|Year : 2014 | Volume
| Issue : 1 | Page : 1-3
Simulations for training in obstetric anesthesia: Essential but better gadgets are needed
Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||20-May-2014|
Department of Anaesthesia, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Trikha A. Simulations for training in obstetric anesthesia: Essential but better gadgets are needed. J Obstet Anaesth Crit Care 2014;4:1-3
|How to cite this URL:|
Trikha A. Simulations for training in obstetric anesthesia: Essential but better gadgets are needed. J Obstet Anaesth Crit Care [serial online] 2014 [cited 2018 Oct 23];4:1-3. Available from: http://www.joacc.com/text.asp?2014/4/1/1/132805
Simulations based training of basic and advanced skills essential to an anesthesiologist has become an inherent part of the anesthesia training curriculum in many medical schools. In obstetric anesthesia, simulators can be used for improving skills (technical and nontechnical), assess clinical performance, competence, and improve safety by identifying unintended errors within the delivery rooms and operation theatres. Hands on anesthesia training, including that in obstetric anesthesia continues to be on patients under the direct supervision of a senior colleague - himself a trainee or a consultant in most of the institutions in the developing world. Logically, this could lead to increased possibility of causing harm or compromising patient safety. This kind of "on patient learning/training" though been carried out ever since modern medicine was taught has a potential to compromise patient safety. Obstetric anesthesia practice has a very low acceptable "margin of error," because any inadvertent mistake could affect two lives-the mother and the baby. It is but natural that only senior trainees or consultants administer analgesia or anesthesia to parturients.
Epidural analgesia/anesthesia are one of the basic skills that an anesthesia trainee acquires during his training. Correct placement of epidural catheters is technically more difficult in laboring parturient because of suboptimal positioning due to term uterus, movement due to labor pains and high stress environment of the delivery room. Though epidural analgesia and anesthesia are very safe, but life-threatening complications do occur during obstetric epidural placement. , Similarly, inadvertent dural tap causing postdural puncture is not uncommon with incidence of about 1%.  Gupta et al. in their study have reported incidence of dural tap of about 2.8% and attributed this increasing rate to inexperience and suggested that newer methods in training should be instituted for correct epidural insertions.  A review of claims between 1995 and 2007 done by National Health Service Litigation Authority of the UK revealed that about 44% of all the claims were related to regional anesthesia, and 50% of these were in an obstetric setting. Most common claims were regarding neurological injury after epidurals for labor, postdural puncture headache, backache after epidurals, and incomplete pain relief during labor and cesarean sections.  Large number of claims in obstetric setting warrant better training techniques in this group of patients.
Simulator based training for epidural placement of catheters could be one of such methods and be of tremendous benefit for obstetric anesthesia trainees. Such training for epidurals has been carried out on many part task innovative simulators. The basic need being, the differential tactile sensation of the epidural needle going through various tissues and finally the ligamentum flavum. Innovations used for simulating this sensation have been mindboggling - needle penetration through bananas, balloons, pieces of bread and even a pillow.  In a recent study, four different fruits - orange, banana, kiwi and honeydew melon - were tried to simulate loss of resistance similar to epidural placement. Banana was found to be the best in this regard.  More sophisticated gadgetry has also been used in the form of a computer and a stylet to provide haptic sensation of a needle moving through various tissue.  These innovations are neither popular nor routinely used.
Modern day human mannequins for epidural placements are made of plastic with solid vertebrae (the structure of the vertebra varying with the level [cervical to lumbar]) covered with artificial skin that needs to be replaced after predetermined skin punctures. A rubber tube placed between the vertebra forms the spinal canal, which is filled with a clear liquid to represent the cerebrospinal fluid. If punctured the clear fluid flows out of the epidural/spinal needle. These simulators do help an anesthesia trainee early in his career, but for obstetric anesthesia training mannequins with anatomy similar to a parturient (spine that cannot be flexed for an ideal position for spinal/epidural) are needed, which can simulate the movements of women during labor contractions. Such a mannequin (for obstetric anesthesia simulation training) ideally would also need to be kept in an environment where the sound of the cardiotocography is audible, and the setting is as stressful as a delivery room with paramedical staff and attendants. Robotic mannequins with artificial intelligence could be the next generation tools for training.
In obstetric anesthesia, one of the most important tasks remains airway management in a parturient and simulators are ideal for it. Airway in this subgroup of women is difficult and neuraxial blocks are usually administered for cesarean sections therefore many trainees hardly get to see or administer under supervision a general anesthetic for a cesarean section. , Difficult airway management guidelines for parturients are readily available,  but for an obstetric anesthesia trainee practice on mannequins with "pregnant airway" is required as this is likely to give enough confidence to administer a general anesthetic in a parturient if the need arises. There are mannequins, on whom airway skills can be practiced, and the degree of difficulty of the airway can be altered, but further improvement in these is required to simulate an airway encountered in a term parturient. However, different commercially available mannequins have been shown to have significant performance differences.  There is a need of improvement and standardization of these mannequins. There is evidence that training for general anesthesia for caesarean section in the simulated environment can improve efficacy. Goodwin and French.  have reported that task competition by trainees was poor during simulated failed intubation drill and there was marked improvement after undergoing simulated session regarding failed intubations. Similarly, low fidelity trainers used for teaching cricothyrotomy and simulated cardiopulmonary resuscitation in pregnancy have been found to be very useful by trainees when faced with such situations in real life. 
