Acta Med. Okayama, 2024
Vol. 78, No. 4, pp. 313‑322
CopyrightⒸ 2024 by Okayama University Medical School.

Original Article

http://escholarship.lib.okayama-u.ac.jp/amo/

Multicenter Remote-Access Simulation of Vaginal Delivery for
High-Flexibility Medical Education during the Coronavirus Pandemic
Eriko Etoa＊, Jota Makia, Noriyuki Yamashitab, Toru Hasegawac,
Ayano Suemoria, Hikari Nakatoa, Hikaru Obaa, Tomohiro Mitomaa,
Sakurako Mishimaa, Satoe Kirinoa, Akiko Ohiraa, and Hisashi Masuyamaa
Departments of aObstetrics and Gynecology, cGeneral Medicine, Okayama University Graduate School of Medicine,
Dentistry and Pharmaceutical Sciences, bCenter for Education in Medicine and Health Sciences,
Okayama University, Okayama 700-8558, Japan

During the coronavirus pandemic, face-to-face simulation education became impossible. Therefore, we aimed
to develop remote-access simulation education with a sense of realism through Information andCommunication Technology (ICT) using a perinatal whole-body management and delivery simulator. In
September 2021, we administered a multi-center simultaneous remote simulation based on our developedmodel. Ten universities in the Chugoku–Shikoku region were connected via a web-conferencing system to a live
broadcast of a virtual vaginal birth in which a fictional hospitalized pregnant woman experienced accelerated
labor and gave birth through vacuum delivery for fetal distress. A Video on Demand (VOD) was made beforehand using a new simulator that allowed for a visual understanding of the process of the inter-vaginal examination. We provided a participatory program that enhanced the sense of realism by combining VOD and realtime lectures on each scenario, with two-way communication between participants and trainee doctors using achat function. Most participants answered “satisfied” or “very satisfied” with the content, level of difficulty, andlevel of understanding. From November 2021, we have used the videos of all processes in face-to-face classes.
Our construction of a high-flexibility education system using remote simulation in the field of obstetrics andgynecology, especially in the vaginal delivery module, is unique, creative, and sustainable.
Key words: remote simulator education, perinatal simulator, information and communication technology,
high-flexibility educationO

ur Obstetrics and Gynecology Department has
focused on the education of medical students,
residents, and specialty doctors as one of the mostimportant issues in our field of research and practice.
Various educational activities have been integrated toprovide training in obstetrics and gynecology that meetsthe needs of students and residents, ultimately leading
to recruitment and competent professional practice.
Received December 12, 2023 ; accepted April 24, 2024.
Corresponding author. Phone : +81-86-235-7320; Fax : +81-86-225-9570
E-mail : eeto@okayama-u.ac.jp (E. Eto)＊

The need for simulation education is clearly stated in
the guidelines for physician clinical training guidance inJapan. In addition to delivering knowledge, much moreis required: nurturing the students’ technical skills,
habits of communication, and attitudes is also essential.
Many problems regarding ethics and safety management arise when inexperienced trainee doctors perform
invasive procedures on patients; they should be given
sufficient simulation training to develop minimal comConflict of Interest Disclosures: No potential conflict of interest relevantto this article was reported.

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petence before performing actual procedures. The
advantages of simulation education include self-study,
the ability to practice repeatedly, and enhanced learning through a combination of simulations and othermethods such as lectures.
Prior to the coronavirus pandemic, instructors andlearners at our institution conducted face-to-face simulation education in groups. For example, in the preresident seminar, participants gathered in a specialized
facility such as the simulation center within the university. They were taught whole-body management ofshock vitals, ultrasound examination using a fetal
phantom, laparoscopic operation, and other powered
devices. It was possible to guide each student as theyrotated through booths about devices, suturing, andthread tying. Additionally, a face-to-face meeting washeld at the medical office with the executive committee,
which had recruited student volunteers and discussed
the contents of the project.
When we surveyed 5th and 6th year medical students undertaking clinical training in our department
before the pandemic, most students wanted to participate in simulation training, even though the training
period lasted only one to two weeks. The most popular
topics were general management, pelvic examinations,ultrasound examinations, uterine cancer screening,and childbirth (Fig. 1). In short clinical clerkships, theprimary medical procedures (vaginal sampling, colposcopy, intravenous injection, and childbirth assistance)
defined by the Ministry of Health, Labor, and Welfare
are often not possible to witness and perform; thus,
simulation training will always be necessary for train-

