Simulation is the imitation or representation of one act or system by another. According to the Society for Simulation in Healthcare (2015), simulation in medicine has four purposes to aid patient safety: (1) education, (2) assessment, (3) research, and (4) health system integration. During the past few years, simulation has been advanced as a technique to improve obstetric training and thus patient safety. Currently, many obstetric surgical techniques are decreasing in frequency, and this stems in large part from inadequate training due to declining procedure numbers. Thus, simulation poses a solution to this negative cycle by providing hands-on practice.

For decades, military and commercial aviation has used simulation not only to train pilots but to test them as well. In simulators, pilots are required to demonstrate their proficiency in basic skills and to practice for rare but critical events. Beginning in the 1990s, simulation in obstetric training was implemented, and evaluation has rapidly developed (Gardner, 2008). Thus, in addition to current training that includes didactic lectures and bedside teaching, simulation provides another learning format.

Initially, educational intentions drove simulation development in obstetrics. Since then, academics has been challenged by limitations that include work-hour restrictions, professional liability concerns, insurance payer pressures for shorter hospital stays, and teaching in front of an alert patient. These spurred medical schools to invest in simulation centers to provide a foundation for clinical teaching across specialties.

In obstetric residency training, profound challenges have arisen, and procedural experience has declined during the past two decades. The Accreditation Council for Graduate Medical Education Residency Review Committee (2015) has markedly restricted the tabulation of resident experience to all but four obstetric categories: (1) spontaneous vaginal delivery, (2) cesarean delivery, (3) operative vaginal delivery, (4) and sonographic examination. It is unclear whether this was done because broad national experience in the management of many conditions has become scarce or because the committee did not believe that procedures such as fourth-degree laceration repair, breech delivery, and twin delivery were important skills to master in residency. Importantly, of the four categories that are still reported to the Residency Review Committee, case log numbers have declined for nearly all categories in the past several years. For example, currently more than half of all graduating residents have performed fewer than 25 operative vaginal deliveries. Thus, simulation curriculums have been developed to supplement teaching of technical skills.

Defining qualities of effective simulation-based education have been described in descending order of their importance: (1) providing feedback, (2) repetitive practice, (3) curriculum integration, (4) range of difficulty, (5) multiple learning strategies, (6) capture of clinical variation, (7) controlled environment, (8) individual learning, (9) defined outcomes, and (10) simulator validity (Issenberg, 2005). As the field fully integrates obstetric simulation into its training armamentarium, the ultimate goal is to make labor and delivery safer and minimize the burden of obstetric disease.

Simulation offers special opportunities to improve patient outcomes in rarely encountered circumstances. Thus, individual performance and team collaboration can be enhanced, and systems-based hurdles can be resolved before they affect the patient (American College of Obstetricians and Gynecologists, 2014). Such implementation has the potential to upgrade resident training. It also allows providers already in practice to update techniques or acquire new expertise. As a result, simulation can improve patient outcomes yet minimize patient risk during training.

Goals for simulator skill acquisition often differ widely. In addition to individual assessment, institutions can assess their teaching. For example, many learners within the same clinical scenario may make the same errors (Maslovitz, 2007). This awareness can help educators identify gaps in training or discrepancies in institutional guidelines (Andreatta, 2011). Another goal of simulation may be to improve a team dynamic or prepare for a specific clinical scenario (Auguste, 2011).

With the broad spectrum of learners in obstetrics, a simulation for one group may not be appropriate for a different group. Thus, when developing a simulation or a curriculum for a specific group, awareness of their baseline knowledge is paramount. Simply stated, know your learner and what you want them to learn.

Obstetric simulators vary from simple to complex, from individual to team focused, and from inexpensive to more costly. Simulators can be immersive, such as a virtual reality suite, or may involve actors or standardized patients. Hybrid simulators combine both sophisticated and crude components.

Simulator Types

Attempts to classify the different simulator subtypes are challenged by the rapid evolution of products, simulation techniques, and hybridization. In general, simulators can be described by a set of groupings, but significant overlap is found between these groups (Table 6-1) (Gardner, 2008). The fidelity of a model summarizes several different factors. These include the physical realism of the simulation, the conceptual realism in relation to actual practice, and the ability to evoke willingness in the learner to invest time and effort in the experience offered (Gardner, 2008). These three factors typically define the success of a model. Simulators described as having high fidelity strive to closely reproduce an actual clinical environment. These tend to be technologically advanced, involve a combination of physical models and computer programs, and are expensive. Simulators described as having low fidelity, such as a pelvic manikin, tend to be inexpensive and less refined. Thus, with any simulation model, realism is balanced against cost.

