Consensus Statement No. 434: Simulation in Obstetrics and Gynaecology.

OBJECTIVE: To provide a comprehensive and current overview of the evidence for the value of simulation for education, team training, patient safety, and quality improvement in obstetrics and gynaecology, to familiarize readers with principles to consider in developing a simulation program, and to provide tools and references for simulation advocates. TARGET POPULATION: Providers working to improve health care for Canadian women and their families; patients and their families. OUTCOMES: Simulation has been validated in the literature as contributing to positive outcomes in achieving learning objectives, maintaining individual and team competence, and enhancing patient safety. Simulation is a well-developed modality with established principles to maximize its utility and create a safe environment for simulation participants. Simulation is most effective when it involves interprofessional collaboration, institutional support, and regular repetition. BENEFITS, HARMS, AND COSTS: This modality improves teamwork skills, patient outcomes, and health care spending. Upholding prescribed principles of psychological safety when implementing a simulation program minimizes harm to participants. However, simulation can be an expensive tool requiring human resources, equipment, and time. EVIDENCE: Articles published between 2003 and 2022 were retrieved through searches of Medline and PubMed using the keywords "simulation" and "simulator." The search was limited to articles published in English and French. The articles were reviewed for their quality, relevance, and value by the SOGC Simulation Working Group. Expert opinion from relevant seminal books was also considered. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE: All health care professionals working to improve Canadian women's health, and relevant stakeholders, including granting agencies, physician/nursing/midwifery colleges, accreditation bodies, academic centres, hospitals, and training programs.

Massive Hemorrhage Protocol Application and Teamwork Skills.

OBJECTIVE: Massive hemorrhages (MHs) are rare but serious complications of pediatric trauma and obstetric cases. This study aimed to evaluate the impact of interprofessional simulation to improve adherence to a MH protocol (MHP), teamwork skills and confidence levels during a hemorrhagic crisis situation.Methods: This was a pre-post experimental study conducted at a tertiary care mother-child simulation center. Pediatric emergency and obstetric teams were submitted to simulated trauma and postpartum MH scenarios. Training consisted of two case scenarios followed by debriefing sessions and a lecture on the MHP. The primary outcome was adherence to MHP processes (checklist) measured prior to and 2 weeks following training sessions. Other outcomes were the measure of teamwork skills (Mayo High Performance Teamwork Scale) and confidence of the participants. RESULTS: Sixty-two health care professionals were involved in eight interprofessional teams. Mean scores for adherence to the MHP improved from 19.1 in the pretraining phase to 25.8 in the posttraining phase (difference of 6.7; 95% confidence interval [CI] = 4.4 to 8.9). Mean scores pertaining to teamwork skills also improved significantly between pre- and posttraining phases (difference = 3.9; 95% CI = 1.5 to 6.4). Confidence questionnaires showed significant improvements in the posttraining phase (difference = 6.9; 95% CI = 5.3 to 8.3). CONCLUSIONS: Targeted training involving simulation and protocol review improved participant adherence to MHP processes and teamwork skills. Confidence levels improved across all disciplines.

Using simulation team training with human's factors components in obstetrics to improve patient outcome: A review of the literature.

OBJECTIVE: to assess the evidence from multidisciplinary simulation team training in obstetrics that integrates human's factors components on patient outcome. INTRODUCTION: It has been stated that simulation-based education has the potential to improve technical and nontechnical skills. Reports from enquiries into maternal and newborn adverse outcomes, highlight that the majority of incidents are due to a breakdown of communication and a lack of crisis resource management skills (CRM). It is therefore reasonable to think that a better training on teamwork based on simulation will ultimately improve obstetrics care. In order to explore further that idea, we conducted a literature review on patient outcome after a multidisciplinary simulation training in obstetrics. METHOD: Pubmed, Advances in health sciences education, BMC in medical education, BMC in pregnancy and Childbirth, BMJ open, BMJ Simulation and technology enhanced learning were searched from inception to May 2020 for full-text publications in English on interprofessional, multidisciplinary, obstetrics, simulation training, non-technical skills, CRM. Searches were limited to studies with a report on patient outcome after a multidisciplinary simulation program that included elements of CRM. RESULT: Out of the ten studies selected in our review, five were single site before and after prospective studies and five were cluster before and after randomized trials. All the single site studies reported a positive outcome in low and high resource countries. Three single site studies reported a reduction between 41 and 50 % of blood transfusion after simulation team training. Two single studies reported a reduction of maternal mortality by 34 % and a decrease in an adverse obstetrics index outcome from 0.052 to 0.048 with a p-value of 0.05. Cluster studies showed either no change or some improvement in patient outcomes such as a 37 % improvement on weighted obstetrics adverse outcome, a 17 % reduction in the incidence of PPH and a 47 % reduction in the incidence of retained placenta. Stillbirths rate was reduced by 34 % while newborn deaths was down by 62 %. There was also a 15 % reduction of maternal mortality in favor of the trained team after adjustment to the secular mortality trend. Neonatal death from 24 weeks during the first 24 h was also reduced by 83 % in the intervention site compare with an increase by 18 % in the control site. CONCLUSION: There is evidence that simulation team training that includes CRM is associated with better patient outcome. In order to consolidate this finding, appropriate methodology should be used in future studies with the support of health authorities.

