Andrew J. Satin

Improving resident competency in the management of shoulder dystocia with simulation training

OBJECTIVE: To determine whether a simulation training scenario improves resident competency in the management of shoulder dystocia. METHODS: Residents from 2 training programs participated in this study. The residents were block-randomized by year-group to a training session on shoulder dystocia management that used an obstetric birthing simulator or to a control group with no specific training. Trained residents and control subjects were subsequently tested on a standardized shoulder dystocia scenario, and the encounters were digitally recorded. A physician grader from an external institution then graded and rated the residents performance with a standardized evaluation sheet. Statistical analysis included the Student t test, χ2, and regression analysis, as appropriate. RESULTS: Trained residents had significantly higher scores in all evaluation categories, including timelines of their interventions, performance of maneuvers, and overall performance. They also performed the delivery in a shorter time than control subjects (61 versus 146 seconds, P = .003). CONCLUSION: Training with a simulation-training scenario improved resident performance in the management of shoulder dystocia. LEVEL OF EVIDENCE: I

Maternal youth and pregnancy outcomes: Middle school versus high school age groups compared with women beyond the teen years

OBJECTIVE We sought to measure and compare pregnancy complications in middle school versus high school versus older maternal age groups. STUDY DESIGN From January 1988 through December 31, 1991, maternal and infant data from 16,512 consecutive nulliparous women were collected and electronically stored. These women were divided into three study groups: middle school (11 to 15 years old), high school (16 to 19 years old), and women 20 to 22 years old at delivery. Statistical analysis included logistic regression to control for potentially confounding demographic variables. RESULTS Middle school-aged mothers were disproportionately black (50% vs 36% Hispanic vs 14% white), and very low birth weight (4% vs. 2%, p = 0.003) was increased in these youthful mothers. First births to high school-aged mothers were not found to be compromised compared with those of women 20 to 22 years old, and, indeed, cesarean birth was less frequent in these women compared with those > or = 20 years old. CONCLUSIONS We conclude that the health hazard associated with school-age pregnancy is predominantly prematurity and is increased only in middle school-aged mothers. High school-aged mothers do not experience excess medical complications of pregnancy compared with older women. We suggest that middle school pregnancy, particularly for inner-city teenagers, should be a special focus for pregnancy prevention and intervention.

Simulation laboratories for training in obstetrics and gynecology

Simulations have been used by the military, airline industry, and our colleagues in other medical specialties to educate, evaluate, and prepare for rare but life-threatening scenarios. Work hour limits for residents in obstetrics and gynecology and decreased patient availability for teaching of students and residents require us to think creatively and practically on how to optimize their education. Medical simulations may address scenarios in clinical practice that are considered important to know or understand. Simulations can take many forms, including computer programs, models or mannequins, virtual reality data immersion caves, and a combination of formats. The purpose of this commentary is to call attention to a potential role for medical simulation in obstetrics and gynecology. We briefly describe an example of how simulation may be incorporated into obstetric and gynecologic residency training. It is our contention that educators in obstetrics and gynecology should be aware of the potential for simulation in education. We hope this commentary will stimulate interest in the field, lead to validation studies, and improve training in and the practice of obstetrics and gynecology.

Exercise During Pregnancy Fetal Responses to Current Public Health Guidelines

OBJECTIVE: To evaluate acute fetal responses to individually prescribed exercise according to existing guidelines (U.S. Department of Health and Human Services) in active and inactive pregnant women. METHODS: Forty-five healthy pregnant women (15 nonexercisers, 15 regularly active, 15 highly active) were tested between 28 0/7 and 32 6/7 weeks of gestation. After a treadmill test to volitional fatigue, target heart rates were calculated for two subsequent 30-minute treadmill sessions: 1) moderate intensity (40–59% heart rate reserve); and 2) vigorous intensity (60–84%). All women performed the moderate test; only active women performed the vigorous test. Fetal well-being measures included umbilical artery Dopplers, fetal heart tracing and rate, and biophysical profile. Measures were obtained at rest and immediately postexercise. RESULTS: Groups were similar in age, body mass index, and gestational age. Maternal resting heart rate in the highly active group (61.6±7.2 beats per minute [bpm]) was significantly lower than the nonexercise (79.0±11.6 bpm) and regularly active (71.9±7.4 bpm) groups (P<.001). Treadmill time was longer in highly active (22.3±2.9 minutes) than regularly active (16.6±3.4) and nonexercise (12.1±3.6) groups (P<.001), reflecting higher fitness. With moderate exercise, all umbilical artery Doppler indices were similar pre-exercise and postexercise among groups. With vigorous exercise, Dopplers were similar in regularly and highly active women with statistically significant decreases postexercise (P<.05). The group×time interaction was not significant. Postexercise fetal heart tracings met criteria for reactivity within 20 minutes after all tests. Biophysical profile scores were reassuring. CONCLUSION: This study supports existing guidelines indicating pregnant women may begin or maintain an exercise program at moderate (inactive) or vigorous (active) intensities. LEVEL OF EVIDENCE: II

A comparison of shoulder dystocia-associated transient and permanent brachial plexus palsies ☆

