Background: Operative vaginal delivery is a common obstetric intervention, with the potential to cause harm to mother and baby. Training in operative delivery traditionally comprised junior trainees learning the skills under supervision, then practicing and refining them independently. Recently this model has come under scrutiny, with the advent of simulation-based training suggesting a method by which the skills of safe delivery may be taught without risk. Multiple training courses exist, but few have been subjected to evaluation. Aims: The primary aim was to investigate if a simulation-based training workshop, where the development of a successful technique for vacuum delivery occurs using a collaborative, problem-solving approach, improves the rate of correct vacuum cup placement. The secondary aim was to determine if the workshop leads to improvement in theoretical knowledge of vacuum delivery. Methods: Participants on three workshops were assessed for their performance in vacuum delivery prior to and following a multimodal training program. Participants included general practitioner obstetricians, obstetric trainees and resident medical officers. Evaluation occurred using a standardised Likert-scaled rating sheet and utilising a diagrammatic representation of cup placement. Results: The participants demonstrated significant improvement (median post-pre score 1, p < 0.001) in the accuracy of cup placement, in a variety of practical core skills and in theoretical knowledge of vacuum delivery. Discussion: Participation in a simulation-based vacuum delivery workshop improves the performance of obstetric trainees and GP obstetricians. Further work is required to evaluate the performance of such training modalities on clinically relevant outcomes.
Operative vaginal delivery is a core skill for obstetricians and General Practitioner obstetricians (GP obstetricians). The rate of vacuum delivery in Australia is 8% [
The senior author, (PM), has developed a simplified problem-based teaching method of vacuum cup placement, which is easy to teach in a short workshop using mannequins [
The primary aim of this study was to investigate if the instrumental delivery workshop improved the rate of correct vacuum cup placement in junior medical staff. We also wanted to determine if the workshop led to improvement in theoretical knowledge of vacuum delivery.
The study was conducted during three vaginal delivery workshops held in Broome and Perth, Western Australia between July 2014 and September 2015. Workshop participants included pre-vocational trainees, specialist obstetric trainees and general practitioner obstetricians from hospitals around Western Australia. The study sample was self-selected as junior doctors volunteered to participate in the workshops, and all workshop participants consented to participate in the workshop and the study.
The demographics of the workshop participants are shown in
Ethical approval was prospectively granted by the Women’s and Children’s Health Service Governance, Evidence, Knowledge and Outcomes (GEKO) Committee (#GEKO6505).
The workshop included theoretical and practical components. At the start of the workshop, participants were asked to answer a questionnaire. Following this they were asked to perform a set of vacuum deliveries using the Lucy TM pelvic model and fetal head. The head was placed in three different positions and each delivery was assessed using a standardised proforma, recording the positioning of the cup, the manoeuvres used during the delivery, and the overall impression of the assessor. In addition, a visual representation of the delivery was made using a diagram of the fetal head, with the position of the cup recorded on the diagram, and measurements taken from the edges of the cup to the bony landmarks on the model (see
Variable | Number | % | |||
---|---|---|---|---|---|
Gender | Male | 8 | 22.2 | ||
Female | 28 | 77.8 | |||
Background | Junior trainee | 21 | 58.3 | ||
Senior trainee | 3 | 8.3 | |||
GP obstetrician | 12 | 33.3 | |||
Estimated number of previous vacuum deliveries | 0 | 4 | 11.1 | ||
1 - 10 | 15 | 41.7 | |||
10 - 30 | 7 | 19.4 | |||
>30 | 10 | 27.8 | |||
The study participants were then provided with an open-ended discussion revising the basic concepts and safety aspects of vacuum delivery using audio visual aids. Particular emphasis was placed on the importance of correct cup placement on the flexion point. This was followed by a 30 minute interactive workshop using the Lucy TM and modified Lucy’s head TM mannequins. The workshop participants were invited to work out the steps required to achieve correct cup placement on the fetal head for each of the three different positions as previously discussed. The group were thus able to collaboratively develop a simple unified technique which helps to achieve correct cup placement in all of the possible fetal head positions.
Following the workshop, each participant was observed doing the same set of vacuum deliveries a second time, and scored by the same assessor, in order to rule out inter-observer variability as a confounding factor. In this way a set of paired observations (pre and post education) were created for each workshop participant. The participants also completed the same questionnaire at the conclusion of the workshop in order to ascertain whether an improvement in knowledge could be demonstrated. Each workshop was completed in 90 minutes.
All assessments for the practical skills were performed using a simple four-level Likert scale between 0 (worst) and 3 (best). Training was provided to all assessors prior to the first workshop, in order to standardise the use of the Likert scales. As the same assessor observed each participant pre and post, and as the results were analysed as post-pre scores, any inter-observer variability in the use of the Likert scales will have been irrelevant to the final data analysis. The actual number of correct answers in the theoretical questionnaire generated a score out of 10 questions.
Performances pre- and post-workshop were summarised for each skill and overall using medians, interquartile ranges (Q1 - Q3) and ranges. Categorical data were summarised using frequency distributions. Assessment of change in performance was performed using paired post-and pre-workshop scores analysed using the Wilcox on Signed Rank test for paired data. SPSS statistical software was used for data analysis (IMB SPSS Statistics for Windows, Version 20.0. Armonk., NY: IBM Corp.). All hypothesis tests were two-sided and p-values < 0.05 were considered statistically significant.
