bony pelvis with a baby to complexsophisticated simulators such as the SimMomTM orNOELLE� models. Part-task trainers can be used alone toteach specific tasks such as instrumental delivery orshoulder dystocia manoeuvres or in combination with asimulated patient in a form of hybrid simulation.Additionally, computer-based virtual reality simulationmodels exist incorporating haptic capabilities, providingkinesthetic feedback to learners in addition to visualfeedback. Simulation training can be provided in purpose-built simulation facilities or as in situ simulation in localunits using clinical areas such as labour ward rooms. Theuses of simulation training can include the teaching oftechnical skills, the promotion of effective teamworking andthe identification of patient safety issues such as placementof specific resources, including drugs, equipment and

Correspondence: Dr Katrina L. Calvert, Department ofPostgraduate Medical Education, 2nd Floor A block, KingEdward Memorial Hospital, 374 Bagot Road, Subiaco, Perth,WA 6008, Australia. Email: [email protected]

There are no conflict of interests or disclosures.

Received 30 January 2013; accepted 23 June 2013.

© 2013 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists 509

Australian and New Zealand Journal of Obstetrics and Gynaecology 2013; 53: 509–516 DOI: 10.1111/ajo.12120

Th e Australian and New Zealand Journal of Obstetrics and Gynaecology

personnel.5 In Australia, particular challenges are faced inmaternity care provision, including the high proportion ofmaternal deaths arising in Aboriginal and Torres IslandStrait women and in women living in remote and ruralareas.6 Australia, in common with other countries, hasdeveloped or adapted the existing model of obstetricemergency simulation training utilising several courses (seeTable 1). This list may not be exhaustive as the number ofinstitutions offering this training is constantly expanding,and in addition to the courses shown, training opportunitiesare offered by individual tertiary education providers aimedat both medical and midwifery care providers.The Royal Australian and New Zealand College of

Obstetricians and Gynaecologists (RANZCOG) has thelicence to run PROMPT (Practical Obstetric Multi-Professional Training), based on the UK PROMPTMaternity foundation © model.7 This model of training isdelivered via the Train the Trainer (T3) program and islikely to become the RANZCOG model of choicethroughout Australia.8

In Western Australia, multidisciplinary obstetricemergency simulation training has been in place for adecade, utilising the Medical Specialist OutreachAssistance Program (MSOAP) course (now known as

Rural Health West Education Workshop in Obstetrics) todeliver training to rural and remote units and theInterdisciplinary Teamwork in the Management ofEmergencies (In Time) course to deliver training in themetropolitan and outer metro areas of Perth.

Aims

This paper aims to review the literature regarding theclinical impact of simulation training in obstetricemergencies and to address some of the concernsregarding appropriate delivery of obstetric emergencytraining in the Australian setting. Evaluation of trainingprogrammes is traditionally divided into four categories, asdescribed by Kirkpatrick in 1975.9 These levels are shownin Table 2. This paper aims to identify evidence atKirkpatrick’s level 4–Results. In real terms, this meansevaluation of programmes with evidence that an impacthas occurred at a clinically relevant level.

Materials and Methods

Two investigators (KC, PMcG) performed a literaturesearch in the PubMed and Cochrane databases using the

Table 1 Obstetric emergency training currently available in Australia and New Zealand

State/territory Course Learners Provider

Western Australia Rural Health West Obstetric EmergencyWorkshops

Multidisciplinary Rural Health West & King EdwardMemorial Hospital

InTime – Interdisciplinary Training inthe Management of Emergencies

Multidisciplinary Postgraduate Medical Education, KingEdward Memorial Hospital, and otherT3 trained metro and rural units.

Northern Territory InTime Multidisciplinary Alice Springs HospitalNew South Wales FONT – Fetal welfare, Obstetric

emergencies and Neonatal resuscitationTraining

Multidisciplinary New South Wales Pregnancy andNewborn Services Network

South Australia CSim Rural maternity careproviders –multidisciplinary

Flinders University Rural Clinical School

ENAME – Emergency Nursing andMidwifery Education

Rural and remotenurses

Country Health SA

Queensland MaCRM – Maternity Crisis ResourceManagement

Multidisciplinary Clinical Skills Development Service,Queensland Health

Victoria MSEP – Maternity Services EducationProgram (Maternity Emergency andPregnancy Care)

Multidisciplinary The Royal Women’s Hospital

Australia wide MEC – Maternity Emergency Care Remote HealthPractitioners –multidisciplinary

