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Kirstine Hansen L, Shennan AH, Louise Eisland-Schmidt Christiansen E, Tydeman G, Stirrat L, Bek Helmig R, Uldbjerg N, Glavind J. Transvaginal cervical cerclage - How well do surgeons assess their own procedures? Eur J Obstet Gynecol Reprod Biol 2024; 302:268-272. [PMID: 39340895 DOI: 10.1016/j.ejogrb.2024.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2024] [Revised: 09/20/2024] [Accepted: 09/23/2024] [Indexed: 09/30/2024]
Abstract
INTRODUCTION In women with cervical incompetence, transvaginal cerclage may help prevent preterm birth. However, training for this procedure poses challenges due to the low number of cases and difficulties in visualizing the operative field. Furthermore, the objective criteria for a successful cerclage procedure are not well-described. Quality assessment relies heavily on self-assessment rather than objective criteria and feedback. To address this issue, training on a simulator may offer a solution. We aimed to objectively assess surgical performance and compare it to the self-assessed performance in transvaginal cerclage procedures. MATERIALS AND METHODS During the Nordic Federation of Obstetrics and Gynecology (NFOG) congress in 2023, surgeons proficient in transvaginal cerclage procedures performed a transvaginal cerclage on a simulator. To compare the observed and self-assessed outcomes we obtained measurements on the cerclage height and number of bites from the detachable cervix, and from computed tomography scans we analyzed suture bite depth, reduction of cervix surface area, and whether cerclages had perforated the cervical canal. The same outcomes were self-assessed by each participant after the cerclage procedure. We visualized the continuous paired data in a Bland-Altman plot and compared these data with a paired t-test. Paired binary data was analyzed using McNemars test. RESULTS 29 participants from eight different nationalities performed one transvaginal cerclage each. The mean height of the cerclage was 26.8 mm (SD 9 mm) and mean depth was 6.5 mm (SD 1.9 mm) across a mean of 4.1 (SD 0.8) bites. The mean reduction of the cervix surface area was 7.6 % (SD 5.9 %). Two sutures perforated the cervical canal. The participants significantly underestimated the height of their cerclage with a mean difference of 6.0 mm (95 % CI 2.1-9.9), (p 0.002), between the observed and the self-assessed height, but otherwise revealed good self-assessment of their performed procedure. CONCLUSIONS Overall, the experienced cerclage surgeons showed a genuine insight into their surgical performance of a transvaginal cerclage. These results could warrant development of a procedural guidelines with objective measures, now reassured that surgeons are capable of self-assessing their procedures.
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Affiliation(s)
- Lea Kirstine Hansen
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.
| | - Andrew H Shennan
- Department of Women and Children's Health, St Thomas' Hospital, King's College London, London, United Kingdom.
| | | | - Graham Tydeman
- Department of Obstetrics and Gynecology, NHS Fife, Kirkcaldy, United Kingdom
| | - Laura Stirrat
- Department of Obstetrics and Gynecology, Royal Infirmary of Edinburgh, United Kingdom.
| | - Rikke Bek Helmig
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.
| | - Niels Uldbjerg
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.
| | - Julie Glavind
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.
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Hall M, Suff N, Stirrat L, Coary C, Abernethy J, Debray R, Tydeman G, Shennan A. Cervical cerclage training: Development and assessment of a simulator. Am J Obstet Gynecol MFM 2023; 5:100853. [PMID: 36587806 DOI: 10.1016/j.ajogmf.2022.100853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/25/2022] [Accepted: 12/26/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Cervical cerclage is a mainstay intervention for the prevention of spontaneous preterm birth in high-risk women. Simulation training facilitates high-level skill transfer in a low-consequence environment, and is being integrated into obstetrics and gynecology training. OBJECTIVE This study aimed to develop a simulator for cervical cerclage, determine its validity as a simulator, and identify parameters suitable as proxy markers for performance. STUDY DESIGN The 3 aims of this study were achieved, namely: (1) simulator design by obstetricians and a commercial company; (2) survey of obstetricians and gynecologists across a variety of training stages to determine need for and opinion of the simulator; and (3) comparison of novice and expert groups across a variety of proxy markers for successful cerclage insertion. RESULTS Obstetricians and gynecologists found the simulator to be similar to clinical scenarios and suitable for skill training. Novice participants stated that the use of the simulator improved their confidence (P=.016). In a comparison between 6 expert and 8 novice surgeons, there seemed to be variations across multiple measurements of cerclage placement. CONCLUSION Simulation is an increasingly prominent training modality for surgical skills. The simulator described herein was considered suitable for training by obstetricians and gynecologists. Further work should focus on the validations of proxy markers of successful insertion, longitudinal assessment of trainees, and correlation of training outcomes with clinical outcomes.
