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Published on November 3, 2023 | http://doi.org/10.5867/medwave.2023.10.2712
Clinical simulation training for the adequate management of obstetrics emergencies: A narrative review
Formación con simulación clínica para manejo adecuado de emergencias obstétricas: revisión narrativa
Obstetric emergencies are critical situations that jeopardize the health of both the mother and the baby during pregnancy or childbirth. This study aimed to validate the effectiveness of clinical simulation training in managing these situations. We conducted a narrative review of studies published between 2008 and 2022, collected from databases including Scopus, Sciencedirect, PubMed, Springer, Scielo, and Google Scholar. Data from studies that met our inclusion criteria were meticulously gathered and summarized. Our findings strongly emphasize that clinical simulation emerges as a highly effective tool in the training of healthcare professionals. This training translates into substantial improvements in various aspects, including performance, knowledge, confidence, satisfaction, attitudes, self-efficacy, teamwork abilities, and the skills necessary to confront critical obstetric situations such as postpartum hemorrhage, eclampsia, shoulder dystocia, maternal cardiac arrest, umbilical cord prolapse, and cesarean sections. Importantly, this training reduces the inherent risks associated with learning on real patients and aligns with the highest ethical standards. Additionally, our results underscore that interdisciplinary collaboration in the management of obstetric emergencies proves to be an effective strategy for providing comprehensive patient care. However, it is crucial to highlight that, in order to ensure patient safety and promote a teamwork approach, it is imperative for healthcare professionals to receive adequate training and be duly qualified. Although we acknowledge that implementing clinical simulation training can entail significant costs and require substantial resources, we firmly believe that this strategy continues to hold immeasurable value in the education of professionals in this field. Ultimately, we anticipate that future high-quality research will further fortify the evidence base regarding best practices in clinical simulation training for obstetric emergencies, thus contributing to enhanced patient outcomes and the overall quality of healthcare in this critical domain.
- Obstetric emergencies can be life-threatening for both mother and newborn and need appropriate care.
- This work can guide educators and researchers who plan, develop, test, and/or implement clinical simulation training in managing obstetric emergencies and other settings.
- As a limitation, experimental studies may provide more relevant results for this study.
According to the World Health Organization (WHO), in 2020, the annual maternal mortality rate was 287 000 patients, and the neonatal mortality rate was 2.4 million . Therefore, improving maternal, fetal, and neonatal care during childbirth is a significant development goal for WHO . Access to skilled delivery attendance and quality emergency obstetric care are key factors in improving maternal and perinatal mortality . One of the WHO recommendations is to improve the management of obstetric emergencies through clinical simulation training . This method constitutes a training technique for healthcare professionals aimed at achieving substantial understanding, improving, and spreading healthcare professionals' knowledge, skills, and attitudes .
Obstetrics constitutes a field of considerable risk in which emergencies can threaten the mother’s and newborn’s life . Obstetric emergencies often involve sudden changes, and the professional team faces situations requiring high-pressure decision-making. Numerous studies have shown the effectiveness of simulation training in obstetrics to improve safety during delivery for both mothers and newborns .
According to the study by Michelet et al. (2019), simulation has been implemented to develop both technical and non-technical skills in specific obstetric emergencies, such as shoulder dystocia, postpartum hemorrhage, eclampsia, and umbilical cord prolapse . Adequate management of these situations requires the collaboration of different disciplines and agile team coordination. Knowledge and skills in teamwork allow adapting to changes and learning from experiences . Obstetric emergencies are often effectively managed by competent and timely multidisciplinary teams . Strengthening collaboration and communication is crucial for quality care. However, despite professionals from different disciplines working together, they sometimes struggle to communicate effectively .
The safety of patients, professionals, and healthcare beneficiaries is fundamental. Consequently, fast-changing situations require highly competent professional teamwork. Poor management of obstetric emergencies is often linked to team competence, and their incompetence can result catastrophic [9,11].
Conventional clinical training in real-life situations has progressed to simulation training. Due to rapid advances in medical technology, applying newly acquired knowledge to real patients is unacceptable for ethical and legal reasons . The idea of learning with real patients along with the possibility of making mistakes, is becoming less and less accepted .
Obstetric simulation is considered a novel field, although its use dates back to prehistoric times. Archaeological records reveal that the ancestors of the Mansai people in Siberia created birthing models with real measurements of women in leather, using them to facilitate the birth process . In the 18th century, Madame du Coudray served as a royal midwife in France, using a life-size leather mannequin to instruct women, decreasing maternal and infant mortality .
Clinical simulation training in managing obstetric emergencies has significant benefits over conventional clinical training. This methodology allows healthcare professionals to practice real-life situations in controlled environments, reinforcing decision-making and technical skills .