CRANA – Council of Remote AreaNurses of Australia

REOT – Rural Emergency ObstetricsTraining

Rural MedicalPractitioners

ACCRM – Australian College of Ruraland Remote Medicine

Australia andNew Zealand

ALSO – Advanced Life Support inObstetrics

Multidisciplinary ALSO

MOET – Management of ObstetricEmergencies and Trauma

Senior clinicians –obstetric or anaesthetic

Advanced Life Support Group

PROMPT – Practical Obstetric Multi-Professional Training

Multidisciplinary PROMPT foundation, RANZCOG

510 © 2013 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists

K. L. Calvert et al.

search terms ‘Obstetric emergency,’ ‘Obstetric simulation,’‘maternal collapse,’ and ‘In situ simulation’. The resultingcitations were reviewed by title or abstract and excludedon the basis of non-English language or nonobstetricevidence. The resulting articles were then reviewed forinclusion using the criterion ‘original research in obstetricemergency simulation’, with an emphasis on clinicaloutcomes of simulation training. Review articles were alsoincluded if they contributed original ideas to the literature.In addition, the bibliographies of the included articles were

hand searched for additional sources (see Fig. 1 for detailsof the literature search and inclusion).

Results

Eight hundred and eighty-seven abstracts were reviewedfor inclusion, 92 met the inclusion criteria.The included articles demonstrated evidence for the

impact of simulation training regarding specific clinicaloutcomes in addition to the overall impact. We present theevidence regarding specific clinical situations followed by theevidence regarding the overall impact of simulation training.

Eclampsia

In 2000, Draycott et al. demonstrated that drills wereeffective teaching modalities for rare emergencies and thatdrill training was feasible and well rated amongst learners.10

In 2008, Ellis et al. published a randomised controlled trialexamining the effects of simulator training on the clinicaleffectiveness of multidisciplinary teams, using time toadminister magnesium sulphate as a surrogate marker forteam effectiveness.11 All training was associated with amore rapid task completion time, with no significantdifference between the in situ training compared withtraining at a simulation centre. This constitutes evidence atK2. Fisher et al. evaluated their training in eclampsiamanagement at K3 level by utilising a randomised

Table 2 Kirkpatrick’s levels of program evaluation

Level Description Expansion

K1 Reaction How participants felt about the training, forexample, self-perceived changes inconfidence

K2 Learning Formally evaluated changes in knowledgeand/or skills following training, forexample, using postcourse questionnairesor quizzes

K3 Behaviour Demonstrable improvement in skill levels ofparticipants, persisting through to theworkplace following training

K4 Results Changes in clinical outcomes followingimplementation of training, for example,improvement in perinatal morbidity ormortality statistics

Total search results N = 887

N = 154

Exclusion based on title or abstract, including non-

English language

Exclusion of duplicates. Exclusion of trials of

undergraduate learners.

N = 92

Non-clinical evidence of impact of training

N = 20

Clinical evidence of impact of training

N = 13

Commentary or review articles N = 59

Figure 1 Literature search results.


Simulation training in obstetric emergencies

controlled trial design.12 They assigned resident doctors toreceive training by lecture or by simulation and then testedtheir performance during a simulated eclampsia drill after atime lag of three to four months. The residents wereassessed by observers who were blinded as to theirrandomisation status, and the performance scores weresignificantly better in the simulation-trained groupscompared with the lecture-only group. There is a lack ofKirkpatrick level 4 evidence for an impact of simulationtraining in the management of eclampsia.

Shoulder dystocia

Included papers defined shoulder dystocia as a delivery inwhich additional manoeuvres are required to deliver theshoulders after normal traction has failed.13 Draycott et al.published a K4 level evaluation utilising a retrospectiveobservational methodology.14 Their results showed thatmultidisciplinary training with part-task trainers wasassociated with a significant reduction in neonatal birthinjury rates, from 9.3% of all shoulder dystocia deliveriesprior to the training program to 2.3% following training.Other authors have published work showing that learnerconfidence or skill is increased following simulation-basedtraining in shoulder dystocia management,15–17 butevidence at Kirkpatrick level 4 remains lacking.

