Keeping it Real: Improving Clinical, Technical, and Team Skills with Obstetric Simulation Training

At a Glance

  • Simulation is a practical and safe approach to the acquisition and maintenance of task-oriented and behavioral skills across the spectrum of medical specialties, including obstetrics and gynecology.
  • NewYork-Presbyterian has launched the advanced simulation training center at Columbia University Medical Center to provide authentic training experiences, including hands-on education in obstetric emergencies and postpartum hemorrhage.

“Simulation-based training can be used to analyze team performance and identify strengths and weaknesses. An immediate debriefing helps to improve knowledge and skills, as well as communication and other teamwork behaviors.”

— Dr. Dena Goffman

Obstetric emergencies can be unexpected and every minute is critical when the lives of a mother and baby are in jeopardy. Given the significant time pressure, as well as the range of clinical skills and experience that must come together swiftly in a team effort, NewYork-Presbyterian has launched an advanced clinical simulation program to provide authentic training experiences in obstetric emergencies.

“Simulation in medicine can provide training in technical skills and teamwork and incorporate bundles and protocols for the care we deliver,” says Dena Goffman, MD, Chief of Obstetrics at NewYork-Presbyterian/ Columbia University Medical Center and Associate Chief Quality Officer, Department of Obstetrics and Gynecology, NewYork-Presbyterian Morgan Stanley Children’s Hospital and Sloane Hospital for Women. “Simulation-based training improves team readiness and expertise by exposing doctors, nurses, and other members of the maternity team to obstetric emergencies that they may not often encounter in their practice. Simulation is also a way to identify systems issues and then work to correct them. All of this can be accomplished without having a patient impacted.”

Dr. Goffman, who created and oversees the simulation curriculum completed her residency training in obstetrics and gynecology at NewYork-Presbyterian/Columbia. During her fellowship in maternal-fetal medicine and obstetric critical care at Albert Einstein College of Medicine, she became interested in obstetric complications and the care of critically ill pregnant women, as well as the importance of education and quality improvement.

“The simulation center puts providers and teams in a setting where they are managing an obstetric emergency,” she says. “They can learn from an immersive simulation experience what went well and what didn’t go well and then apply these lessons in real clinical circumstances.”

Simulation Training: Rigorous Standards, Authentic Setting

The advanced simulation training center, which is housed in the Roy and Diana Vagelos Education Center, Columbia University’s new, state-of-the-art, 14-story medical and graduate education building is equipped with space for mock examination rooms, clinics, and operating rooms. The PROMPT Flex Birthing Simulator incorporates many features that enhance training, including an anatomically correct bony pelvis in the mother, silicone pelvic floor musculature, and a stretchable perineum. The baby is of newborn size and weight and is fully articulated. Other birthing simulators can replicate a full range of preprogrammed obstetrical events, including breech birth and cesarean deliveries, forceps, and vacuum delivery, hemorrhage, and true-to-life shoulder dystocia.

Shoulder dystocia is an unpredictable and largely unpreventable obstetric complication during which the fetal shoulders do not deliver after the head has emerged from the vaginal canal and one or both shoulders becomes impacted against the bones of the mother’s pelvis.

“There are technical skills that a provider needs to have to safely accomplish delivery with shoulder dystocia,” says Dr. Goffman. “Through our simulator, we teach how to do these maneuvers safely and correctly in a stepwise fashion. If there is too much traction applied to the head while the shoulder is stuck in the bony pelvis, the baby can suffer a brachial plexus injury that can lead to long-term consequences. The simulator has a force monitoring system with an electronic strain gauge to measure the amount of force being applied. We teach maneuvers to minimize force and to try to mitigate those risks of injury.”

Nurses play a critical role in helping the provider safely deliver the baby. “Nurses receive the same hands-on training for the portions of care that they provide,” says Dr. Goffman. “Certain parts of the shoulder dystocia algorithm include how you hold the mother’s legs and how to apply suprapubic pressure. Those are things the provider can’t do because their hands are tied up doing the maneuvers to accomplish delivery.”

According to Dr. Goffman, while technical skills are essential, probably more important is teaching teams to function in an emergency.

“One of the exciting aspects about an offsite center like this is that we bring people away from their clinical area, eliminate distractions and multitasking, and have them focus on team learning,” she explains. “Residents, fellows, attendings, and nurses come together in one place to run through a simulated shoulder dystocia delivery. Then we debrief the simulated delivery afterward. We talk about what went well and what we can learn from it. Often we go back and run it a second time to solidify the improvements we wanted to make from the first delivery.”

Dr. Goffman believes that debriefing as a concept does not get as much attention as it should. “We’re working on incorporating debriefing into clinical practice after real events,” she says. “One of the benefits of doing this in the simulation center is having people get comfortable with how the process works. You can then build a cadre of people that recognizes the value of debriefing for systems learning and quality improvement work. It’s that sitting down and talking to each other afterward where the benefit happens.”

Simulation training also focuses on postpartum hemorrhage, the leading cause of maternal mortality worldwide. “Postpartum hemorrhage is a very relevant and important topic and typically occurs in 4 to 6 percent of deliveries,” says Dr. Goffman, who has co-authored an American College of Obstetricians and Gynecologists Practice Bulletin on the subject in the October 2017 issue of Obstetrics and Gynecology.

Dr. Goffman is also a member of the Steering Committee of the Safe Motherhood Initiative for New York State; Mary E. D’Alton, MD, Director of Services, NewYork-Presbyterian Sloane Hospital for Women, serves as Co-Chair of the Safe Motherhood Initiative. The initiative, launched by the American Congress of Obstetricians and Gynecologists, is developing and implementing standard approaches for managing the three leading causes of maternal death – severe hypertension, venous thromboembolism, and obstetric hemorrhage.

“How prepared we are to handle postpartum hemorrhage when it happens is critically important,” says Dr. Goffman. “One way to prepare teams is to bring them to a simulation center and run them through the management of a hemorrhage.”

In her teaching, Dr. Goffman incorporates the national guidelines and recommendations for how to safely manage this emergency. The full body simulator used includes simulated spontaneous breathing, variable respiratory rates, and blood and other fluids. The simulation program offers up to four training sessions a month.

“Large numbers of staff work in labor and delivery, and there could never be just one dedicated team assigned to handle emergencies,” adds Dr. Goffman. “Emergencies happen quickly and need to be dealt with in minutes. Therefore, it is important that we train everyone with the same protocols and practice. Then whoever is on the floor when an emergency occurs can be interchanged to help.”

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