Patients expect their labor and delivery team to be prepared for complications and emergencies and they trust that hospitals are using everything available to ensure the best outcomes possible. However, maternal morbidity and mortality have increased significantly in the United States over the past two decades, with mortality increasing 26% between 2000 and 2014.1 Headlines like “United States named the ‘Most Dangerous’ developed country for women to give birth” and “Hospitals know how to protect mothers. They just aren’t doing it” continue to remind both patients and providers of these facts and emphasize the need to address this problem.2,3 While the response to this issue is broad, simulation is a critical part of the comprehensive strategy to impact maternal morbidity and mortality in obstetrics. It is already used extensively in both resident and nursing training and is becoming a key component of local, regional, and national programs being implemented to improve maternal obstetric outcomes.
Obstetric simulation has been around for centuries, with its first use likely predating written history. There is archaeologic evidence showing that the Siberian Mansai created life-sized birth models from leather for teaching delivery techniques.4 In the 18th century, a French midwife, Madame du Coudray, used a leather birthing mannequin to teach obstetric delivery management and is reported to have reduced both maternal and infant mortality.5
In modern obstetrics, simulation began to emerge in the literature in the early 2000s. While initial reports focused on its use for training medical students and residents, this quickly transitioned to staff physicians and the entire labor and delivery care team. Obstetric simulation training is now recommended by every major national professional organization in our specialty, and the American Board of Obstetrics and Gynecology has even incorporated simulation into both its certifying exam and maintenance of certification program.
Obstetric simulation as a means to improve patient outcomes is generally focused in three areas: skill acquisition, interval training, and in-situ drills.
1. Skill acquisition: Simulation for skill acquisition may be focused on trainees, such as medical or nursing students or residents, or be used by staff when a new procedure/technique is introduced. Often, simple task trainers are designed specifically to address a complication. Some examples include techniques for shoulder dystocia management, such as posterior arm delivery, and placement of uterine compression sutures (Figure 1).
2. Interval training: Interval training is meant to refresh skills and update providers on new recommendations in a manner similar to courses like the American Heart Association Advanced Cardiac Life Support (ACLS) courses. These may be done through local initiatives or with national courses such as the Emergencies in Clinical Obstetrics (ECO) Course from the American College of Obstetricians and Gynecologists (ACOG) or the Advanced Life Support Course (ALSO) from the American Academy of Family Physicians (AAFP).
3. In-situ drills: This refers to simulation drills that are run on actual hospital delivery and postpartum units, usually in a multi-professional manner, and can include other services such as anesthesia and the blood bank. These are important in that they provide the opportunity to practice as a team and can help identify facility or system issues that may impact patient safety and would not be found when practiced in a simulation center.
1. Levels of Maternal Care. Obstetric Care Consensus. No. 2, February 2016, reaffirmed 2016.
2. Mazziotta J. United States names the ‘most dangerous’ developed country for women to give birth. People. July 26, 2018. Available at: https://www.msn.com/en-us/health/medical/united-states-named-the-most-dangerous-developed-country-for-women-to-give-birth/ar-BBL6joM Accessed September 5, 2018.
3. Young A. Hospitals know how to protect mothers. They just aren’t doing it. USA Today. July 27, 2018. Available at: https://www.usatoday.com/in-depth/news/investigations/deadly-depveries/2018/07/26/maternal-mortapty-rates-preeclampsia-postpartum-hemorrhage-safety/546889002/ Accessed September 5, 2018.
4. Macedonia CR, Gherman RB, Satin AJ. Simulation laboratories for training in Obstetrics and Gynecology. Obstet Gynecol. 2003;102:388-392.
5. Gelbart NR. The King's Midwife: A History and Mystery of Madame du Coudray. Berkeley, Univ of Capfornia Press, 1998, pp 16-17.
6. Siassakos D, Hasafa Z, Sibanda T, Fox R, Donald F, Winter C, Draycott T. Retrospective cohort study of diagnosis-depvery interval with umbipcal cord prolapse: the effect of team training, BJOG. 2009;116, 1089-1096.
7. Fuhrmann L, Pederson TH, Atke A, Møller AM, Østergaard D. Multidiscippnary team training reduces the decision-to-depvery interval for emergency caesarean section. Acta Anaesthesiol. Scand 2015;59:1287–1295.
8. Main EK, Cape V, Abreo A, et al. Reduction of severe maternal morbidity from hemorrhage using a state perinatal quapty collaborative. Am J Obstet Gynecol. 2017;216:298.e1-11.
9. Egenberg S, Øian P, Bru LE, Sautter M, Kristoffersen G, Eggebø TM. Can inter-professional simulation training influence the frequency of blood transfusions after birth? Acta Obstet Gynecol Scand. 2015;94:316–323.
10. Gossett DR, Gilchrist-Scott D, Wayne DB, Gerber SE. Simulation training for forceps-assisted vaginal depvery and rates of maternal perineal trauma. Obstet Gynecol. 2016; 128:429-435.
11. Draycott TJ, Crofts JF, Ash JP, et al. Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol. 2008. 112(1):14–20.
12. Crofts JF, Lenguerrand E, Bentham GL, Tawfik S, Claireaux HA, Odd D, et al. Prevention of brachial plexus injury – 12 years of shoulder dystocia training: an interrupted time-series study. BJOG. 2016; 123:111-118.
13. Grobman WA, Miller D, Burke C, Hornbogen A, Tam K, Costello R. Outcomes associated with introduction of a shoulder dystocia protocol. Am J Obstet Gynecol. 2011;205(6):513–517.
14. The Joint Commission: Sentinel Event Alert: Preventing infant death and injury during depvery. Sentinel Event Alert. Issue 30. Jul 21, 2004.
15. Riley W, Davis S, Miller K, Hansen H, Sainfort F, Sweet R. Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital. Joint Commission J on Quapty and Patient Safety. Aug 2011;37(8):357-364.