Using simulation technology to reduce maternal morbidity

Introduction

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. 

Background 

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 18^th 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. 

Evidence of benefit

While research continues into how obstetric simulation can affect patient outcomes, there is already evidence that demonstrates its potential. Some examples of these include:

Umbilical cord prolapse: In one study, a labor and delivery unit implemented multi-professional simulation training for umbilical cord prolapse. They then reviewed the care and outcomes of actual cord prolapse cases for six years before and after training.⁶The group found that not only did the diagnosis-to-delivery interval decrease from 25 to 14.5 minutes (P< 0.001) but the teams also were much more likely to perform recommended maternal interventions after training (82% after training vs 34% before, P< 0.001). In addition, Apgar scores < 7 at five minutes were not seen in any of the 28 cases of cord prolapse that occurred after the program began. Another report from Denmark showed similar findings for a reduction in diagnosis-to-delivery interval for emergency cesarean deliveries.⁷

Postpartum hemorrhage: The California Maternal Quality Care Collaborative (CMQCC) developed a comprehensive quality improvement toolkit for obstetric hemorrhage based on the National Partnership for Maternal Safety Consensus Bundle and focused on readiness, recognition and prevention, response and reporting/systems improvement. The CMQCC bundle was introduced and implemented in 99 hospitals within the collaborative and the outcomes of women who experienced obstetric hemorrhage were compared with those at 48 hospitals who did not implement the hemorrhage bundle.⁸ Unit-based simulation drills for obstetric hemorrhage that included both a standardized stage-based emergency management checklist and debriefings were part of the education and implementation bundle. The team found a 20.8% reduction in severe maternal morbidity when a hemorrhage occurred in a hospital that had implemented the bundle, compared to only a 1.2% reduction in hospitals that did not implement the bundle (P< .0001). In another study, a multi-professional training program for postpartum hemorrhage done in Norway demonstrated that after simulation training was implemented, there was a significant decrease in the rate of blood transfusion (12% vs 21%, P< .01) and uterine curettage (6% vs 11%, P< .01).⁹

Forceps: As the rate of operative delivery, especially with forceps, has decreased, simulation has emerged as a way to provide opportunities for training and practice. In one residency program, a simulation training curriculum for operative delivery was implemented and the residents trained until they achieved mastery-level performance on the simulator.¹⁰ During the study period, more than 6000 forceps deliveries were performed and after training, there was a 26% reduction in incidence of third- and fourth-degree lacerations in forceps deliveries.

Shoulder dystocia: The best evidence for improved outcomes in obstetrics with simulation is related to management of shoulder dystocia. In the United Kingdom, Draycott et al implemented a training program for personnel involved in labor and delivery management. This training was mandatory and used a relatively inexpensive hybrid birthing simulator to teach and allow practice of the basic maneuvers for management of a shoulder dystocia delivery. After implementing this training, the group found that use of McRobert’s maneuver dramatically increased during actual deliveries from 29.3% to 87.4% and there was a decrease in head-to-body delivery time from three minutes to two minutes.¹¹ Neonatal outcomes also improved and risk of neonatal injury at births complicated by shoulder dystocia decreased from 9.3% to 2.3% post-training with risk of brachial plexus injury falling from 7.4% to 2.3%. In a follow-up study, the same group found that not only was the improvement sustained over 12 years, but in the final year of the study period, there were no brachial plexus injuries in over 560 deliveries complicated by shoulder dystocia.¹² These findings were replicated in the United States as well. In 2011, Grobman et al implemented a simulation-based shoulder dystocia training program that showed a similar decrease in incidence of brachial plexus injury after deliveries complicated by shoulder dystocia, from 10.1% to 4.0% (P< 0.001).¹³

Teamwork & communication: In addition to technical skills, communication and teamwork are key to achieving optimal outcomes in obstetrics and it has been reported that communication failures are part of the root cause of over 70% of sentinel events on labor and delivery units.¹⁴ Because of this, programs have been developed to teach these skills to teams on labor and delivery. Simulation has been studied as a method to improve the effectiveness of this teamwork training. Riley et al reported their results with a three-hospital trial in which they used one hospital as a control (no intervention), a second that received standardized TeamSTEPPS didactics only and a third hospital that had TeamSTEPPS didactics followed by simulation exercises for obstetric emergencies based on actual cases from that hospital.¹⁵ The team evaluated the Weighted Adverse Outcomes Score (WAOS), which is a weighted measure that adjusts for severity of events at every delivery, and found that while there was no improvement at the control or didactics-only hospitals, the simulation-trained hospital had a 37% decrease in perinatal morbidity.

