Simulation training in obstetric practice

The practice of obstetrics is characterised by unpredictable emergency events that require a co-ordinated team-based approach to achieve optimal maternal and/or fetal outcomes. Many emergency situations in obstetrics are largely unpredictable (eg shoulder dystocia, post-partum haemorrhage), and it is therefore crucial that healthcare professionals involved in obstetrics and midwifery attain and maintain core skills in the management of acute obstetric emergencies. Concerningly, there have been several publications indicating that some adverse obstetric outcomes may have been ameliorated by improvements in emergency skills training. However, the exposure of any individual healthcare professional to obstetric emergencies on a regular basis is low, especially in smaller maternity units. Maintaining an appropriate level of timely recognition to patient deterioration and skills to intervene to minimise adverse outcomes may be difficult to achieve in the daily workplace environment. Two major practice points have evolved over the past decades for emergency response strategies in obstetrics: firstly, the central role of multidisclipinary team work in obstetric emergencies and secondly, the importance of regular simulation training and drills in various emergency scenarios. Both of these two critical practice points are presented and discussed in this issue of ANZJOG. I would encourage readers to review these manuscripts and consider the information presented in relation to their own hospital and workplace practices. Simulation models are being used with increasing frequency in medical training. The concept of simulationbased medical training centres around utilising a technical device in one or more created medical scenarios to evaluate practitioner responses to the problem presented. Acute obstetric emergencies lend themselves to simulation training, and there have been several studies evaluating their usefulness. A recent systematic review evaluating multidisciplinary team training in a simulation setting for obstetric emergencies concluded that there was an improvement in participant knowledge, practical skills, communication and teamwork collaboration. Whether this simulation training occurred off-site in a simulation training centre or within the hospital environment did not influence the core educational values achieved. The influence of on-site or off-site training is currently under investigation in a randomised clinical trial setting. Studies of simulation training have had several positive effects in improving strategies for obstetric emergencies beyond the basic lines of initial response. The randomised controlled trial by Ellis and coworkers, which demonstrated improved performance following simulation training in basic task completion and team work, lead to the creation of ‘eclampsia boxes’. These boxes contain both protocols and equipment in one container to facilitate the administration of appropriate emergency care in this acute scenario. Similarly, for post-partum haemorrhage, many units have developed a specific ‘PPH box’ brought to the site of the emergency which contains all the necessary elements to manage this condition, thus decreasing time spent retrieving medications and equipment from various locations within the institution. Observations during simulated post-partum haemorrhage scenarios have exposed further the inadequacies in estimating blood loss. Estimates of blood loss in all the studies have shown a significant underestimation of blood loss in high volume situations (up to 49%) prior to the training sessions, with an improvement in volume loss accuracy following completion of the education program. There are many challenges in managing an obstetric emergency – one important aspect is the recognition that a young, previously well woman can become very unwell in a short period of time. Often there can be a failure to appreciate clinical deterioration in a timely manner in the pregnant woman – she may not exhibit signs of decompensation until late in the clinical pathway of her illness. Sepsis is a typical scenario in which there may be failure to recognise deterioration until late in the disease course. There has been an increase in maternal deaths secondary to Group A streptococcus in recent years, and indeed, it was the leading cause of direct maternal death in the most recent United Kingdom maternal mortality review. Secondly, during an obstetric emergency, there are usually many healthcare providers involved in the acute event setting – the necessity for interdisciplinary teamwork is paramount. Simulation training in obstetric emergencies can prove an invaluable resource in practising the establishment of lines of communication and responsibility between the often divergent providers involved. Such emergency simulation sessions can encourage the development of a collective mindfulness attitude. That is, all participants are aware that small failings in protocols may lead to severe adverse outcomes, and thus, continual vigilance is central to maintaining safety. Communication failures are a common feature in reviews of adverse outcomes. Although simulation training in emergency obstetric situations has clear benefits to reducing adverse outcomes and will continue to increase in utilisation for emergency preparedness, in itself it is not a solution in isolation. As Walker and colleagues have shown in this issue of ANZJOG, there is a loss of knowledge and confidence if training occurs in isolation as a single educational