Recurrent obstetric management mistakes identified by simulation

Simulation-based drills offer a partial solution to the problem of providing hands-on clinical experience in emergency medicine. They permit repeated practice and aid the acquisition of skills in managing conditions that are not amenable to traditional bedside teaching. The investigators developed a simulation-based curricular unit for hands-on training using mannequins in 4 obstetrical emergencies: eclamptic seizures, postpartum hemorrhage, shoulder dystocia, and breech presentation. The obstetrical teams consisted of at least 1 resident in the first 3 years of a 6-year program and 2 midwives; the midwives had a mean delivery room experience of 2.5 years. Sixty residents and 88 midwives took the course, and 42 labor and delivery teams completed all 4 sessions. Sessions were videotaped from several angles, and tutors observing the sessions completed checklists of required actions and noted whether each action was done correctly according to predefined criteria. The commonest management errors were: • Delayed transport of a bleeding patient to the operating room (82%). • Lack of familiarity with administering prostaglandin to reverse uterine atony (82%). • Poor cardiopulmonary resuscitation technique (80%). • Inadequate documentation of shoulder dystocia (80%). • Delayed administration of blood products to reverse consumption coagulopathy (66%). • Inappropriate omission of episiotomy in cases of shoulder dystocia and breech extraction (32%). Eighteen residents were asked to repeat their training day 6 months or longer after simulation-based training. Their scores were significantly higher in the repeat sessions than in the initial hands-on course. Among the areas in which improvement was most evident were in team organization and mission assignment, knowing how much of commonly used drugs to deliver and how to administer them, and early transfer to the operating room of patients with postpartum bleeding. More than 90% of all trainees expressed great interest in hands-on practice. More than 80% of those who initially were confident in their ability to perform well in these situations acknowledged a change of heart when responding to the concluding feedback questionnaire. The authors believe that simulation-based training in obstetrical emergencies should have a prominent role in the ongoing medical education of labor and delivery teams.