Postpartum haemorrhage

A positive effect of training in the management of PPH hasbeen shown at K4 by Sorensen et al. working in a hospitalsetting in Tanzania.18 Staff in the unit received theoreticaland drill-based training following the ALSO model on a2-day training course. PPH rates were assessed for sevenweeks prior to and seven weeks following the training. PPHrates fell from 33 to 18% following training, and rates ofsevere PPH fell from 9 to 4%. The mean blood loss atdelivery was significantly lower after the training, 293 mL(276–310) compared with 384 mL (363–408) before.Markova et al. found no change in the rate of bloodtransfusion required for PPH pre and postimplementationof multidisciplinary simulation-based training.19

Maternal collapse

Fisher et al. demonstrated an improvement in themanagement of maternal collapse at K2 by evaluatingmaternal–fetal medicine specialists’ performance in asimulated resuscitation scenario following training.20

Participants demonstrated a significant improvement inappropriate initiation and performance ofcardiopulmonary resuscitation (120 vs 32 seconds) andperimortem caesarean section (240 vs 159 seconds)following simulation-based training.Regarding an impact at K4, Zafar et al. used a self-

reporting logbook to record the post-training clinicalexperiences of 120 participants on an obstetric emergencytraining course.21 Participants recorded their use of

resuscitation skills over a 12-month period followingtraining. 53% of course participants submitted a logbook,with a total of 1123 resuscitations performed. Theresuscitation situations included, but were not limited to,pregnant patients, and the skills deployed includedadvanced techniques such as intra-osseous access andintubation. There was an 89% survival rate amongst thedocumented cases. Dijkman et al. utilised a retrospectivecohort methodology to investigate the incidence andoutcome of perimortem caesarean section following theintroduction of MOET training in the Netherlands.22

They found that the use of perimortem caesarean in casesof maternal collapse increased significantly following theintroduction of the MOET course. Outcomes for motherand baby remained poor, with maternal survival onlyoccurring in cases where the collapse and the interventionoccurred in an in-hospital setting.

Cord prolapse

In a retrospective cohort study, Siassakos et al.demonstrated a statistically significant reduction in mediandiagnosis delivery interval from 25 to 14.5 minutesfollowing simulation-based training.23 The authors noted anonsignificant reduction in the rate of Apgar scores of lessthan seven and in the rate of admission to NICU. Thisconstitutes evidence at Kirkpatrick level 3 (i.e skill retentionon the part of the obstetric team) rather than level K4.

Teamwork

The SaFE study, published in the UK in 2007, was one ofthe first large-scale randomised controlled trials attemptingto evaluate the usefulness of team training in obstetricemergencies at K2 and K3 using a simulation model.24 Thestudy was a large multicentre trial examining the impact oftraining delivered at a specialised simulation centre versus insitu simulation training delivered in local hospital-basedsettings. The authors demonstrated that clinical skills atindividual and team levels improved with the delivery oftraining and that knowledge of the participants improvedpost-training, with the improvement being sustained over a12-month time period. The training delivered in localhospital settings had the additional benefit of givingindividuals better insight into teamworking and betterawareness of safety climate compared with trainingdelivered at a simulation centre. Similar evidence at level K2was provided by Siassakos et al. who demonstrated a stronglink between the clinical effectiveness of a multidisciplinaryemergency team and their teamwork behaviours.25

Overall impact of training

In 1997, ALSO was evaluated at K1 by Bower et al.26

They found that ALSO training significantly increasedresidents’ confidence in their abilities to manage obstetricemergencies. More recently, Reynolds et al. demonstrateda similar effect of training on the self-reported confidence



of participants, with 87% reporting an improvement intheir knowledge and skills during real emergencies oneyear following simulation training.27 Crofts et al. analysedthe impact of their emergency skills training at K2 byexamining knowledge gained through training utilising theSaFE study data.28 Participants involved in obstetricemergency training completed pre- and post-trainingquestionnaires and demonstrated a significant increase inknowledge following training. Ameh et al. combined theseconcepts to provide a multidimensional evaluation modelof obstetric emergency training.29 Not only did theircourse participants rate the training highly, they alsodemonstrated an increase in knowledge following trainingand an improved use of the techniques taught, both at anindividual level utilising self-reporting and at aninstitutional level utilising hospital reporting systems. Thisconstitutes evaluation at K1, K2 and K3.In 2005, Draycott et al. published the first K4 level

paper demonstrating a clinically important improvement inperinatal outcomes, with a significant reduction in5-minute Apgar scores less than seven and in rates ofhypoxic ischaemic encephalopathy in babies followingemergency obstetric training.30 Similar results have beenobtained in rural and remote Western Australia, followingthe introduction of the MSOAP obstetric simulation-basedtraining program in 2002. Following the introduction ofthe program, there was a highly significant decrease in therate of infants born with 5-minute Apgar scores less thanseven and a significant decrease in caesarean section ratesin the study population.31