One of the most important aspects of obstetric care is teamwork. In an event of a crisis of even a minor consequence an efficient teamwork can be very helpful for tiding over the crisis and this can be best learnt by repeated simulation exercises. Development of a closely coordinated behavior system, assets such as leadership, good communication, and assertion, information sharing and work distribution can be developed using high fidelity simulators. The situations where these are useful are collapse due massive hemorrhage, cardiac arrest, severe hypotension, total spinal, local anesthetic toxicity, preeclampsia, and eclampsia. Many authors have reported that such teamwork training can result in improved team performances. ,,,, However, there have been reports that specific teamwork training is not use full when it is added to teaching of clinical skills in obstetrics. , Teamwork training is totally different from specific skill acquisition and Gum et al. have reported that such behavioral changes can only be acquired by repetitive training. 
In conclusion, repeated simulator based training in obstetric anesthesia is the need in the present anesthesia training program where "on patient training" is likely to become outdated. It is up to the industry that more realistic mannequins are made that are "near natural."
| References|| |
|1.||Paech MJ, Godkin R, Webster S. Complications of obstetric epidural analgesia and anaesthesia: A prospective analysis of 10,995 cases. Int J Obstet Anesth 1998;7:5-11. |
|2.||Jenkins JG. Some immediate serious complications of obstetric epidural analgesia and anaesthesia: A prospective study of 145,550 epidurals. Int J Obstet Anesth 2005;14:37-42. |
|3.||Gleeson CM, Reynolds F. Accidental dural puncture rates in UK obstetric practice. Int J Obstet Anesth 1998;7:242-6. |
|4.||Gupta S, Collis R, Harries S. Increasing dural tap rate: Is this a national trend? Int J Obstet Anaesth 2007;16:S17. |
|5.||Szypula K, Ashpole KJ, Bogod D, Yentis SM, Mihai R, Scott S, et al. Litigation related to regional anaesthesia: An analysis of claims against the NHS in England 1995-2007. Anaesthesia 2010;65:443-52. |
|6.||Leighton BL. A greengrocer's model of the epidural space. Anesthesiology 1989;70:368-9. |
|7.||Raj D, Williamson RM, Young D, Russell D. A simple epidural simulator: A blinded study assessing the 'feel' of loss of resistance in four fruits. Eur J Anaesthesiol 2013;30:405-8. |
|8.||Glassenberg R, Glassenberg S. Development of a tactile feedback simulator for placement of an epidural or spinal needle. Anesthesiology 2004;101:A-1358. |
|9.||Johnson RV, Lyons GR, Wilson RC, Robinson AP. Training in obstetric general anaesthesia: A vanishing art? Anaesthesia 2000;55:179-83. |
|10.||Tsen LC, Camann W. Training in obstetric general anaesthesia: A vanishing art? Anaesthesia 2000;55:712-3. |
|11.||Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013;118:251-70. |
|12.||Jordan GM, Silsby J, Bayley G, Cook TM, Difficult Airway Society. Evaluation of four manikins as simulators for teaching airway management procedures specified in the Difficult Airway Society guidelines, and other advanced airway skills. Anaesthesia 2007;62:708-12. |
|13.||Goodwin MW, French GW. Simulation as a training and assessment tool in the management of failed intubation in obstetrics. Int J Obstet Anesth 2001;10:273-7. |
|14.||Friedman Z, You-Ten KE, Bould MD, Naik V. Teaching lifesaving procedures: The impact of model fidelity on acquisition and transfer of cricothyrotomy skills to performance on cadavers. Anesth Analg 2008;107:1663-9. |
|15.||Osman H, Campbell OM, Nassar AH. Using emergency obstetric drills in maternity units as a performance improvement tool. Birth 2009;36:43-50. |
|16.||Eason M, Olsen ME. High spinal in an obstetric patient: A simulated emergency. Simul Healthc 2009;4:179-83. |
|17.||Thompson S, Neal S, Clark V. Clinical risk management in obstetrics: Eclampsia drills. BMJ 2004;328:269-71. |
|18.||Robertson B, Schumacher L, Gosman G, Kanfer R, Kelley M, DeVita M. Simulation-based crisis team training for multidisciplinary obstetric providers. Simul Healthc 2009;4:77-83. |
|19.||Freeth D, Ayida G, Berridge EJ, Mackintosh N, Norris B, Sadler C, et al. Multidisciplinary obstetric simulated emergency scenarios (MOSES): Promoting patient safety in obstetrics with teamwork-focused interprofessional simulations. J Contin Educ Health Prof 2009;29:98-104. |
|20.||Draycott T, Crofts J. Structured team training in obstetrics and its impact on outcome. Fetal Matern Med Rev 2006;17:229-37. |
|21.||Crofts JF, Ellis D, Draycott TJ, Winter C, Hunt LP, Akande VA. Change in knowledge of midwives and obstetricians following obstetric emergency training: A randomised controlled trial of local hospital, simulation centre and teamwork training. BJOG 2007;114: 1534-41. |
|22.||Gum L, Greenhill J, Dix K. Clinical simulation in maternity (CSiM): Interprofessional learning through simulation team training. Qual Saf Health Care 2010;19:e19. |