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Editors Note: Send submissions to jfreeman3@kumc.edu. Articles should be between 5001,000words and clearly and concisely present the goal of the program, the design of the interventionand evaluation plan, the description of the program as implemented, results of evaluation, andconclusion. Each submission should be accompanied by a 100-word abstract. Please limit tables orfigures to one each. You can also contact me at Department of Family Medicine, KUMC, Room1130A Delp, Mail Code 4010, 3901 Rainbow Boulevard, Kansas City, KS 66160. 913-588-1944.Fax: 913-588-2496.

Joshua Freeman, MD, Feature EditorAlison Dobbie, MD, Feature Editor

Innovations in Family Medicine Education

Severe perineal lacerations are anuncommon complication in obstet-ric practiceestimates of the inci-dence of third- or fourth-degree lac-eration range from 5.85%29.7%.1,2Although risk factors for severeinjuries are knownnulliparity,shoulder dystocia, operative deliv-

ery, macrosomiatheir occurrenceis still an unpredictable, unplanned,intrapartum event. Opportunitiesfor residents to repair these injuriesunder authentic circumstances willinevitably be few. Further, thoughthese injuries and their repair areincluded in residency curricula,most learners lack hands-on repairexperience, even with simulations.Even in obstetrics and gynecology(OB-GYN) residency programs,59% of residents receive no struc-tured training in perineal repair.3Given the limitations of residencyexperience, this is an ideal scenario

for a simulation to teach severeperineal laceration repair.

We conducted a review of thepublished and presented literaturefor models of perineal lacerationrepair. One model uses a beeftongue to simulate the tissue foundduring the repair.4 This has a real-istic texture but is time-consumingto prepare, expensive, and learn-ers may have religious or moralobjections to meat products. Twopublished models allow for repairof second-degree lacerations butnot more-severe injuries.5,6 TheAdvanced Life Support in Ob-

The Sponge Perineum: An Innovative Method

of Teaching Fourth-degree Obstetric PerinealLaceration Repair to Family Medicine Residents

Rhonda A. Sparks, MD; Andrea D. Beesley, PhD; Andrew D. Jones, MD

From the Department of Family Medicine,University of Oklahoma (Dr Sparks); Mid-con-tinent Research for Evaluation and Learning,Denver (Dr Beesley); and Exempla Saint JosephHospital Family Medicine Residency Program,Denver (Dr Jones).

Background:Fourth-degree perineal lacerations are an uncommon, unpredictable injury that familyphysicians may face. Methods:After a needs assessment and feasibility review, we developed goals,objectives, instructional tools, and a feedback survey for a curriculum using a novel model to simulateperineal laceration repair. Results:Fifty-six learners evaluated the session, expressing increasedconfidence with perineal laceration repair, the usefulness of the model, and their desire to see it

included in the Advanced Life Support in Obstetrics course. Conclusions: The sponge perineumis an inexpensive, effective tool to teach perineal laceration repair. Further study is needed withactual patient experiences.

(Fam Med 2006;38(8):542-4.)

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stetrics (ALSO) course includes apresentation on this subject but nosimulation.7 This paper describesour inexpensive, simple model toteach perineal laceration repair andfeedback from its use at the Univer-sity of Oklahoma Family Medicine

Residency Program (OUFMRP).Our goal was that graduates becomfortable performing fourth-degree perineal laceration repairin clinical practice.

Methods

OUFMRP is a 12-12-12 univer-sity-based residency program thattrains residents to provide broad-spectrum care, including obstetrics.Because many of our residents goon to practice obstetrics in rural

areas, we had a strong local needfor effective training in perineallaceration repair. The subjectsof this study were residents atOUFMRP and participants in theALSO course at OUFMRP.

This project began with a novelidea for a perineal model. Thesponge perineumis constructed us-ing a two-layer car-washing sponge andis shown in Figure

1. The sponge isoval shaped, 8 cmtall, 15 cm wide,and 20 cm long.The sponge has twolengthwise layers,a coarsely texturedwhite layer 2 cmthick and a largersmooth blue layer.To construct themodel, the sponge iscut to represent the

perineal anatomy ofa fourth-degree lac-eration. For detailson the appearanceconstruction of themodel, see the fullinstructors guideand teaching mate-rials located at theFamily Medicine

Digital Resources Library (www.fmdrl.org).8 Through some experi-mentation, we found that a modelconstructed in this way provided anopportunity to repair the spongeusing the same sequence of stepsneeded to repair an actual perineal

laceration.We conducted an informal needsassessment for the session to deter-mine its fit within current teachingefforts. We planned our curriculumto both be used during the ALSOcourse and as a module to teachresidents on our family medicineobstetrics service. We designed andpilot tested a curriculum to teachperineal laceration repair with themodel. We generated goals andobjectives and developed a skill

checklist for the procedure and apost-session survey to gather learn-er feedback about their confidencewith perineal repair, the spongemodel and its place in ALSO, andother aspects of our teaching ses-sion. We obtained Institutional Re-

view Board approval to study thiscurriculum with resident learnersthrough the University of Okla-homa Health Sciences Center inOklahoma City. All our teachingmaterials can be accessed at www.fmdrl.org.

