Évaluation de la formation des internes de gynécologie obstétrique sur simulateur d’accouchement

Analysis of the obstetrician's posture and movements during a simulated forceps delivery

BACKGROUND

The objective of this study was to identify and qualify, by means of a three-dimensional kinematic analysis, the postures and movements of obstetricians during a simulated forceps birth, and then to study the association of the obstetricians' experience with the technique adopted.

METHOD

Fifty-seven volunteer obstetricians, 20 from the Limoges and 37 from the Poitiers University hospitals, were included in this multi-centric study. They were classified into 3 groups: beginners, intermediates, and experts, beginners having performed fewer than 10 forceps deliveries in real conditions, intermediates between 10 and 100, and experts more than 100. The posture and movements of the obstetricians were recorded between December 2020 and March 2021 using an optoelectronic motion capture system during simulated forceps births. Joint angles qualifying these postures and movements were analysed between the three phases of the foetal traction. These phases were defined by the passage of a virtual point associated with the forceps blade through two anatomical planes: the mid-pelvis and the pelvic outlet. Then, a consolidated ascending hierarchical classification (AHC) was applied to these data in order to objectify the existence of groups of similar behaviours.

RESULTS

The AHC distinguished four different postures adopted when crossing the first plane and three different traction techniques. 48% of the beginners adopted one of the two raised posture, 22% being raised without trunk flexion and 26% raised with trunk flexion. Conversely, 58% of the experts positioned themselves in a "chevalier servant" posture (going down on one knee) and 25% in a "squatting" posture before initiating traction. The results also show that the joint movement amplitude tends to reduce with the level of expertise.

CONCLUSION

Forceps delivery was performed in different ways, with the experienced obstetricians favouring postures that enabled observation at the level of the maternal perineum and techniques reducing movement amplitude. The first perspective of this work is to relate these different techniques to the traction force generated. The results of these studies have the potential to contribute to the training of obstetricians in forceps delivery, and to improve the safety of women and newborns.

Evaluation of Suzor forceps training by studying obstetric anal sphincter injuries: a retrospective study

BACKGROUND

Instrumental deliveries are an unavoidable part of obstetric practice. Dedicated training is needed for each instrument. To identify when a trainee resident can be entrusted with instrumental deliveries by Suzor forceps by studying obstetric anal sphincter injuries.

METHODS

A French retrospective observational study of obstetric anal sphincter injuries due to Suzor forceps deliveries performed by trainee residents was conducted from November 2008 to November 2016 at Limoges University Hospital. Perineal lesion risk factors were studied. Sequential use of a vacuum extractor and then forceps was also analyzed.

RESULTS

Twenty-one residents performed 1530 instrumental deliveries, which included 1164 (76.1%) using forceps and 89 (5.8%) with sequential use of a vacuum extractor and then forceps. Third and fourth degree perineal tears were diagnosed in 82 patients (6.5%). Residents caused fewer obstetric anal sphincter injuries after 23.82 (+/- 0.8) deliveries by forceps (p = 0.0041), or after 2.36 (+/- 0.7) semesters of obstetrical experience (p = 0.0007). No obese patient (body mass index> 30) presented obstetric anal sphincter injuries (p = 0.0013). There were significantly fewer obstetric anal sphincter injuries after performance of episiotomy (p <  0.0001), and more lesions in the case of the occipito-sacral position (p = 0.028). Analysis of sequential instrumentation did not find any additional associated risk.

CONCLUSION

Training in the use of Suzor forceps requires extended mentoring in order to reduce obstetric anal sphincter injuries. A stable level of competence was found after the execution of at least 24 forceps deliveries or after 3 semesters (18 months) of obstetrical experience.

Guidelines for minimal report in gynaecologic sonography: Are they useful for emergency department resident physicians?

OBJECTIVES

This study aimed to evaluate the impact of Collège National des Gynécologues et Obstétriciens Français (CNGOF) guidelines on the minimal sonographic reports generated by emergency department resident physicians.

MATERIAL AND METHODS

This prospective observational study was conducted in the gynaecologic emergency unit of a teaching hospital from November 2016 to May 2017. We analysed sonographic reports generated by residents during gynaecological emergencies before and after training on the minimal report standards. An analysis of the evaluated items was carried out. We also compared residents according to their specialities and seniority.

RESULTS

A total of 240 reports were analysed, 120 before and 120 after the training. Half of the reports concerned women with an early pregnancy while the others concerned women with negative hCG. All residents significantly improved their practice after the training, as shown by the increase in ratings of the evaluated items (38 % before training vs 44.8 % after, p < 0.01). General practitioners had greater improvement (48.1 % of evaluated items), whereas older residents reported fewer items before or after the training (43.5 %) than younger residents. Finally, all residents improved their practice with a conclusion that followed the guidelines in 92.5 % of cases (versus 68.3 % before the training; p < 0.01).

CONCLUSION

Training on the CNGOF minimal sonographic report guidelines significantly improved the emergency sonographic reports generated by residents. Wider dissemination of this training, particularly to young residents, would probably improve the quality of sonographic reports performed at gynaecological emergencies.

Complete 3 dimensional reconstruction of parturient pelvic floor

INTRODUCTION

The women pelvic floor is a complex system, which seems to endure several modifications during pregnancy and childbirth. Our primary purpose was to build an extensive 3 dimensional (3D) numerical anatomical model of the women pelvic floor.

METHODS

First, the role and the location of each organ, muscle, or ligament, were identified through an extensive literature review. Then, different entities were selected because of their visibility and importance in the pelvic floor. Each entity was identified using anatomical knowledge, and outlined on 2 dimensional (2D) MRI images, that were carried out on 4 pregnant women, using sequences T1, T2 and proton density weighted, through AVIZO program. The overlay of these 2D outlines produced a 3D geometrical reconstruction, which was then reworked with the program CATIA to obtain a usable geometric model.

