Objective
To compare eclampsia and magnesium toxicity management among residents randomly assigned to lecture or simulation-based education.
Study Design
Statified by year, residents (n = 38) were randomly assigned to 3 educational intervention groups: Simulation→Lecture, Simulation, and Lecture. Postintervention simulations were performed for all and scored using standardized lists. Maternal, fetal, eclampsia management, and magnesium toxcity scores were assigned. Mann-Whitney U , Wilcoxon rank sum and χ 2 tests were used for analysis.
Results
Postintervention maternal (16 and 15 vs 12; P < .05) and eclampsia (19 vs 16; P < .05) scores were significantly better in simulation based compared with lecture groups. Postintervention magnesium toxcitiy and fetal scores were not different among groups. Lecture added to simulation did not lead to incremental benefit when eclampsia scores were compared between Simulation→Lecture and Simulation (19 vs 19; P = nonsignificant).
Conclusion
Simulation training is superior to traditional lecture alone for teaching crucial skills for the optimal management of both eclampsia and magnesium toxicity, 2 life-threatening obstetric emergencies.
Simulation training has been recognized as an effective method for training pilots and military to deal with rare life-threatening events. Over the years, the medical profession has begun to incorporate simulations as a tool to teach the management of low-frequency, high-risk medical emergencies. In obstetrics, rare events such as shoulder dystocia, postpartum hemorrhage, vaginal breech delivery, and eclampsia require prompt recognition and management to minimize maternal and neonatal morbidity and mortality. Decrease in learning time exposure secondary to work hours limitations and the increased availability of experienced senior physicians create a setting in which junior physicians are less prepared to manage such rare obstetric emergencies. With the worsening malpractice climate and growing concerns for patient safety, it becomes extremely important to identify physician-training methods that lead to improved knowledge, skills, and competency and therefore could help to optimize outcomes. Simulation provides a safe setting for repeated deliberate practice and reflective learning that has been shown to translate in improved resident management skills in shoulder dystocia, breech vaginal delivery, and in enhanced team performance during postpartum hemorrhage and eclampsia management.
Eclampsia is a rare, life-threatening obstetric emergency with the potential for poor maternal and perinatal outcomes. Management strategies must be optimized for both eclampsia management and for dealing with complications of magnesium sulfate used for seizure prophylaxis in patients with preeclampsia.
We performed PubMed and Medline search using key words “resident education,” “simulation training,” “obstetrical emergency simulations,” and “drills” without date limitations. To date, no study has specifically addressed the potential incremental benefits of using simulation-based training in addition to traditional lecture education to improve resident management skills for these obstetric emergencies. We hypothesize that given the rare nature of eclampsia and magnesium toxicity, resident physicians may encounter these conditions infrequently, or not at all. We hypothesize that the addition of simulation training to our curriculum may teach skills crucial to management of obstetric emergencies better than traditional lecture-based teaching modalities alone.
Our primary objective was to compare obstetrics and gynecology residents’ management of eclampsia and magnesium toxicity in those randomized to receive simulation-based training/debriefing vs those who receive lecture alone.
Materials and Methods
We conducted a prospective, randomized controlled study. Thirty-eight obstetrics/gynecology residents (this represents all of the residents at our institution), all with prior exposure to simulation-based obstetric education, were stratified by year of training and randomized to 1 of 3 educational intervention groups: simulation followed by classroom lecture (SL), simulation only (S), and lecture only (L) groups. Randomization was achieved using block of 6 and sequentially numbered opaque-sealed envelopes containing allocation cards, designating group assignment. The residents and the instructors grading the residents at the final evaluative simulation were not aware of group assignment. Institutional review board approved our comprehensive study protocol for simulation training of rare obstetric emergencies and each trainee consented at the beginning of the academic year to participate in research projects related to obstetric emergency simulations. Thus, when asked to participate in a simulation drill, participants did not anticipate which emergency drill was being conducted and remained unaware of the group assignment. All data collected was deidentified.