Health Care Team Training and Simulation-Based Education in Obstetrics During the COVID-19 Pandemic.

Health care team training and simulation-based education are important for preparing obstetrical services to meet the challenges of the COVID-19 pandemic. Priorities for training are identified in two key areas. First, the impact of infection prevention and control protocols on processes of care (e.g., appropriate and correct use of personal protective equipment, patient transport, preparation for emergency cesarean delivery with the potential for emergency intubation, management of simultaneous obstetric emergencies, delivery in alternate locations in the hospital, potential for increased decision-to-delivery intervals, and communication with patients). And second, the effects of COVID-19 pathophysiology on obstetrical patients (e.g., testing and diagnosis, best use of modified obstetric early warning systems, approach to maternal respiratory compromise, collaboration with critical care teams, and potential need for cardiopulmonary resuscitation). However, such training is more challenging during the COVID-19 pandemic because of the requirements for social distancing. This article outlines strategies (spatial, temporal, video-recording, video-conferencing, and virtual) to effectively engage in health care team training and simulation-based education while maintaining social distancing during the COVID-19 pandemic.

Early Versus Delayed Postoperative Feeding After Major Gynaecological Surgery and its Effects on Clinical Outcomes, Patient Satisfaction, and Length of Stay: A Randomized Controlled Trial.

OBJECTIVE: To compare early versus delayed postoperative feeding in women undergoing major gynaecological surgery with regard to clinical outcomes, duration of postoperative stay, and patient satisfaction. METHODS: We conducted a parallel-randomized controlled trial at a tertiary care centre in Montreal, Quebec, between June 2000 and July 2001. Patients undergoing major gynaecological surgery were randomized following a 1:1 allocation ratio to receive either early postoperative feeding in which oral clear fluids were begun up to six hours after surgery followed by solid foods as tolerated, or delayed postoperative feeding, in which clear fluids were begun on the first postoperative day and solid foods on the second or third day as tolerated. The primary outcomes analyzed were duration of postoperative stay and patient satisfaction. Secondary outcomes included mean time to appetite, passage of flatus, and bowel movement, as well as the presence of symptoms of paralytic ileus. RESULTS: A total of 119 patients were randomized; 61 patients were assigned to the early feeding group and 58 to the delayed feeding group. Demographic characteristics, including age, weight, smoking status, and prior surgical history were comparable between both groups. There was no difference in length of postoperative stay between the two groups (86.4 ± 21.0 hours in the early feeding group vs. 85.6 ± 26.2 hours in the delayed feeding group; P > 0.05). No significant difference was noted in patient satisfaction (P > 0.05). No difference was found in the frequency of postoperative ileus, mean time to appetite, passage of flatus, or first bowel movement. CONCLUSION: The introduction of early postoperative feeding appears to be safe and well tolerated by patients undergoing major gynaecological surgery. The duration of postoperative stay, patient satisfaction, and gastrointestinal symptoms are comparable between patients undergoing early or delayed postoperative feeding.