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Affiliation(s)
- Megan Hall
- Department of Women and Children's Health, St Thomas' Hospital, King's College London, London, United Kingdom (Drs Hall and Suff, Mses Coary, Abernethy, and Debray, and Dr Shennan); Department of Perinatal Imaging and Health, St Thomas' Hospital, King's College London, London, United Kingdom (Dr Hall).
| | - Natalie Suff
- Department of Women and Children's Health, St Thomas' Hospital, King's College London, London, United Kingdom (Drs Hall and Suff, Mses Coary, Abernethy, and Debray, and Dr Shennan)
| | - Laura Stirrat
- Simpson Centre for Reproductive Health, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (Dr Stirrat)
| | - Carrie Coary
- Department of Women and Children's Health, St Thomas' Hospital, King's College London, London, United Kingdom (Drs Hall and Suff, Mses Coary, Abernethy, and Debray, and Dr Shennan)
| | - Jessie Abernethy
- Department of Women and Children's Health, St Thomas' Hospital, King's College London, London, United Kingdom (Drs Hall and Suff, Mses Coary, Abernethy, and Debray, and Dr Shennan)
| | - Raphaelle Debray
- Department of Women and Children's Health, St Thomas' Hospital, King's College London, London, United Kingdom (Drs Hall and Suff, Mses Coary, Abernethy, and Debray, and Dr Shennan)
| | | | - Andrew Shennan
- Department of Women and Children's Health, St Thomas' Hospital, King's College London, London, United Kingdom (Drs Hall and Suff, Mses Coary, Abernethy, and Debray, and Dr Shennan)
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Frenken MWE, Goossens SMTA, Janssen MCR, Mulders LGM, Laar JOEHV. Cervical cerclage for prevention of preterm birth: the results from A 20-year cohort. J OBSTET GYNAECOL 2022; 42:2665-2671. [PMID: 35653798 DOI: 10.1080/01443615.2022.2081792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Cerclages can be used to prevent preterm birth, although their effectiveness and safety is disputed. We aimed to describe obstetric outcomes after cerclage procedures. We included 156 singleton pregnancies and six multiple pregnancies. In singleton pregnancies with history-indicated, short cervix-indicated and emergency cerclages, respectively 84.6, 76.5 and 43.8% resulted in late preterm or term deliveries. In singletons, the following complications were reported: excessive bleeding in one emergency cerclage procedure and three re-cerclage procedures in the history-indicated cerclage group. No perioperative rupture of membranes occurred in singletons. When comparing results of experienced and less-experienced gynaecologists, a remarkably smaller take home child rate was observed for singletons treated by less-experienced gynaecologists: 90.7% and 94.4% for the two experienced gynaecologist as compared to 85.0% for the group of less-experienced gynaecologists. In conclusion, cerclages in singletons result in few cerclage-associated complications and a high take home child rate, when performed by experienced gynaecologists. Impact statementWhat is already known on this subject? Prematurity is the leading cause of perinatal and neonatal mortality and morbidity worldwide. Cervical cerclages can be used to prevent preterm birth, although their effectiveness and safety is disputed.What the results of this study add? In our cohort study, singleton pregnancies with cerclages seem to have satisfactory obstetric outcomes. We found a very low prevalence of cerclage-associated complications in singleton pregnancies, for both history-indicated, short cervix-indicated and emergency cerclages. Additionally, take home child rates in singleton pregnancies were remarkably higher when cerclage procedures were performed by experienced gynaecologists, compared to less experienced gynaecologists.What the implications are of these findings for clinical practice and/or further research? Based on the observed difference in take home child rates, we advise all cerclage procedures to be performed by experienced gynaecologists only. This may mean that women with an indication for cerclage will be referred to a more experienced colleague, either in the same, or in another hospital. To ensure treatment by an experienced gynaecologist, simulation-based training could also provide a solution.