Our curriculum began witha teaching session explaining perineal laceration repair and thesponge model. This was followed by hands-on practice with thesponge model, including a testduring which learners skills wereverified with the checklist. Aftercompleting the session, learnerscompleted our survey. These resultswere tabulated, and averages andstandard deviations for each ques-tion were calculated.

Results

The sponge perineum model hasbeen in use for 3 years at OUFMRP,integrated with our ALSO courseworkshops and our inpatient OBservice. It is also frequently used

Figure 1

Picture of Sponge Model

For more detailed description and pictures, see complete materials at www.fmdrl.org/656.

Vaginal wall

Hymenal ring

Rectal sphincter

Rectal sphincter

Perineum

Rectalmucosa

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544 September 2006 Family Medicine

to review perineal laceration repair.Fifty-six learners have completedour survey about the model. Over-all learner response was strongly

positive, as reported in Table 1.Learners reported being somewhatunfamiliar with the procedure be-fore the session (2.95 on a Likertscale, with 1 being unfamiliar and5 being very familiar). Despite this,they stated that they felt confidentperforming the procedure after thesession (4.13). Learners felt that thesponge model was useful (4.48) andshould be included in ALSO (4.82).An early group of learners wasasked to submit their checklist forreview. All seven of these learnersreported successfully completingall steps of the repair noted on ourtask checklist.

Discussion

The use of the sponge perineumhas been a positive addition toour ALSO course and obstetricscurriculum, providing residentswith skill practice and the facultywith an inexpensive, convenient,

ready tool to use in teaching. Themodel has been easy to use and provides practice in the repair ofall perineal lacerations. Limita-

tions are that some learners havedifficulty visualizing the anatomi-cal structures as represented onthe sponge. It can be challengingto use this model with a group oflearners with heterogeneous sutureand surgical skills. The study alsodoes not assess perineal lacerationrepair skill among graduates of theprogram, instead relying on learnerexpressions of confidence in theirskills. The next steps for the spongeperineum are to develop an objec-tive structured clinical examination(OSCE) to objectively measureresidents procedural competence.To evaluate actual patient care, weare considering a questionnairecomparing real patient experiencewith the sponge model and assess-ing the use of skills learned with themodel. Overall, learners expressedincreased confidence after practic-ing with the model and wanted it tocontinue to be a part of our ALSO

class. At OUFMRP, we feel wehave developed an inexpensive,effective tool to teach perineal lac-eration repair to family medicineresidents.

Acknowledgments: All financial support for this project was from the University of Oklahoma

Department of Family Medicine.This study was presented in a different

format at the Society of Teachers of FamilyMedicine 2002 Annual Spring Conference inSan Francisco.

Corresponding Author: Address correspondenceto Dr Jones, Exempla Saint Joseph HospitalFamily Medicine Residency Program, 2005Franklin Street, Midtown II, Suite 350, Denver,CO 80205. 303-318-2007. Fax: 303-318-2003.

jonesand@exempla.org.

REFERENCES

1. Handa VL, Danielsen BH, Gilbert WM.Obstetric anal sphincter lacerations. Obstet

Gynecol 2001;98:225-30.2. Oberwalder M, Connor J, Wexner SD.

Meta-analysis to determine the incidence ofobstetric anal sphincter damage. Br J Surg2003;90:1333-7.

3. McLennan MT, Melick CF, Clancy SL,Artal R. Episiotomy and perineal repair: anevaluation of resident education experience.J Reprod Med 2002;47:1025-30.

4. Sauerwein M, Maier R. Teaching advancedepisiotomy repair with a beef tongue model.Presented at the Society of Teachers of Fam-ily Medicine 2001 Annual Spring Confer-ence in Denver.

5. Cain JJ, Shirar E. A new method for teachingthe repair of perineal trauma of birth. FamMed 1996;28:107-10.

6. Nielsen PE, Foglia LM, Mandel LS, ChowGE. Objective structured assessment oftechnical skills for episiotomy repair. Am JObstet Gynecol 2003;189:1256-60.

7. American Academy of Family Physicians.Perineal lacerations. In: American Academyof Family Physicians. 2000 Advanced LifeSupport in Obstetrics slides. Leawood, Kan:AAFP, 2000.

8. Sparks RA, Beesley AD, Jones AD. Thesponge perineum: a model to teach perineallaceration repair. www.fmdrl.org. AccessedJune 5, 2006.

Table 1

Learner Survey Results

Score

Familiarity with procedure before 2.95 (1=not at all, 5=a lot)

Confidence about procedure after the session 4.13 (1=not at all, 5 =a lot more confident)

Usefulness of model 4.48 (1=not at all, 5=very)

Should teaching model be included in ALSO 4.82 (1=definitely not, 5= definitely yes)

ALSOAdvanced Life Support in Obstetrics