The intervention consisted of either a lecture and/or a simulation. A faculty member not involved in evaluation or debriefing gave a traditional 45-minute lecture to those whose group assignment included lecture at the appropriate time. The residents were not aware of the topic in advance of their lectures or simulations. It covered topics of eclampsia and magnesium toxicity incidence, risk factors, clinical manifestations, complications, recognition, and management strategies, as well as pathophysiology, epidemiology, prediction, and prevention. The management section of a lecture was modeled after the simulation checklist to ensure equivalent information was included. The lecture was based on information from publications by American College of Obstetricians and Gynecologists. An investigator not involved in evaluation and grading knew the allocation to groups and ensured residents’ presence at the appropriate times.
Each simulation scenario consisted of 2 parts. During the first part, a trainee encountered term pregnant patient with severe headache being cared for by an inexperienced triage nurse in our fully stocked mock triage room. An immediate seizure, followed by postictal state and fetal bradycardia ensued. The second part of the scenario started with introduction of the same now unresponsive and postpartum patient on magnesium sulfate for seizure prophylaxis. A standardized patient actor (the same Maternal-Fetal Medicine [MFM] faculty member) with a display of simulated maternal vital signs and fetal heart rate monitoring (NOELLE; Gaumard Scientific, Coral Gables, FL) were used for each simulation. All simulations were digitally recorded for analysis and teaching purposes. An individualized debriefing session was performed after each simulation by the same 2 MFM attendings from the same institution, who were also the evaluators, after they had completed their evaluations. The scored checklist was used for debriefing. Subsequent to the assigned intervention (lecture, simulation, or both) at a time interval of 3-4 months, all residents were evaluated with a postintervention simulation on their management of eclampsia and magnesium toxicity ( Figure ). The same faculty team conducted the same scenario. Each simulation was scored based on standardized checklist adapted and modified from a different institution. All the items in the checklist are equally weighted ( Table 1 ). Maternal eclampsia (recognition, assessment, and seizure management, total score = 21), fetal eclampsia (assessment and delivery plan, total score = 9), and eclampsia management (total score = 30) scores, as well as magnesium toxicity recognition and management (total score = 6) scores, were obtained for simulation based intervention groups (SL and S) at their initial simulation. By study design, no simulation baseline score was performed for Lecture only group. Given randomization and no statistically significant difference between baseline simulation scores for SL and S groups, the baseline score for L was assumed to be no different and a pooled peer median score was used for statistical analysis as a baseline for the L group. Postintervention maternal eclampsia, fetal eclampsia, total eclampsia, magnesium toxicity recognition, and management scores were obtained for all 3 groups. Mann-Whitney U , Wilcoxon rank sum, and χ 2 tests were used for comparison.
| Recognition of eclamptic seizure Recognized eclamptic seizure ____ Called for help (obstetric attending, senior resident) ____ Called for anesthesia ____ Called for pediatrics ____ Called for operating room ____ |
| Patient assessment Correct left lateral positioning ____ Requested vital signs (blood pressure, heart rate, respirations) ____ Requested pulse oximetry ____ Requested supplemental oxygen ____ Requested IV access ____ Requested preeclampsia laboratories ____ Requested Foley placement ____ |
| Seizure management Requested magnesium sulfate ____ Correct IV bolus dose ____ Correct time of bolus administration ____ Correct IV maintenance dose ____ Correct IM dose ____ Correct maximum concentration of magnesium sulfate allowed IV ____ Correct maximum concentration of magnesium sulfate allowed IM ____ Correct alternative agent for persistent seizure activity ____ Correct dose of alternative agent ____ |
| Fetal assessment Recognized fetal heart rate decelerations ____ Obtained maternal vital signs ____ Obtained oxygen saturation ____ Requested supplemental oxygen ____ Repositioned to left lateral ____ |
| Delivery plan Correct delivery plan for fetal bradycardia after seizure ____ Planned for vaginal delivery if resolution of fetal deceleration after 5 min after seizure ____ Planned for cesarean delivery if after seizure FHT still in 60’s, maternal condition stable ____ Expressed concern for placental abruption ____ |
| Magnesium toxicity Requested blood pressure, respiratory rate, heart rate ____ Requested pulse oximetry ____ Recognized diagnosis of magnesium toxicity ____ Discontinued magnesium sulfate ____ Initiated Bag-Mask ventilation (anesthesia not available) ____ Requested calcium gluconate ____ Correct calcium gluconate administration ____ |
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