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Affiliation(s)
- Maria W E Frenken
- Department of Obstetrics and Gynaecology, Máxima MC, Veldhoven, The Netherlands.,Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands.,Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, The Netherlands
| | - Simone M T A Goossens
- Department of Obstetrics and Gynaecology, Máxima MC, Veldhoven, The Netherlands.,Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands.,Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, The Netherlands
| | - Minke C R Janssen
- Department of Obstetrics and Gynaecology, Máxima MC, Veldhoven, The Netherlands
| | - Leon G M Mulders
- Department of Obstetrics and Gynaecology, Máxima MC, Veldhoven, The Netherlands
| | - Judith O E H van Laar
- Department of Obstetrics and Gynaecology, Máxima MC, Veldhoven, The Netherlands.,Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands.,Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, The Netherlands
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Whittington JR, Shnaekel KL, Ramseyer AM, Cato M, Ounpraseuth S, Hughes DS, Magann EF. Longitudinal assessment of obstetrics and gynecology resident perceptions and comfort following cerclage placement simulation. J Matern Fetal Neonatal Med 2022; 35:9222-9226. [PMID: 34978240 DOI: 10.1080/14767058.2021.2022646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Utilization of simulation training in medical education has increased over time, particularly for less common scenarios and procedures. Simulation allows trainees to practice in a low-stress environment and eliminates patient risk. Cerclage placement has become less frequent, which limits obstetrics and gynecology (OB/GYN) exposure to cerclage placement during training. This exposes an area of training requiring simulation in OB/GYN resident education. OBJECTIVE To evaluate resident reception to cerclage simulation, their self-reported comfort with and ability to troubleshoot difficult cerclage placement immediately and 12 months following didactic education and simulation. METHODS In 2019, 18/20 (90%) OB/GYN residents in our university program underwent didactic teaching and simulation in cerclage placement using a pelvic model with removable cervix. Residents completed a survey immediately and 12 months following simulation. Wilcoxon signed-rank test was used to analyze resident self-report of comfort with cerclage placement and skill techniques for navigating difficult placement before and after simulation training. Descriptive statistics were analyzed as means and standard deviations. RESULTS Eighteen of twenty (90%) residents participated in the education session in cerclage placement. All 18 (100%) completed a postsimulation survey and 17/18 (94%) completed a survey 12 months later. All reported improved comfort with cerclage placement and statistically significant improvement in knowledge on techniques for troubleshooting difficult placement after simulation. All residents reported that the simulation enhanced their learning and recommended the simulation for future educational opportunities. CONCLUSIONS Cerclage simulation was well-received by OB/GYN residents in learning and practicing cerclage placement. Residents demonstrated improved comfort with placement following simulation.
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Affiliation(s)
- Julie R Whittington
- Department of Obstetrics and Gynecology, Naval Medical Center Portsmouth, Portsmouth, VA, USA.,Uniformed Services University of the Health Sciences, Bethesada, MD, USA
| | - Kelsey L Shnaekel
- Departments of Obstetrics and Gynecology, College of Medicine, University of A rkansas for Medical Sciences, Little Rock, AR, USA
| | - Abigail M Ramseyer
- Departments of Obstetrics and Gynecology, College of Medicine, University of A rkansas for Medical Sciences, Little Rock, AR, USA
| | - Mattison Cato
- Department of Family and Preventative Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Songthip Ounpraseuth
- Departments of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Dawn S Hughes
- Departments of Obstetrics and Gynecology, College of Medicine, University of A rkansas for Medical Sciences, Little Rock, AR, USA
| | - Everett F Magann
- Departments of Obstetrics and Gynecology, College of Medicine, University of A rkansas for Medical Sciences, Little Rock, AR, USA
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Delgado A, Cleberg R, Gimovsky AC. A Novel Transvaginal Cervical Cerclage Model for Resident Training. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2021; 17:11102. [PMID: 33768142 PMCID: PMC7970640 DOI: 10.15766/mep_2374-8265.11102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 11/14/2020] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Vaginal suturing can be challenging to teach and learn due to the surgical assistant's limited operative field visualization. Data on resident training and comfort with cerclage placement using models are limited. The aim of this activity was to assess learner satisfaction with practice using a novel model allowing for full visualization during transvaginal cervical cerclage placement. METHODS OB/GYN residents participated in a 1-hour combined lecture and hands-on cerclage training simulation with the novel model. Pre- and postsession survey responses were assessed with descriptive statistics and paired t tests. RESULTS Twenty residents with a median of 2 (SD = 1.6) years of residency experience participated. Ninety-five percent reported no prior cerclage simulation training; 60% reported placing cerclages in practice. Pre- and posttest analysis indicated a significant decrease in perceived need for further training (M = 4.05, SD = 1.07, vs. M = 3.45, SD = 0.86; p = .024) and an increase in comfort performing a cerclage placement (M = 2.55, SD = 1.16, vs. M = 3.85, SD = 0.79; p < .001). After the simulation, residents reported more comfort in cerclage placement with decreasing supervision (M = 2.05, SD = 1.02, vs. M = 2.30, SD = 1.01; p = .021); 90% reported that learning to place a cerclage was easy. DISCUSSION Implementing a novel, low-cost model allowing full operative field visualization significantly improved reported comfort regarding cervical cerclage placement and resulted in high satisfaction amongst residents. Future research should evaluate the training's impact on clinical skills.