Objectif : Comparer, chez des femmes devant subir une chirurgie gynécologique majeure, les effets de la reprise postopératoire précoce ou différée de l'alimentation en ce qui a trait aux résultats cliniques, à la durée de l'hospitalisation postopératoire et à la satisfaction de la patiente. Méthodes : Nous avons mené un essai comparatif randomisé parallèle dans un centre de soins tertiaires de Montréal, au Québec, entre juin 2000 et juillet 2001. Les patientes devant subir une chirurgie gynécologique majeure ont été affectées au hasard (selon un ratio d'attribution 1:1) à un groupe devant connaître une reprise postopératoire de l'alimentation précoce (dans le cadre de laquelle l'administration de liquides clairs par voie orale a été entamée dans les six heures suivant la tenue de la chirurgie, suivie de celle d'aliments solides, en fonction de la tolérance) ou différée (dans le cadre de laquelle l'administration de liquides clairs a été entamée au cours de la première journée postopératoire et celle d'aliments solides, au cours de la deuxième ou de la troisième journée postopératoire, en fonction de la tolérance). Les principaux critères d'évaluation analysés ont été la durée de l'hospitalisation postopératoire et la satisfaction de la patiente. Parmi les critères d'évaluation secondaires, on trouvait le délai moyen avant le retour de l'appétit, de l'expulsion de flatuosités et de la défécation, ainsi que la présence de symptômes d'iléus paralytique. Résultats : Au total, nous avons recruté 119 patientes : 61 patientes ont été affectées au hasard au groupe « alimentation précoce ¼ et 58, au groupe « alimentation différée ¼. Toutes les participantes comptaient des caractéristiques démographiques (dont l'âge, le poids, le statut quant au tabagisme et les antécédents chirurgicaux) comparables. Aucune différence n'a été constatée entre les deux groupes en ce qui concerne la durée de l'hospitalisation (86,4 ± 21,0 heures au sein du groupe « alimentation précoce ¼ vs 85,6 ± 26,2 heures au sein du groupe « alimentation différée ¼; P > 0,05). Aucune différence significative n'a été constatée en matière de satisfaction de la patiente (P > 0,05). Aucune différence n'a été constatée en ce qui a trait à la fréquence de l'iléus postopératoire ni en ce qui concerne le délai moyen avant le retour de l'appétit, de l'expulsion de flatuosités et de la défécation. Conclusion : La reprise postopératoire précoce de l'alimentation semble être une pratique sûre et bien tolérée par les patientes ayant subi une chirurgie gynécologique majeure. La durée de l'hospitalisation postopératoire, la satisfaction de la patiente et les symptômes gastro-intestinaux sont comparables chez les patientes qui connaissent une reprise postopératoire précoce de l'alimentation et chez celles pour qui cette reprise est différée.

Assessment of correlation between p16INK4a staining, specific subtype of human papillomavirus, and progression of LSIL/CIN1 lesions: first comparative study.

OBJECTIVES: To study and compare the effectiveness of p16(INK4a) staining and specific human papillomavirus (HPV) subtypes as a prognostic marker in cervical intraepithelial neoplasia grade 1 (CIN1; low-grade squamous intraepithelial lesions). METHODS: Sixty-four cervical samples diagnosed as CIN1 and stained with p16(INK4a), with HPV status assessed by polymerase chain reaction-direct sequencing. RESULTS: Of the 34 p16(INK4a)-negative biopsy specimens, 26 regressed, seven persisted, and one progressed. Of the 20 p16(INK4a) diffusely positive biopsy specimens, seven regressed, eight persisted, and five progressed. Ten biopsy specimens stained positive only in the lower one-third of the sample, of which seven regressed and three persisted. p16(INK4a) diffusely positive CIN1 lesions were associated with only high-risk HPV subtypes, with the exception of one HPV-negative biopsy specimen. Three different high-risk HPV subtypes and one low-risk HPV subtype (HPV66) were identified in the six CIN1 lesions that progressed. CONCLUSIONS: There is a significant relationship between p16(INK4a) immunostaining and follow-up (P = .002). p16(INK4a)-negative specimens or positivity in the lower one-third of CIN1 lesions seldom progress to a CIN2-3 lesion.

Early versus late amniotomy for labour induction: a randomized controlled trial.

OBJECTIVE: To evaluate the impact of early vs. late amniotomy on delivery mode in women undergoing induction of labor. STUDY DESIGN: 143 women admitted for induction were randomized to early amniotomy (EA, concomitant with the beginning of oxytocin infusion; n = 71) or to late amniotomy (LA, four hours after the beginning of oxytocin; n = 72). Randomization was stratified by parity. The primary outcome was the rate of cesarean. Secondary outcomes were duration of labor and intrapartum fever. RESULTS: The cesarean rate was similar between groups (18% vs. 17% among nulliparous; and 3% vs. 0% among parous women, in EA and LA group, respectively). However, EA was associated with shorter oxytocin-to-delivery interval (12 vs. 15 h) and a non-significant decrease in intrapartum fever (3% vs. 25%) than LA in nulliparous women (p = 0.05). CONCLUSION: For women undergoing oxytocin induction, early amniotomy is associated with shorter labor in nulliparous women with no effect on the risk of cesarean section in both nulliparous and multiparous women.