In 2011, Wagner et al. published the results of acomprehensive perinatal safety initiative implemented bytheir unit.32 They demonstrated an overall decrease in anAdverse Outcome Index, which included perinatal andmaternal outcomes, following implementation of amultifactorial training program involving teamworktraining, training in obstetric emergencies and training infetal assessment interpretation. Phipps et al. published asimilar study in 2012, demonstrating a reduction in theAdverse Outcome Index from 0.052 pretraining to 0.043post-training.33

Discussion

Specific aspects of training supported byevidence at Kirkpatrick level 4

Shoulder dystocia has been described as ‘the obstetric eventmost ideally suited for simulation’.34 Evidence for thepositive impact of training on the confidence or skill levelsof practitioners exists, and there is in addition someevidence for a benefit of training at a clinically relevant level.Postpartum haemorrhage (PPH) contributes to 21% of

maternal mortality on a global scale and up to 34.6% inunder-resourced areas.35 Training in the management ofPPH is specifically emphasised in the WHO publication‘The Partnership for Maternal, Newborn & Child Health2011’, which outlines 56 essential interventions likely to

improve the health and safety of mothers and babies andto enable countries to meet Millennium DevelopmentGoals 4 and 5.3 Markova’s study19 failed to demonstrate apositive benefit of training in the management of PPH butthere may have been confounding variables in this group –for example, following training staff were encouraged tomeasure the blood loss by weighing, which increases therate of PPH by eliminating the underdiagnosis inherent inblood loss estimation. The authors speculate that theremay have been a background increase in PPH incidenceover the study period.Cardiopulmonary arrest occurs in 1:30 000

pregnancies.36,37 Causes are varied and some, particularlyamniotic fluid embolism, can be challenging in theirdiagnosis and management.38,39 Outcomes depend oneffective resuscitation and cardiorespiratory support inaddition to successful deployment of perimortem caesareansection as a management option where appropriate.40 In thestudy by Zafar et al.21 there was a potential for self-selectionbias amongst the responders, but the responses provideevidence of the successful implementation of simulation-acquired skills in the clinical resuscitation scenario.Umbilical cord prolapse is a rare obstetric emergency

occurring in <1% of deliveries.41 It is associated with afetal mortality rate of up to 10% due to cord compressionor vasospasm.42 Management is generally by promptdelivery, either by caesarean section or by vaginal deliveryif the prolapse occurs at an advanced stage in labour.The diagnosis delivery interval has been considered animportant determinant of neonatal outcome.42,43 and thestudy by Siassakos et al. provides evidence that training inthis area can improve clinical performance.23 Whereimmediate access to caesarean delivery is not possible, themain aim of management is to keep the presenting partfrom compressing the cord.44 This can be achieved bymanually elevating the presenting part, filling the bladder,or when the woman is not in the active phase of labour,positioning the patient in a manner which will allowgravity to move the presenting part away from the cervix,for example, in the exaggerated Sim’s or all fourspositions. These manoeuvres can result in successfuloutcomes and may be required in rural settings whereother options are not available. Our literature search didnot reveal evidence that simulation-based training has beenevaluated based on these specific interventions.Multidisciplinary training is by its nature a cooperative

interactive activity with a strong focus on teamworking.There is mixed evidence that doctors are team players and‘individualism’ may have reluctantly evolved towards‘teamwork’ as a function of clinical necessity.45 Beneficialaspects of teamwork training have been described,including improved personal role awareness, interpositionalknowledge, mutuality and leadership.46 Critical care areassuch as emergency departments, operating theatres andlabour wards claim improved patient care outcomes withteam training.47 In the SaFE study, Strachan et al.concluded that ‘multiprofessional drill training in obstetricemergencies works’.24 The evidence demonstrates that



multidisciplinary training increases interprofessionalawareness of the roles, capabilities and attitudes of differentmembers of the team, suggesting that team training usingthis model has the potential to influence the attitudes oflearners in addition to their knowledge and skills.5,46

Regarding the overall impact of simulation training onobstetric emergency outcomes, the evidence remains sparse.Although Wagner’s program32 showed an overall clinicalbenefit, it is difficult to determine which aspects of theirintervention cascade were responsible, and their evidencecannot be taken as proof of benefit of simulation training. Inthe case of Phipps et al.33 the multidisciplinary simulationtraining was the only intervention implemented and thereduction in the Adverse Outcome Index was likely to bedue to the simulation-based training. The most convincingevidence remains the UK study by Draycott et al.30 and theWest Australian study by Maouris et al.31