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Affiliation(s)
- Arlin Delgado
- Obstetrics and Gynecology Resident, Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine
| | | | - Alexis C. Gimovsky
- Assistant Professor, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Women & Infants Hospital, Warren Alpert Medical School of Brown University
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El-Chaar D, Manley J, LeBouthillier F, Ryan G, Windrim R. Development of a High-Fidelity Simulator for Teaching Chorionic Villus Sampling. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:1178-1181. [PMID: 30030058 DOI: 10.1016/j.jogc.2017.10.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 10/16/2017] [Accepted: 10/20/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The objective of this study was to develop a synthetic high-fidelity simulator for teaching chorionic villus sampling. METHODS Working with a medical sculptor, the authors developed a simulator, constructed from various synthetic rubber materials, of a gravid female pelvis, including the vulva, vagina, cervix, and a 13-week-sized uterus with a gestational sac. RESULTS This simulator is high fidelity and durable, and it does not require any organic materials. Maternal-fetal medicine trainees valued this educational tool. CONCLUSION This novel, high-fidelity simulator is an additional tool for educators involved in teaching chorionic villus sampling.
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Affiliation(s)
- Darine El-Chaar
- Department of Obstetrics and Gynecology, The Ottawa Hospital, Ottawa, ON
| | - Jennifer Manley
- Fetal Medicine Unit, Mount Sinai Hospital, University of Toronto, Toronto, ON
| | | | - Greg Ryan
- Fetal Medicine Unit, Mount Sinai Hospital, University of Toronto, Toronto, ON
| | - Rory Windrim
- Fetal Medicine Unit, Mount Sinai Hospital, University of Toronto, Toronto, ON.
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Sahbaz A, Aynioglu O, Isik H. A guide on how to build a novel home-made part task training simulator for cervical cerclage training. J Perinat Med 2016; 44:597-8. [PMID: 26495921 DOI: 10.1515/jpm-2015-0196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 09/29/2015] [Indexed: 11/15/2022]
Abstract
Cervical cerclage is a experience demanding procedure and which is difficult for most of the residents and maternal fetal medicine fellows to have the first experience on real patients. In this study we presented an in-expensive and easy to build model for cervical cerclage training.
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Shea KL, Rovera EJ. Vaginal Examination Simulation Using Citrus Fruit to Simulate Cervical Dilation and Effacement. Cureus 2015; 7:e314. [PMID: 26457235 PMCID: PMC4592286 DOI: 10.7759/cureus.314] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
This technical report describes the creation and use of a cervical dilation and effacement model in a pre-licensure nursing course in reproductive health. Vaginal examination is typically taught in reproductive health courses; however, nursing students do not always have sufficient opportunity to practice on actual patients. This low-cost task-training model provides undergraduate nursing students the opportunity to experience performing a vaginal examination to assess for cervical dilation and effacement during the labor process.
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Development of a Novel Task Trainer for Second Trimester Ultrasound-guided Uterine Evacuation. Simul Healthc 2015; 10:49-53. [DOI: 10.1097/sih.0000000000000063] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Eichelberger KY, Bengtson AM, Tolleson-Rinehart S, Menard MK. Training needs in operative obstetrics for maternal-fetal medicine fellows. J Matern Fetal Neonatal Med 2014; 28:1467-70. [DOI: 10.3109/14767058.2014.957669] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
Many fields of medicine now routinely employ simulation while educating all levels of medical trainees. Unfortunately, OB-GYN has been slow to incorporate these beneficial adjuncts to traditional medical education, but thankfully the use of simulation is now increasing. Maternal-Fetal medicine procedures such as amniocentesis, in-utero stent placement, chorionic villus sampling, percutaneous umbilical blood sampling, and cervical cerclage placements are an area where simulation has great potential benefit. Here we describe the currently available simulation models for these procedures and outline specific training curricula designed to aid trainees in obtaining procedural competency in each. Although initial experiences with these training models and the curricula centered around them have been positive, in many cases their use remains limited. Our hope is that this manuscript will encourage others to incorporate simulation into their training programs as we believe it will enhance medical training and improve patient safety.
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Affiliation(s)
- Joshua F Nitsche
- Wake Forest University School of Medicine, Division of Maternal Fetal Medicine, Department of OB/GYN, Medical Center Blvd., Winston-Salem, NC 27157, USA.
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