Would you like to set aside time for simulation practice?
5th year (n=153)

2%
46%

6th year (n=64)

1%

Yes (As many as
possible)41%

Yes (Once or twicea week)52%

Yes (As many as
possible)Yes (Once or twicea week)

58%

No

No

What would you like to learn as a simulation education?
(multiple answers possible)
General management
Laparotomy
Ultrasonic diagnosis
Pelvic examitation
Normal labor
Abnormal labor
Uterine cancer screening
Speculum examination
Peripheral Catheterization
Postpartum hemorrhage
Perineorrhaphy
Basic life support
0

20

40

60

80

100

120

number of respondents
6th yearFig. 15th year

Questionnaire for learners: Answers from 217 5th and 6th year medical students.

Remote-Access ObGyn Simulator Education

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ing. We decided to aim for effective simulation education that would meet the needs of learners. Several
previous studies reported that medical students need tobe repeatedly exposed to simulation education to have asense of psychological stability and to competently
deliver medical treatment in a clinical setting [1 , 2].
Moreover, simulation education not only improved
students’ short-term medical knowledge but also had along-term impact on their understanding [3 , 4].

Materials and Methods
New developments in remote-access simulator education.
We decided to administer multicenter,
simultaneous remote simulation education at the
Chugoku–Shikoku Society of Obstetrics andGynecology Plus One seminar in September 2021.
Titled “Live Broadcast of Vaginal Delivery at Okayama
University,” the program provided participants with theopportunity to relive rotations and internal examinations, which are challenging to teach, through a virtual
vaginal delivery program using the childbirth simulator
developed by our department just prior to the pandemic, together with videos and scenario acting. The
program also included lectures, group discussions, andother horizontal developments. Moreover, we planned
an expansion program. This program was 80 min long
and was prepared over nine months, targeting earlytrainee doctors and 6th year students interested inobstetrics and gynecology. Given the timing of the pandemic and the sense that instructional delivery would
never be the same as before, the purpose of the seminar
was to establish a high-flexibility educational module in
the field of obstetrics and gynecology.
High-flexibility education is an method of instructional delivery that grew out of the changes in classpolicy required by the coronavirus 19 pandemic. It is an
educational style in which the same class content istaught face-to-face and online simultaneously, combined with asynchronous online or on-demand classes
later. High-flexibility education is a term coined tomean hybrid-flexible classes, in which students,
depending on their preference and diverse schedules,
can choose to take a course face-to-face or online [5].
We conducted what is informally called “on-the-job
training” (OJT) through theexperience by streaming inreal-time and created a retrospective video for asynchronous online education; the basic aim was to reach315

students throughtout the region. The regions of
Chugoku and Shikoku are located in western Japan andspan approximately 400 km straight from the Sea ofJapan to the Pacific Ocean. With the Setonaikai Sea andthe Sanin Mountains in between, it would take a person
four to five hours to drive from Kochi Prefecture to
Tottori Prefecture via Okayama Prefecture, for example.
University hospitals are located in each prefecture, and10 universities serve students’ academic needs while
establishing exchanges with one another for morein-depth studies and experiences.
Planning and preparations leading up to the event.
During the planning process, which was nine months
prior to the program, we used a delivery simulator tocreate a scenario called “live broadcast of a virtual vaginal birth” that combined Video on Demand (VOD) andreal-time streaming. The 10 universities were connected using the web-conferencing system Zoom;
furthermore, some face-to-face instructions were given
at the headquarters, Okayama University, with students participating from home together with remoteparticipants from the other nine universities simultaneously in an online format. Lectures pre-recorded fromthe headquarters were used to present cases and pose
problems, along with two-way communication using
the chat function. Simulation videos, played during
each phase of childbirth, were also recorded in advanceto ensure smooth progress (Fig. 2).
Six months in advance, we contacted each of the 10
universities to request that they recruit instructors andparticipants. After repeated team discussions, wedeveloped a scenario where a pregnant woman was
admitted to the hospital with ruptured membranes andexperienced weak labor, accelerated labor, rotational
abnormalities, fetal dysfunction, and rapid delivery
before birth.
One month before the program, we recorded lectures, filmed the new training mannequin from multiple viewpoints at close range, and created videos for
VOD. With the cooperation of an external video company, medical staff became the actors, and each scene
was filmed and edited. Images were taken from two
viewpoints, the perineum side and the inside of thepelvis, at a close range from the simulator and withrepeated trial and error to see if we could create a video
that enhanced the sense of realism (Fig. 3).

