Clinical Simulation
Shad Deering
GENERAL PRINCIPLES
Simulation training has a long history in the field of obstetrics with archaeologic evidence even showing the use of scale leather birthing models by the Siberian Mansai people (1).
The principle of practicing on a simulator to improve skill and technique is now well accepted in medicine and has a critical role in obstetrics, given the range of emergent and potential high-risk procedures that are part of the specialty. Every year, more and more evidence and options for obstetric simulation become available.
Procedures and Techniques
When considering how to implement simulation training, the first question to ask is what are the training objectives?
Considering who you need to train and then what the learning outcomes should be (i.e., improved surgical technique, knowledge, or communication) will guide decisions about what simulators and tools will be needed.
For technical training, it is often best to focus on a task trainer where the procedure is broken down into steps and each of these is practiced on the simulator. This type of training is applicable to many of the obstetric emergencies and procedures discussed in other chapters of this book.
Simulation training can be used at any level of medical training. For students and residents, it is often focused on learning basic surgical skills and techniques and gaining experience.
Some examples of common topics at this level include episiotomy repair, breech vaginal delivery, and shoulder dystocia management. For more advanced learners or when new procedures and techniques are being developed in the field, simulations may involve topics such as intrauterine fetal surgical techniques, cerclage placement, or amniocentesis.
The most immersive and resource-intensive (with regard to personnel) type of simulation training is when it is conducted in-situ in the actual location where clinical care/procedures are done. There are significant benefits to having the entire team present and practicing together as it brings into focus teamwork, communication, and facility factors such as where equipment and resources are physically located as all of these things are unique to each institution.
Cerclage (See Chapter 2.4)
Cerclage placement may be performed as a prophylactic procedure or more urgently when cervical insufficiency results in a dilated cervix with exposed or prolapsed membranes.
The procedure carries with it a risk of both hemorrhage and rupture of the amniotic membranes, and proper technique is important. This is especially important with more advanced degrees of membrane prolapse when the risk of rupture is higher.
Currently, there are both reports of cervical cerclage trainers that can be made at the institution and, more recently, even a commercially available one (2,3). An example of a commercially available cerclage simulator can be seen in Tech Figure 1.6.1A and B.
Invasive Prenatal Diagnostic/Therapeutic Procedures (See Chapter 3.4)
Given both the technical skill and potential risks involved in performing invasive prenatal procedures through simulation before exposing a fetus to risk is of the utmost importance.
Even those previously more common procedures such as amniocentesis are done with much less frequency now because of the introduction of improved prenatal testing with cell-free DNA screening for aneuploidy.
Fundamental skills for ultrasound-guided needle procedures can be taught in a variety of ways, and there is published evidence that a simulation curriculum focused on the specific techniques required can help trainees improve their skills (4,5).
In their studies, Nitsche et al developed an ultrasound simulation program that includes five different skills aimed at teaching the following skills, all of which are critical to performing ultrasound-guided procedures. These include:
In-plane and out-of-plane needle guidance
Needle imaging optimization techniques to include:
Probe translation
Rotation
Heel-toe standoff
Amniocentesis is performed to evaluate the fetal karyotype, check for infection, drain off excess fluid, or sometimes to assess for fetal lung maturity.
There are several commercially available simulators to train for this procedure. Some are simple and can be made at the local institution level with different types of gelatin or ballistic gel
mixtures with different targets suspended in them, whereas others are commercially made and have a fluid-filled bladder from which fluid can be drained (6,7,8).
Tech Figure 1.6.1. A, B: Limbs & Things cerclage model. (Photo courtesy of Limbs & Things, https://limbsandthings.com/us/products/80180/80180-prompt-flex-cervical-cerclage-module-light/.)
In terms of evidence for training efficacy, Pittini et al integrated a physical amniocentesis simulator in a simulation with a standardized patient and then assessed communication and technical skills (9).
They assessed a total of 30 trainees including medical students, residents, and maternal-fetal medicine fellows, and they found a significant improvement in both knowledge and technical performance after simulation training.
At this time, there are no studies to validate whether simulation training for amniocentesis improves outcomes in actual patients; given the potential risks of the procedure and the availability of validated simulation training platforms, it is a reasonable option before performing the procedure on patients.
Fetal Surgery (See Chapter 3.10)
As the field of fetal surgery and the ability to perform intrauterine procedures expands, the need to train fetal surgeons on new techniques will grow in tandem.
When compared to more common surgical procedures, such as cesarean delivery or even cerclage placement, the number of actual fetal surgery cases will certainly be lower, whereas potential complications and risks remain high.
To date, there are a handful of studies published and courses that have been run utilizing simulation for fetal surgical techniques.
In 2018, a group published a paper that described the development and validation of a mixed-reality surgical trainer for fetoscopic laser treatment of twin-twin transfusion syndrome (10).
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