Workshop data were collected on 36 workshop participants; 21 junior trainees (58.3%), 3 senior trainees (8.3%) and 12 GP obstetricians (33.3%). Analysis as to the impact of training on specific groups of participants was not performed due to the small numbers of senior trainees and GP obstetricians.
Pre-, post-scores and post-pre score differences are shown in
Significant improvements were seen in the primary criterion of cup placement accuracy as well in almost all of the secondary criteria evaluated, with the exception of episiotomy timing, where the small number of participants with paired data recorded precluded any valid conclusions regarding the timing of episiotomy.
There was also an improvement in theoretical knowledge in all 36 participants with a demonstrated increase in the questionnaire score from a median of 5 (interquartile range 3 - 5.8, range 2 - 7) before the workshop to a median of 7 (interquartile range 7 - 8, range 6 - 10) at the end of the workshop (p < 0.001). The median increase in the score was 3 (interquartile range 2 - 4, range 1 - 6).
The demonstration of improvement in clinical outcomes following simulation based training is an essential endeavour and a challenging one [
ment remains elusive, and there are several reasons why that may be the case. Demonstration of a clear impact of education would ideally take place under circumstances where the population was standardised in terms of prior experience, where a simple evaluation tool was available, and where the population could be evaluated, educated, and evaluated again a second time, without the corruption of external training modalities or clinical experience diluting the effect of the training. Clearly in obstetrics this is not possible. Training occurs in an ad hoc way during clinical interactions, with the educational value of the experience taking a distant second
place to the clinical considerations for mother and child. Clinical outcomes of great consequence, such as severe trauma or perinatal death, are thankfully rare, requiring large studies to demonstrate any measurable impact of training. Using simulation as a proxy to assess clinical skills could be argued to be a suboptimal level of evaluation, as an improvement in simulation skills may not necessarily translate into an improvement in clinical skills.
Item | Pre-scores | Post-scores | Post-pre scores | p value | |||
---|---|---|---|---|---|---|---|
Med (Q1 - Q3) | N | Med (Q1 - Q3) | N | Med (Q1 - Q3) | N | ||
Practical skills* | |||||||
Cup insertion technique | 1 (1 - 2) | 36 | 2 (2 - 3) | 36 | 1 (1 - 2) | 36 | p < 0.001 |
Cup application position | 1 (1 - 2) | 36 | 2 (2 - 3) | 36 | 1 (1 - 2) | 36 | p < 0.001 |
Distance to perineum | 1 (0 - 2) | 25 | 2 (2 - 3) | 29 | 1 (0.8 - 2) | 22 | p = 0.001 |
Initial axis of traction | 1 (0 - 2) | 36 | 3 (2 - 3) | 35 | 2 (1 - 3) | 35 | p < 0.001 |
Position of accoucher | 0 (0 - 2) | 36 | 3 (3 - 3) | 36 | 2 (1 - 2) | 36 | p < 0.001 |
Timing of upward pull | 1 (1 - 2) | 34 | 3 (2 - 3) | 36 | 2 (0 - 2) | 34 | p < 0.001 |
Episiotomy timing | 1 (0 - 2) | 11 | 2 (1.3 - 3) | 16 | 0 (0 - 1.5) | 9 | p = 0.197 |
Overall impression | 1 (1 - 2) | 36 | 2 (2 - 3) | 36 | 1 (1 - 2) | 36 | p < 0.001 |
Theoretical skills** | 5 (3 - 5.8) | 36 | 7 (7 - 8) | 36 | 3 (2 - 4) | 36 | p < 0.001 |
*Pre- and post-scores range between 0 and 3, and post-pre scores between −1 and 3 with score of 0 representing no change and positive scores indicating improvement. **Max pre- and post-scores total score is 10. P-values obtained using Wilcoxon signed ranks test.
*Corresponding author.
This workshop was successful in its primary aim of demonstrating a significant improvement in the rate of correct vacuum cup placement. As previous clinical studies have shown [
The secondary aim of demonstration of an improvement in theoretical knowledge was also achieved (see
This study demonstrates that a short, low-cost intervention of an instrumental delivery training workshop can lead to an improvement in a variety of core clinical skills, including overall technique and theoretical knowledge. Further research in this area is required to demonstrate whether such skills are incorporated into routine clinical practice and retained over time, and whether a clinical benefit of training on maternal or paediatric outcomes can be demonstrated.
The authors would like to thank the participants in the operative delivery workshops for their involvement in this project. The authors have no competing interests to declare.
Katrina Calvert,Mathias Epee,Anne Karzcub,Cliff Neppe,Michael Allen,Wendy Hughes,Paul McGurgan,Richard King,Alexander Maouris,Dorota Doherty,Panos Maouris, (2016) Novel Simulation Workshop Improves Performance in Vacuum Delivery. Open Journal of Obstetrics and Gynecology,06,439-444. doi: 10.4236/ojog.2016.68058