The simulator and skill goal should also be aligned. For example, a simple model may provide the desired educational experience, and a more realistic or expensive model may not necessarily offer additional educational benefit. This tenet is summarized by the acronym, the ARRON (As Reasonably Realistic as Objectively Needed) rule. This guides a simulation organizer to match the educational goal to the available assets. These resources also include the time and preparation level of those undergoing the simulation (Macedonia, 2003).

Simulator Centers and Curricula

In 2008, the American College of Obstetricians and Gynecologists (2015) formed a Simulations Consortium to create simulation-based curricula to improve residency education and clinical competence. The consortium included members from free-standing simulation centers, most of which were affiliated with university-based medical schools and residency training programs. Centers help develop a culture of simulation and patient safety. Additionally, they can serve multiple medical specialties and promote interdisciplinary and multilevel training (Fig. 6-1). Advantageously, free-standing simulation centers allow institutions to consolidate costly simulation resources and provide technical support for the conduct of simulation training.

Both the College and the Society for Simulation in Healthcare (SSIH) have criteria for simulation centers and for the conduct of simulations. Efforts have been made to transition these centers out of classrooms and into more universally accessible locations. Simulation courses are promoted at national conferences, and development of mobile platforms allows transport of a mobile simulation center to hospitals that may not be affiliated with academic centers (Guise, 2013). The U.S. Department of Defense established one of the first mobile obstetric simulation programs (Deering, 2009).

From dedicated simulation centers to mobile simulation programs, broad efforts have sought to implement obstetric simulation training across a spectrum of settings to help train providers. The American College of Obstetricians and Gynecologists, the Royal College of Obstetricians and Gynaecologists, and the Society for Maternal-Fetal Medicine have established obstetric simulation courses for postgraduate medical education. The American Board of Obstetrics and Gynecology provides maintenance of certification (MOC) credit for these simulation courses.

Medical Student Education

Vaginal delivery embodies a basic skill set that easily lends itself to simulation prior to clinical exposure. Skill acquisition builds confidence in the unseasoned provider and can later benefit a potentially apprehensive patient. Numerous birth simulators are available in the marketplace. Evidence suggests that cheaper models may not be inferior to more expensive versions (DeStephano, 2015). This is relevant, in that simulators costing a few hundred dollars can provide equal teaching experiences to those costing upwards of $50,000.

Using a simulator, an educator can teach hand positioning, perineal support, fetal birth, placental delivery, uterine massage, and correct carriage of the neonate (Fig. 6-2). Using a pelvic model may be as effective as using an obstetric mannequin to provide a positive learning experience for students. Such models also are a more mobile teaching tool that can be implemented even in an intrapartum suite immediately prior to delivery.

These simulators can augment a traditional lecture both by minimizing time in a seated classroom and by providing three-dimensional content to the learning experience. Evidence supports their role as an adjunct to traditional teaching methods (Scholz, 2012). Compared with traditional lecture, simulation curricula can lead to superior test scores and an improved sense of clinical confidence (Holmstrom, 2011). However, it is unclear whether a boost in confidence after simulation persists over time. Also, as a simulator supplement, use of actors as patients appears to improve not only skills and confidence but also patient communication (Siassakos, 2010).

Residency Preparation

For graduating students preparing to enter obstetric residency, simulation can bolster basic skills. The Association for Professors of Gynecology and Obstetrics (APGO) and the Council on Resident Education in Obstetrics and Gynecology (CREOG) have outlined obstetric skills that are desirable for residents to master prior to residency. Some include cervical examination, basic sonographic techniques, spontaneous vaginal delivery management, and first- or second-degree laceration repair. A foundation in surgical skills and knot tying is also encouraged. Last, accurate estimation of blood loss at time of delivery is another valuable topic (Straub, 2013). Ideally, these skills minimize situations in which learners find themselves not fully prepared.

For this goal, many institutions hold a “boot camp” for fourth-year students or new first-year residents. This can be accomplished expediently, and various topics can be presented in the few days prior to residency. However, institutions vary considerably in their offerings. Some schools may offer a robust session, whereas others provide nothing at all.

Intrapartum Simulation

During residency, obstetric simulation has perhaps its most robust application. The spectrum of skills to be acquired is wide and includes antepartum emergencies, intrapartum management, and postpartum complications (Table 6-2).

Specialization in maternal-fetal medicine similarly requires mastery of numerous obstetric skills in a short period of time. However, because some clinical events are rare, training without simulation may lead to significant skill gaps. Several complex scenarios can be modeled in simulation to provide training in critical care obstetric skills. Some examples include amnionic fluid embolism, diabetic ketoacidosis, myocardial infarction, cardiac arrest, and eclampsia (Birsner, 2013). Simulation of such advanced obstetric skills is still relatively novel compared with birth simulators and perineal laceration repair. These will likely evolve in coming years.