Forceps simulation associated with reduction in severe perineal lacerations
1. Resident participation in a forceps delivery simulation curriculum was associated with a 26% reduction in third and fourth degree perineal lacerations.
2. A provider’s volume of forceps deliveries was not significantly associated with odds of severe lacerations.
Evidence Rating Level: 2 (Good)
Study Rundown: With a cesarean delivery rate of nearly 1 in 3, there is currently a widespread national effort to reduce the rate of c-sections. When used properly, forceps can be a valuable tool to assist a vaginal delivery and help decrease cesarean deliveries done for maternal exhaustion or failure of descent. However, forceps are associated with some increased risks, namely of higher order perineal lacerations. Third and fourth degree lacerations, which by definition involve the anal sphincter, can cause long-term maternal morbidity including flatal and fecal incontinence, chronic pain, infection, bleeding risk, and loss of sexual function. Studies have not identified an association between experience and rates of severe lacerations among practicing physicians; however, no prior studies have assessed the impact of obstetric resident training on delivery outcomes. Over the past few decades, medical residency education has placed increased emphasis placed on surgical skills training, including simulation training. While studies demonstrate that simulation trainings are associated with improved patient outcomes for procedures like central line placement, lumbar puncture, and paracentesis, little has been on simulation curricula in obstetrics and gynecology and most involves management of shoulder dystocia. At one large, university based residency program, experts developed and implemented a simulation-based curriculum for forceps-assisted vaginal delivery with obstetric residents. They then compared rates of severe laceration before and after implementation of the program.
The simulation curriculum was associated with a 26% reduction in severe perineal lacerations. There was no association found between a provider’s volume of forceps deliveries and odds of a laceration. Strengths of this study include the novel curriculum design and large sample size. The institution where the study was performed has a notably high rate of forceps deliveries (7-10%), so it’s unknown whether results will be generalizable to lower volume training centers. Future studies are warranted to evaluate this simulation program in a variety of training settings.
Click to read the study in Obstetrics & Gynecology
Click to read the accompanying editorial in Obstetrics & Gynecology
Relevant Reading: Association Between Obstetrician Forceps Volume and Maternal and Neonatal Outcomes
In-Depth [retrospective cohort]: In 2013, clinicians at a large, academic medical center developed and implemented a forceps-assisted vaginal delivery simulation curriculum for obstetric residents. Researchers compared outcomes of all forceps deliveries performed in the 2.5 years after the implementation of the training program (with those in the 7.5 years prior to the training program, for a total of 3,500 resident performed deliveries. The primary outcome was rates of severe perineal lacerations (third- or fourth degree, defined by the involvement of the anal sphincter). Known risks of lacerations were incorporated into a multivariable model.
Women who had a forceps delivery after the implementation of the training simulation experienced reduced odds of developing a sever perineal laceration compared to those who delivered prior to the training program (aOR: 0.74, p: 0.002). Provider volume of forceps delivery was not significantly associated with odds of experiencing a laceration.
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