[Obstetricians/gynaecologists and breastfeeding: practice, attitudes, training and knowledge]. / Obstétriciens-gynécologues et allaitement maternel : pratique, attitudes, formation et connaissances.

OBJECTIVE: Sole use of breastfeeding is recommended during the first six months of life. The treating physician's opinion influences whether or not the patient will opt for breastfeeding. We wanted to ascertain if obstetricians-gynaecologists and obstetrics and gynaecology residents from Quebec offered counselling on breastfeeding and to examine various aspects of their disposition towards such counselling. METHODS: A questionnaire evaluating five aspects of physicians' disposition towards breastfeeding was used: practice and confidence, attitudes, training, knowledge. We emailed obstetrics and gynaecology residents from Quebec and members of the Association des obstétriciens et gynécologues du Québec who had a valid email address to invite them to complete the questionnaire, which was offered on a secured website. RESULTS: Only 49% of obstetricians-gynaecologists and 35% of residents periodically offer counselling on breastfeeding. Furthermore, 56% and 35% respectively of both groups have confidence in their ability to meet the needs of breastfeeding patients, while 79% of the former and 93% of the latter believe that such counselling comes under their authority. On average, obstetricians-gynaecologists answered correctly 82% of the questions concerning theoretical knowledge. Only 16% of obstetricians-gynaecologists and 22% of residents believe they have received an "at least adequate" training on how to support breastfeeding women. CONCLUSION: Respondents have not adequately integrated breastfeeding counselling into their practice, in spite of the fact that they had adequate theoretical knowledge on the matter and that they were convinced that such a role was important and that it came under their authority. A more practical form of training could enhance their confidence level and encourage them to integrate such counselling into the obstetrical follow-up.

Choosing the right physical laparoscopic simulator? Comparison of LTS2000-ISM60 with MISTELS: validation, correlation, and user satisfaction.

BACKGROUND: The LTS 2000-ISM60 (LTS; Realsim Systems, Alburquerque, NM, USA) is a computer enhanced video-laparoscopic training system. Our purpose was to validate the LTS and to correlate its scoring performance with that of the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS), a widely used and well-validated physical simulator. METHODS: Participants (n = 124) included medical students, residents, fellows, and attending surgeons from general surgery, gynecology, and urology in 3 Canadian universities. They were classified in groups based on laparoscopic experience: novice, intermediate, competent, and expert. Participants (n = 124) were tested on the LTS, and 74 were tested on both the LTS and the MISTELS. A user satisfaction questionnaire was completed after each performance. RESULTS: LTS metrics showed a progressive improvement in total scores according to academic level as well as level of laparoscopic experience (P < .001). Good correlation was found between the LTS and the MISTELS (r = .79). Level of user satisfaction was highest with LTS. CONCLUSIONS: Based on laparoscopic experience and academic level, the LTS has a comparable discriminating capability for level of performance with that of the MISTELS. The higher degree of user satisfaction attributed to the LTS could justify its use as a training and assessment tool for surgical specialties.

Twin delivery after a previous caesarean: a twelve-year experience.

OBJECTIVES: To compare maternal and neonatal morbidities between trial of labour (TOL) and elective Caesarean section in women with twin pregnancies who have had a prior Caesarean. METHODS: An observational study was conducted of women with a prior Caesarean who delivered twins at 28 weeks gestation or greater in Ste-Justine Hospital between 1988 and 2001. Maternal and neonatal outcomes were compared between women who had a TOL (group 1) and those who had an elective Caesarean delivery (group 2). RESULTS: Twenty-six women and 52 fetuses were included in group 1 and compared to the 71 women and 142 fetuses in group 2. Maternal age, gestational age, and birth weight were comparable in both groups. In group 1, 22 (85%) out of 26 women delivered twin A vaginally and 19 (73%) delivered both vaginally. There was no significant difference in the umbilical artery cord pH, Apgar score, ventilatory support, and admission to the neonatal intensive care unit between the 2 groups. There was also no significant difference in the rate of postpartum maternal fever or decrease of serum hemoglobin between the 2 groups, but the median hospital stay was higher in the group with elective Caesarean (5.0 vs. 3.0 days, p <0.001). There were no uterine ruptures or other major complications in either group. CONCLUSION: There were no significant differences in maternal and neonatal morbidity outcomes between births by trial of labour and by elective Caesarean, in twin pregnancies after a prior Caesarean section. A trial of labour is associated with a shorter hospital stay.