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Fig. 2Concept of multicenter simultaneous remote-access simulator education.

Fig. 3Pre-recording for VOD video creation.

Results
At the September, 2021 seminar, we ran the multicenter remote delivery simulation education connecting
the 10 universities in Chugoku and Shikoku. The number of participants and instructors from each prefectureis shown in Table 1.
On that day, the moderators made announcements
via video. The delivery simulator was also set up forquestion-and-answer sessions on the same day. We
enabled two-way communication via Zoom for remoteparticipants (Fig. 4). To imitate a TV program, we
switched to a pre-recorded video midway through theprogram when an announcement started to connect theexam room to the broadcast. The moderator proceededwith the scenario, alternating between the studio andpre-recorded videos. As the lectures that were inserted
midway were also pre-recorded, we had to be careful
about the timing to make it appear as if the lecture wasbeing live-streamed from an adjacent lecture room. The
students answered questions about reading comprehension on the cardiotocogram (CTG) monitor. Question

Remote-Access ObGyn Simulator Education

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Fig. 4

Scenes of the day of the simulation.

Table 1
The number of participants and instructors from eachprefecture
Prefecture

317

Instructors

Participants

Okayama (Okayama)

6

8

Okayama (Kawasaki Medical)

1

2

Tottori

1

2

Shimane1

2

Hiroshima

1

2

Yamaguchi

1

2

Kagawa

1

12

Ehime

1

3

Kochi

1

2

Tokushima

12(Q) 1 was “How should this CTG finding be interpreted?”
Q2 was “What does this ultrasound finding mean?” Q4
was, again, “How should this CTG finding be interpreted?” Q5 was “What treatment decision will you
make?” They received answers using a chat function,with instructors providing support to students at each
university in the remote venue, and the answers were
submitted on the chat. In the scene where the ultrasound movement and ultrasound images were shown,and the abnormal rotation was disclosed, the time axis
was expressed by combining the ultrasound procedurescene and the ultrasound image one frame at a time,

together with changes in the CTG. We explained rotation and how to evaluate pelvic examination findings
while showing the position in the pelvic region of thesimulator. A medical staff member was also placed at
the head of the simulator to move the baby.
We simulated a vacuum-assisted delivery as a rapid
delivery for fetal distress, taking care to make the scene
as realistic as possible (Fig. 5). The lecture immediately
prior to the session had taught participants how to deal
with malrotation, weak labor, and fetal dysfunction.
After the session, our instructors repeatedly raised
problems and provided feedback, enabling participants
to understand the content and leaving them with thefeeling of “being there”. The medical staff, whose role
was to push the baby model from above the simulator inline with the suction side, found it quite challenging tomatch the amount of force and timing; this had takenmuch practice the day before. Subtitles reported key
details regarding the patient and procedure, and thesession ended with everyone working together todeliver the baby successfully.
We evaluated the impact on participants andinstructors. A total of 33 participants, comprising earlytrainee doctors and medical students, answered thequestionnaire, and three-quarters were women. Most
respondents were satisfied with the content and felt thedifficulty level was appropriate. The majority also
regarded 80 min as rather long for a learning experience. Many respondents said they would like to participate in future seminars like this, both locally andonline. However, the online seminars would have been

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Fig. 5

Video streamed from headquarters on the day of simulation education.

more effective held in other prefectures. We received
positive responses in the free writing section — forexample, students felt motivated and enjoyed getting toknow the atmosphere of each university’s medical officethrough the scenes conveyed by Zoom; it was hands-on
and effortless to understand — and we were glad we could
produce some output. Fifteen preceptors responded
that the event schedule and recruitment period wereappropriate, and that the content, difficulty level, andduration were also appropriate.
All participants answered that they would like tocontinue attending future Plus One seminars, and mostof them had positive opinions regarding the practicalcontent of this seminar, making this first attempt a success (Fig. 6). The video created by recording the entire
process was also used for face-to-face and asynchronous online classes commencing in November 2021.