Challenges of evaluation of simulation trainingprograms

Evaluation of training programs at a meaningful level is achallenge faced by all providers of education. Evaluationat K1 remains relevant as the success of any trainingprogram will rely on the continuing enrolment andparticipation of learners, no matter how great the clinicalbenefits might be. Evaluation at K4 remains unusual inthe global obstetric simulation literature. This may bebecause there are many potential confounding variables.Obstetric emergency training does not exist in a vacuum,and the implementation of alternative training strategiessuch as neonatal resuscitation program development willcontinue to cloud the perinatal outcome picture. Theimportance of institutional support for emergency trainingprogram effectiveness is stressed in the literature, and it isinteresting to note that several of the programmes outlinedin Table 1 specify that the training is mandatory for allobstetric care providers.

Limitations of simulation training in obstetrics

One of the potential difficulties in providing education atlocal level can be a lack of local expertise in the provision ofthis type of training.48–50 Provision of expert teachers is aprerequisite for successful training and for the provision ofappropriate feedback following the training scenarios. It hasbeen reported that feedback and debriefing are the principlesources of learning in simulation training51 and that skilledfeedback slows the rate of decay of clinical skills acquiredvia simulation-based learning.52 It has been pointed out thatembarrassment or fear of ridicule is major barrier to learningin simulation environments and that course participantshave concerns in these areas prior to training.52–54 Smallunits can have practical difficulties in releasing staff fromclinical duties to allow participation in training activities.In addition to the personnel issues, there may be local

resource issues.54–56 Provision of high-tech high-fidelitymodels and specialised simulation training centres is

expensive.54–56 This is of particular relevance in theAustralian setting where access to specialised simulationcentre resources is limited for many healthcare providersin the rural and remote setting. This creates a resourceimbalance and potentially places further risk on thosemembers of the Australian community already at adisadvantage in healthcare provision.4,57 Small units willhave problems in providing physical space for simulationtraining with high environmental fidelity as a two-beddelivery suite will find it less convenient to lose a room fortraining purposes than a larger delivery suite.

The current focus for Australian obstetricsimulation education

Simulation training in obstetric emergencies is an area ofgrowing interest to the specialty, with training providerssuch as ALSO and MOET well established in Australiaand New Zealand. This model of training is supported byprofessional bodies from the United States, Europe, Africaand the RANZCOG in Australia and NewZealand.2,3,6,49,56 The current Australian Department ofHealth focus on simulation-based training means thatthere is a window of opportunity for units to seek fundingfor these applications. Health Workforce Australia (HWA)is committed to simulation-based education funding, with$75.92 million currently allocated for investment insimulation resources to allow expansion of simulatedlearning, particularly in remote and rural areas.58 Theavailability of Commonwealth-funded support resourcesmakes this an ideal time for individual units andorganisations to embrace simulation-based education.Obstetrics and gynaecology, in common with other

surgical specialties, faces a workforce crisis, with pressure onclinical training placements likely to increase over the comingdecade in Australia.59 Concerns regarding training capacitylimitations, including limited availability of supervision andtraining in the private sector, and increasing demand forpart-time training have led to the consideration of alternativetraining pathways,60 including the use of simulation tosupport both training and assessment.34,56 Simulation hasbeen used in this way by other surgical specialties.61–64

Conclusion

The delivery of high-quality training to small units farfrom tertiary centres is a concern with particular relevanceto the Australian medical paradigm. The literature showsevidence for the positive impact of simulation-basedtraining on individual aspects of emergency obstetric careand for a benefit in terms of overall impact on perinataloutcomes. Effective training can be delivered to remoteunits by a small team of obstetrician and midwife trainersat a low cost with the benefit of the multidisciplinary teamtraining together without the requirement for expensivefacilities or long-distance travel, as demonstrated by theWestern Australian study.31 In situ training confers anadditional benefit by utilising a familiar environment,



identifying local concerns and issues and incorporatinglocal guidelines into training.Current evidence emphasises the impact of training on

confidence, knowledge and skills of participants withminimal evidence for the clinical impact of training onmaternal or perinatal morbidity or mortality. There aretrials currently underway to look specifically at clinicaloutcomes from simulation-based training.65,66 Furtherwork is required in this area.

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Emergency obstetric simulation training: How do we know where we are going, if we don't know where we have been?