OBJECTIVE To estimate differences between shoulder dystocia-associated transient and permanent brachial plexus palsies. METHODS We performed a retrospective case-control analysis from national birth injury and shoulder dystocia databases. Study patients had permanent brachial plexus palsy and had been entered into a national birth injury registry. Cases of Erb or Klumpke palsy with documented neonatal neuromuscular deficits persisting beyond at least 1 year of life were classified as permanent. Cases of transient brachial plexus palsy were obtained from a shoulder dystocia database. Non-shoulder dystocia–related cases of brachial plexus palsy were excluded from analysis. Cases of permanent brachial plexus palsy (n = 49) were matched 1:1 with cases of transient brachial plexus palsy. RESULTS Transient brachial plexus palsy cases had a higher incidence of diabetes mellitus than those with permanent brachial plexus palsy (34.7% versus 10.2%, odds ratio [OR] 4.68, 95% confidence interval [CI] 1.42, 16.32). Patients with permanent brachial plexus palsies had a higher mean birth weight (4519 ± 94.3 g versus 4143.6 ± 56.5 g, P < .001) and a greater frequency of birth weight greater than 4500 grams (38.8% versus 16.3%, OR, 0.31, 95% CI 0.11, 0.87). There were, however, no statistically significant differences between the two groups with respect to multiple antepartum, intrapartum, and delivery outcome measures. CONCLUSION Transient and permanent brachial plexus palsies are not associated with significant differences for most antepartum and intrapartum characteristics.

Evaluation of residents' delivery notes after a simulated shoulder dystocia

OBJECTIVE: To describe and analyze delivery notes after a shoulder dystocia drill with a birthing simulator METHODS: A total of 33 residents from 2 university training programs underwent testing on a standardized shoulder dystocia scenario with an obstetric birthing simulator. After the completion of the delivery, each resident was informed of the infants Apgar scores and birth weight and told that the infant was moving all extremities. The resident was then given a blank progress note and asked to write a delivery note. The notes were evaluated for 15 key components. RESULTS: Seventy-six percent (n = 25) of residents recorded less than 10 of 15 key components of a delivery note after a shoulder dystocia. The majority of residents (91%, 30/33) included the correct order of the maneuvers used during the delivery, but most did not note which shoulder was anterior (18%, 6/33) or how long the head-to-body interval was during delivery (45%, 15/33). CONCLUSION: Residents’ delivery notes after a shoulder dystocia simulation often lacked critical elements. Training in documentation is needed in residency training. The addition of the delivery note and feedback regarding the note represents a simple innovation in this teaching scenario that may help identify deficiencies in documentation. LEVEL OF EVIDENCE: III

Physical and sexual abuse in a middle-class obstetric population.

To evaluate the prevalence of a history of physical and sexual abuse in pregnant, economically stable, middle-class women with access to comprehensive health care, we issued self-report questionnaires to prenatal orientation classes at Wilford Hall Medical Center from October 19,1992, to March 15,1993. After identifying women who had been physically or sexually abused, we identified the assailant, the number of occurrences, and injuries resulting from the abuse. Of the 563 women who responded, 100 (18%) reported previous physical or sexual abuse. Seven women (1%) stated that they were physically abused during the pregnancy. Women were more likely to be physically than sexually abused by a spouse or lover (46% versus 13%). To identify women who have a history of abuse and to address their needs, practitioners should incorporate taking a history of physical and sexual abuse during the routine new obstetric visit.

Factors affecting the dose response to oxytocin for labor stimulation

For nearly 40 years synthetic oxytocin has been used for labor stimulation by titrating dosage rate to uterine contractions. We used a computerized data base to determine variables affecting the dose response to oxytocin in 1773 pregnancies. Statistically important predictors of required oxytocin dosage included cervical dilatation, parity, and gestational age. Maternal body surface area was found to be associated with a higher oxytocin dosage in women undergoing induction of labor. However, the broad range of the statistical confidence intervals precluded prediction of a given pregnancys oxytocin requirement.

A prospective study of two dosing regimens of oxytocin for the induction of labor in patients with unfavorable cervices

The ideal regimen for induction of labor with oxytocin with respect to the magnitude and frequency of dosage changes has not been defined. In spite of few data regarding labor induction with an unfavorable cervix, the initial dose recommended by the American College of Obstetricians and Gynecologists is lower than that of other commonly used protocols. Eighty patients with unfavorable cervices and unruptured membranes, without evidence of labor, were randomized to one of two protocols and met criteria for data analysis. Patients in both protocols were given an initial dose of oxytocin of 2 mU/min. Patients in protocol A (n = 32) then received incremental increases of oxytocin of 1 mU/min at 30-minute intervals, while those in protocol B (n = 48) received incremental increases of 2 mU/min at 15-minute intervals. Induction failures were higher among patients on protocol A (31% vs 8%, p less than 0.05). Patients on protocol B had shorter times to delivery (mean = 10 hours 57 minutes vs 8 hours 3 minutes; p less than 0.05). The number of operative deliveries were similar regardless of protocol. There were no significant differences (p = NS) among groups and protocols in maternal and fetal complications, cesarean section rate, and uterine hyperstimulation. In this population a more aggressive protocol may lead to fewer induction failures and shorter induction-to-delivery intervals.

Hand-held computer operating system program for collection of resident experience data.

Objective: To describe a system for recording resident experience involving hand-held computers with the Palm Operating System (3 Com, Inc., Santa Clara, CA). Program Description: Hand-held personal computers (PCs) are popular, easy to use, inexpensive, portable, and can share data among other operating systems. Residents in our program carry individual hand-held database computers to record Residency Review Committee (RRC) reportable patient encounters. Each residents data is transferred to a single central relational database compatible with Microsoft Access (Microsoft Corporation, Redmond, WA). Patient data entry and subsequent transfer to a central database is accomplished with commercially available software that requires minimal computer expertise to implement and maintain. The central database can then be used for statistical analysis or to create required RRC resident experience reports. As a result, the data collection and transfer process takes less time for residents and program director alike, than paper-based or central computer–based systems. Conclusion: The system of collecting resident encounter data using hand-held computers with the Palm Operating System is easy to use, relatively inexpensive, accurate, and secure. The user-friendly system provides prompt, complete, and accurate data, enhancing the education of residents while facilitating the job of the program director.