Discussion
Our department jointly developed a perinatal wholebody management simulator with a company specializing in medical mannequins. The simulator was made to
be as realistic as possible, and the scenario included
rotation during delivery, pelvic examination findings,
and changes in maternal vital signs. New features
included the ability to realistically observe the inside of
the vagina and external cervix and a device that allowed
for administering fluids from an intravenous drip after
securing an intravenous route.
This novel simulator had been introduced into theteaching environment in January, 2020, and training
was conducted based on situations that young doctors
are likely to encounter while on duty, such as obstetricemergencies and ultrasound diagnoses. Simulation
education can be expanded to other areas. In ultrasonography, while transabdominal ultrasound was used
to guide Focused Assessment with Sonography inTrauma, assuming intra-abdominal bleeding due toectopic pregnancy rupture, transvaginal ultrasound canalso be simulated. Practicing internal examinations,
CUS examinations, and cytological examinations
repeatedly in a more realistic manner is now possible.
Furthermore, the range of instruction will be expanded,such as the perineal suture model and intravaginal techniques for shoulder dystocia. Questionnaires conducted
before and after the training revealed that the simulation education gave students the abilities “to explain therole of an obstetrician and gynecologist in delivery,” “toexplain emergency obstetrics and gynecology,” and “touse specific methods and useful responses in teambased medical care.” The number of respondents who
found the new simulator applicable for practiceincreased (Fig. 7), confirming that the introduction of
the new simulator was practical.
Of course, within the month, all simulator-based
education, including face-to-face classes, and grouplearning became impossible. All aspects of medical andsurgical education were severely impacted by the pandemic. Shortages of personal protective equipment,
suspension of clinical clerkships, and reduction in elective surgical cases unavoidably affected education [6 , 7].

Remote-Access ObGyn Simulator Education

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3

sa
tis
4
fa
ct
io
n
5

di
ss
at
is
fa
ct
io
n

2

1

Level of satisfaction

Diﬃculty

easy 1

2

3

4

319

Time

diﬃcult
5

short 12

3

4long 5

4long 5

I would like to participate in any way possible
If the event is held in another prefecture, I would liketo participate if it is held online.
I would like to participate if it is held in myprefecture.

If the event is held in another prefecture, I would liketo participate in the local event as well.

I donʼt want to participate

5

4

2

io

easy 1

3

4

Time

diﬃcult
5

short 1

2

3

sa

tis

fa

ct

ct
fa
is
at

Diﬃculty

di

ss

n

2

3

io

n

1

Level of satisfaction

Fig. 6

Post-seminar questionnaire.

Educational activities had to be redesigned on very
short notice. Online classes soon started [8 , 9]; however, OJT, which is practical training, including training in obstetrics and gynecology, was still needed.
There followed a period of alternative implementationof so-called off-the-job training (Off-JT), typicallyclassroom lectures. As reported by the Ministry of
Education, Culture, Sports, Science, and Technology,
while this format is effective for individual learning, it
is disadvantageous for team or group learning.

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Fig. 7
Survey results before and after training with the introduction of the new simulator: Responses from 217 5th and 6th year medical
students.

Disadvantages of online classes, such as less interaction, that is, asking questions, also became apparent,
as well as the fact that content is more difficult to grasp
remotely than in face-to-face classes [10 , 11]. By combining OJT and Off-JT while using a perinatal wholebody management/delivery simulator, remote simulation education with a sense of realism could be
developed. ICT could be used effectively to implement
remote-delivery simulation education in a multicentersetting with a sense of realism even when face-to-facesessions were impossible.
Since the COVID-19 pandemic, educational pro-grams are increasingly moving online, and there is aneed to share examples of multi-disciplinary collaborative education that is flexible and can be repurposed andrealized according to the circumstances of each facility.
In this study, we focused on high-flexibility educationthat is delivered remotely while trying to maintaining a
sense of realism and direct participation. In the development of the simulator itself, we received full support
from the company and cooperation from an external
video company. And, because the simulator we used
was jointly developed between the company and ourschool, it is permanently leased to us free of charge. We