Simulation technology and implementation

Many obstetric simulator options are available, and more are being developed. There are task trainers that allow for practicing regular deliveries or specific procedures, such as episiotomy repair or cesarean hysterectomy (Figure 2). For obstetric emergencies, there are hybrid models in which an actor plays the part of the patient and uses a lower torso mannequin for practicing emergencies such as shoulder dystocia and full-size female mannequins that include the ability to palpate pulses and administer intravenous medications. Cost for these devices varies, from approximately $750 for some very basic birthing trainers, to hybrid simulators in the $5,000 to $7,000 range, to full-body, high-fidelity mannequins that can be over $80,000 (Figures 3 and 4). While these dollar figures may sound high, birthing simulators can be used for years and in general, costs are minimal for maintenance or consumables that need to be replaced after training. 

When planning to purchase a simulator, it is important to begin with a review of both who you will be training and what your learning objectives are as well as what kind of support you will have to run simulations. For example, if you have dedicated simulation-operating specialists to help run your simulations, then a full-body, high-fidelity birthing simulator with integrated physiology and vital signs may work. If you need something more portable that can be used by multiple providers who need a less complicated model, a hybrid simulator may be more appropriate.

Even though simulation training is encouraged by many national organizations and health care systems, there is often a disconnect between recognizing it is needed and having the expertise to implement a program. First, simulation training is a significant shift away from the typical lecture style of education that providers typically use. It is also more labor-intensive to run and requires a higher faculty-to-student ratio to be effective. Providers may also feel as if they will be put on the spot and potentially “fail” in front of their team and peers. Successful implementation requires support from leadership as well as an upfront understanding that simulation training is meant to educate and improve team performance and outcomes, not single out individual mistakes. Debriefing after training must emphasize this as well. 

Recognizing the importance of simulation in our specialty and the challenges of implementation, ACOG created the Simulation Working Group in 2008, which has expanded to represent 24 institutions and every ACOG district across the country. This group works to create and offer simulation-based training for education and patient safety initiatives and serves as a resource for both ACOG and providers across the country who are interested in implementing simulation training.Current initiatives

Given the mounting evidence that obstetric simulation can improve outcomes, it is not surprising that its use continues to increase. At present, many hospitals and institutions are using obstetric simulation to teach basic and emergency skills, practice teamwork and communication, and test new units to identify any potential facility or system issues before opening for patients. In 2016, the US Military Healthcare System (MHS) began mandating obstetric simulation training for all providers, physicians, and nurses, at all 50 of their hospitals that offer maternity care across the world. This requirement includes monthly team drills on labor and delivery units and all providers must take either the Emergencies in Clinical Obstetrics (ECO) course or the Advanced Life Support in Obstetrics (ALSO) course every 
two years. 

There are also many national initiatives in place and being developed as well. Besides the CQMCC, which was discussed previously, some additional training opportunities include:

• Emergencies in Clinical Obstetrics (ECO) course

This course was created by the ACOG Simulation Working Group and includes short, focused didactic sessions followed by hands-on simulation practice for four common obstetric emergencies: shoulder dystocia, postpartum hemorrhage, breech vaginal delivery, and umbilical cord prolapse (Figure 6). The course is multidisciplinary and teaches technical skills and also emphasizes teamwork and communication. It is offered at the ACOG Annual Clinical Meeting and District meetings as well as other institutions. 

• Advanced Life Support in Obstetrics (ALSO) course

The ALSO course has been around for more than 25 years and was created by the AAFP. It is now a one-day course with 20 different topics, including common obstetric emergencies, and it combines didactics with hands-on simulation practice.

• Practicing for Patients

The Patient Safety Council for Women’s Health Care has worked closely with the AIM team to create the Practicing for Patients initiative as a resource for any hospital to run in-situ drills for postpartum hemorrhage. This program is modeled directly on the AIM postpartum hemorrhage bundle and features a full online instruction manual that includes demonstration videos with everything needed to implement drills at a hospital. It also has a list of commonly used obstetric simulators that can be used to simulate hemorrhage. All of these resources are available for free on the Patient Safety Council’s website.

• Society for Maternal Fetal Medicine (SMFM) Obstetric Critical Care Courses

SMFM has offered simulation-based courses for obstetric emergencies and critical care since 2012 (Figure 7). These courses address topics such as obstetric hemorrhage, sepsis, hypertensive emergencies and maternal cardiac arrest. SMFM courses are offered at the SMFM annual meeting as well as at stand-alone courses such as the one held every year in conjunction with Banner Health and the University of Arizona, where over 400 providers go through focused didactics followed by high-fidelity immersive team simulations.

Conclusion

In the final analysis, it is clear that obstetric simulation has been successfully used to improve maternal morbidity in several areas. It is not, however, a stand-alone solution, but rather, an important part of the overall response to the challenge of managing and improving care when obstetric complications occur. Future studies will continue to refine where and how obstetric simulation can best be used to affect patient safety. While there are always obstacles to implementation and culture change, the benefits of simulation training for practicing obstetric emergencies is worth the effort and a list of resources can be found here to assist those interested.

References:

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.