The role of simulation in knowledge dissemination and improving clinical outcomes for the management of impacted fetal head at cesarean delivery.

Abstract

Objective: Impacted fetal head (IFH) is an obstetrical emergency with associated maternal and fetal morbidity. The aim of this study was to assess the role for a simulation session about the management of IFH at cesarean delivery as a method of disseminating guideline recommendations to obstetricians. The secondary aim was to assess the clinical impact of this initiative.

Methods: An IFH simulation session based on recent guidelines was developed using the PROMPT FLEX enhanced cesarean section model to review pull, push, and Patwardhan techniques. All faculty and obstetrical trainees were invited to participate. Participants completed baseline and post-session surveys. Survey scores were compared using paired t-test and ANOVA. To assess clinical impact, a 6 month pre/post cohort of all patients who underwent second stage cesarean delivery was assembled. Multivariable robust Poisson regression models were used to estimate relative risk of a composite maternal/neonatal morbidity outcome pre/post implementation.

Results: 34 clinicians participated (21 trainee,13 faculty). Trainees demonstrated significant, sustained improvement in knowledge following participation (P < 0.001). Trainees reported sustained comfort level with push and pull techniques but comfort with Patwardhan waned (P = 0.03). Faculty comfort was unchanged for push and pull techniques but significantly improved for Patwardhan (P = 0.01). The adjusted relative risk of composite maternal/neonatal morbidity following implementation was unchanged (RR 1.03, 95% CI 0.75-1.42). However, NICU admissions were reduced (P = 0.01).

Conclusion: An IFH simulation session was associated with improvement in trainee knowledge and faculty and trainee comfort with the Patwardhan technique. Simulation may be an effective tool to improve obstetrician comfort with novel recommendations.