Remote-Access ObGyn Simulator Education

August 2024

also received the company’s full cooperation in the
preparations, and the video company was able to shoot,edit, and air the film on the day for a price of 1 million
yen, which was a great advantage for us in terms ofmanagement. The pre-recording took about 6 h, andthe preparation the day before took about half aday; overall, we believe the results were both cost- andtime-effective.
As a result, a hybrid-flexible educational module
was devised (Fig. 8). To conduct two-way communication while streaming the teacher’s video and audio in
real-time, careful decision-making with the moderator
was necessary regarding the timing of switching over to
VOD. On the day of the event, there was no time lagfor remote participants. We have now established a system that provides highly flexible education by fully
utilizing ICT and simulators, allowing us to be highly
adaptable in case of infectious disease epidemics andsituations that make face-to-face education impossible,
such as natural disasters. As simulator education is a
helpful tool, it could expand educational activities in
the future.
In the participant survey, many participants answeredthat the program duration was rather long. There were
five questions this time, and one to three minutes wereallocated for writing in the chat function. The majorityof respondents answered that the difficulty level was justright or slightly difficult, and the majority expressedthat the seminar took a long time because the required
writing took up a considerable amount of time. We
agreed that it was necessary to consider shortening the
scenario.
Simultaneous education via remote access also provides an opportunity to deepen horizontal connections

Fig. 8321

among obstetricians and gynecologists responsible for
local medical care in regional cities. In addition to
recruiting medical students and residents at each facility
and university, this initiative connecting the nine prefectures of Chugoku and Shikoku has the potential tocontribute to an increase in the number of obstetricians
and gynecologists in this region.
Finally, nationwide expansion of our program, andexpansion of remote simulation education into othermedical fields is possible. Even in the post-COVID era,
remote and asynchronous methods of providing
instruction and feedback through digital platforms havebeen effectively employed in the creation of a network ofongoing simulation-based training [12 , 13]. This styleof education has become very popular in the laparoscopy education field [14 , 15]. We believe that remoteaccess simulator education can be applied in all fields.
In the field of laparoscopic surgery training, attempts
have already been made to perform simultaneous training remotely. In other surgical fields, such as the fieldof surgical techniques, which requires the preparationof relatively large-scale simulators and educational
materials, it is possible to practice using the environment at each site and connecting other learners using
ICT technology, eliminating the need to prepare a simulator at each site. The system could thus prove highly
beneficial in terms of reducing the effort involved inmoving human resources from site to site. Moreover,equal educational opportunities can be created regardless of location.
As far as we know, this is the first report of aremote-access vaginal delivery learning module A survey of the participants’ subsequent career paths revealed
that 19 of the 23 participants, still in early training at

Practicing high-ﬂexibility education using ICT and simulators.

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the time of participation, became obstetricians andgynecologists and worked primarily at the 10 university-affiliated hospitals. We were pleased to hear that thestudents were encouraged by the training.
Our study contains the following limitation. It
focuses on reporting the benefits of remote practice andis unable to compare and examine the effects of educational activities before and after the coronavirus pandemic, excluding remote practice. It is difficult toassess whether this simulation education is superior to
the educational methods used before the coronavirus
pandemic in terms of participants’ understanding,skills, and motivation. However, when participants
were asked in a post-survey, “Would you like to participate in a seminar like this in the future?,” the mostcommon response was, “I would like to participate
either face-to-face or remotely.” This certainly shows apositive educational effect.
In conclusion, we designed a remote-access educational simulation program as a response to the special
conditions of the coronavirus pandemic and propose its
usefulness for high-flexibility education post-pandemic.
At the 10 universities in the Chugoku–Shikoku region,
we implemented multicenter, simultaneous remoteaccess simulation education that maximized the sense ofrealism even when face-to-face meetings were impossible, and confirmed the value of this learning to students. This study has the potential to promote the connection of students with appropriate preceptors andrecruitment. We believe our construction of ahigh-flexibility education system using remote simulation in obstetrics and gynecology, especially in theperinatal field (a vaginal delivery module), is unique,original, and sustainable.
Acknowledgments. We thank Kyoto Kagaku Co., Ltd. for the joint
development of a perinatal whole-body management simulator.

3.

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14.

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