RESULTS

We identified and integrated 15 anatomical structures to the geometrical model, including organs, ligament and muscles from the pelvis and perineum. This geometrical model allowed us to obtain a visual interactive representation with 3D images. These different steps resulted in the creation of a complete numerical model of the female pelvic floor, which might be used in Finite Element simulation.

CONCLUSION

A new complete and accurate 3D numerical anatomical model of the women pelvic floor was elaborated. It presents simultaneously analytical prospects, through the observation of the strains and deformations that are imposed on the different structures, and educational prospects, through the detailed visual representation of several situations.

Operator experience affects the risk of obstetric anal sphincter injury in vacuum extraction deliveries

INTRODUCTION

Delivery by vacuum extraction is a major risk factor for obstetric anal sphincter injury. The aim of this study was to assess risk factors for obstetric anal sphincter injury in vacuum extraction in nulliparous women, specifically operator-related factors. A secondary aim was to assess other complications of vacuum extraction that are dependent on operator experience.

MATERIAL AND METHODS

A historical cohort study of nulliparous women with a live single fetus ≥34 weeks, delivered by vacuum extraction at a teaching hospital in Sweden in 1 year (2013), using data from medical records. Risk of obstetric anal sphincter injury was assessed for obstetricians (reference), gynecologists, and residents, and adjusted for maternal, fetal, procedure-related, and operator-related covariates using unconditional logistic regression. Results are presented as prevalence and crude and adjusted odds ratio (aOR) with 95% CI.

RESULTS

In total, 323 nulliparous women delivered by vacuum extraction were included. Obstetric anal sphincter injury occurred in 57 (17.6%) women. Fifteen (11.5%) obstetric anal sphincter injuries occurred in vacuum extractions performed by obstetricians, 10 (13.5%) by gynecologists (aOR 1.84, 95% CI 0.72-4.70), and 32 (26.9%) by residents (aOR 5.13, 95% CI 2.20-11.95). Maternal height ≤155 cm (aOR 4.63, 95% CI 1.35-15.9) and conversion to forceps (aOR 19.4, 95% CI 1.50-252) increased the risk of obstetric anal sphincter injury. Operator gender, night shift work, or being a frequent operator did not affect the risk of obstetric anal sphincter injury. Postpartum hemorrhage and fetal complications did not differ between operator categories.

CONCLUSIONS

The adjusted risk of obstetric anal sphincter injury in nulliparous women was five times higher in vacuum extractions performed by residents compared with those performed by obstetricians. Vacuum extractions performed by gynecologists did not carry an increased risk of obstetric anal sphincter injury. Experience in years of training, rather than frequency of the procedure, seemed to have the highest impact on reducing obstetric anal sphincter injury in vacuum extractions, which indicates a need for increased training and supervision.

[French residents' training in instrumental deliveries: A national survey]

OBJECTIVES

To evaluate French residents in Obstetrics and Gynaecology's training in instrumental deliveries in 2015.

PATIENTS AND METHODS

We conducted a national descriptive survey among 758 residents between December 2014 and January 2015. Respondents were invited by email to specify their University Hospital, their current university term, the number of instrumental deliveries performed by vacuum extractor, forceps or spatulas, and whether they made systematic ultrasound exams before performing the extraction.

RESULTS

Response rate was 34.7 % (n=263). There were important differences between regions in terms of type of instruments used. Vacuum extractor was the most commonly used instrument for instrumental deliveries by French residents (56.9 %), more than forceps (25.2 %) and spatulas (17.9 %). At the end of the residency, all the residents had been trained in instrumental deliveries with at least two instruments.

CONCLUSION

The training of difficult techniques as well as their perfect control is required for instrumental deliveries. Yet, we are forced to note that there are substantial differences in the French residents' training in instrumental deliveries depending on their region. So, teaching at least two techniques seems essential as well as improving the training capacities and standardizing practices. A greater systematization of the teaching of the mechanics and obstetric techniques might be a solution to be considered too.

[Assessment of shoulder dystocia related knowledge among French obstetrics and gynecology residents]

OBJECTIVE

To study the related knowledge of French residents in obstetrics concerning maneuvers for shoulder dystocia (SD).

MATERIALS AND METHODS

Multicenter descriptive transversal study conducted from June to September 2014. Data collection was performed through questionnaires sent by email to French resident in obstetrics.

RESULTS

Among the 1080 questionnaires sent, 366 responses were obtained with a response rate of 33.9%. One hundred and forty-three residents (39.1%) were in the first part of their training (≤5th semester) and 60.9% (n=223) were in the second part of their training. Theoretical training on the SD was provided to 88.2% of resident (n=323). In total, 38.8% (n=142) obtained their French degree in mechanical and technical obstetric and among them 77.5% (n=110) had the opportunity to train on simulators and dummies. Concerning their practical experiences, 31.5% (n=45) residents ≤5th semester reported having experienced SD during their residency vs 58.3% (n=130) amongst oldest residents (P<0.001). In the second part of residency, 40% of residents (n=89) expressed to feel able to manage shoulder dystocia. Only 19.1% (n=70) were satisfied with their residency training program vs 39.1% (n=143) who were unsatisfied.

CONCLUSION

Our study showed that less than one resident out of two (40%) felt able to perform maneuvers for SD in the second part of residency. We think that simulation activities should be mandatory for residency training programs in Obstetrics and Gynecology, which have to develop dependable measures to assess resident competencies to execute practical maneuvers for clinical emergencies in obstetrics.