Recent research supports that simulation training results in higher knowledge retention and confidence in obstetric emergencies than conventional clinical training. In addition, it provides a safe environment to make and learn from mistakes, which contributes to a steady improvement in clinical competence . The combination of technical and non-technical aspects in simulation training can be crucial for effective and safe patient care . Using clinical simulation as a tool for learning to manage obstetric emergencies represents an innovation that seeks to elevate the safety of patients, fetuses, and newborns . Sarfati et al.  conducted a systematic review in MEDLINE/PubMed from 2000 to 2015, merging terms such as Patient Simulation, Medication Errors, and Simulation Healthcare; they concluded that clinical simulation is effective for training staff, both in standard procedures and in exceptional situations, by integrating human aspects and the iatrogenic risk of medical errors .
The clinical performance of obstetric care teams is linked to the quality of their teamwork skills rather than individual performance. Teams with satisfactory clinical performance detect emergencies early and maintain effective internal communication . In the context of obstetric emergency management, interdisciplinary simulation training is effective in enhancing team development . Interprofessional training seeks to engage diverse professionals in a learning exchange, fostering collaborative practice and improved healthcare . Simulation training is valuable as it provides continuous and focused practice opportunities, allowing healthcare professionals to acquire knowledge and skills while minimizing patient risk .
The present review aims to determine the effectiveness of clinical simulation training aimed at healthcare professionals in adequately managing obstetric emergencies. For this purpose, clinical simulation training is assumed to be effective for adequately managing obstetric emergencies.
This narrative literature review analyzes articles retrieved from the bibliographic databases Scopus, ScienceDirect, MEDLINE/PubMed, Springer, SciELO, and Google Scholar between 2008 and 2022. The search strategy included the following keywords "emergencies, obstetric", "clinical simulation training", "teamwork", and "efficacy". The following inclusion criteria selected studies:
Studies of observational, qualitative, quasi-experimental design, clinical trials.
Studies on training with clinical simulation for the management of obstetric emergencies.
Studies published in English or Spanish.
Healthcare professionals and students as the studied population.
Results and discussion
Clinical simulation has become a common component of healthcare professional training in many healthcare institutions. This study aimed to validate the efficacy of clinical simulation training to train healthcare professionals in the appropriate management of obstetric emergencies.
In this review, we define outcomes as any measurement reported to validate the effectiveness of healthcare professional simulation training for the appropriate management of obstetric emergencies (e.g., knowledge, confidence, and performance). Details on the methods used to measure outcomes and specific results for each of the included studies can be found in Table 1.
The clinical simulation training carried out in the selected articles reproduces some of the main obstetric emergencies [3,7,21,22,35,37]. They specifically address postpartum hemorrhage [3,8,23,24,25,29,36], eclampsia [3,26,27], shoulder dystocia [3,24,27,28,29,36], maternal cardiac arrest [30,31], umbilical cord prolapse  and cesarean section  in controlled environments, using high, medium and low-fidelity simulators.
Some authors who evaluated the outcomes of simulation training highlighted that the intervention improved performance [8,23,25,26,27,28,29,30,31,32,37], knowledge [3,7,21,22,25,30,33], confidence [21,24,30], satisfaction [22,33,34], attitudes  and self-efficacy . In addition, simulation training had a positive impact on skills (both practical and communication) [7,33,35], self-competence, awareness , and teamwork [3,26].
Sami et al. , in a quasi-experimental study, demonstrated that simulation training enhances knowledge acquisition, retention, and confidence . Also, in another quasi-experimental study, Osman et al.  demonstrated that this training method increases participants' knowledge, confidence, and satisfaction .
In this context, simulation is established as an essential element in the training of obstetric teams, improving their competence and ability to respond to emergencies. The fundamental relevance of these findings becomes evident when considering the complexity and inherent severity of the obstetric scenarios addressed in the studies. These range from the management of postpartum hemorrhage, eclampsia, shoulder dystocia, maternal cardiac arrest, umbilical cord prolapse, and cesarean section.
Below, we will present the results and analysis for all obstetric emergencies addressed in this study.
Postpartum hemorrhage is an obstetric emergency and a leading cause of maternal morbidity and mortality worldwide. It accounts for 27.1% of maternal deaths globally . In a quasi-experimental study, Pansuwan et al. (2012) examined how using simulated scenarios in a laboratory setting affected nursing performance in managing early postpartum hemorrhage. The results showed improvements in the care of women with this condition . Another quasi-experimental study by Andrighetti et al.  showed that simulation-based training increases midwifery students' confidence in managing postpartum hemorrhage . Also, in a randomized clinical trial aimed at examining the effect of simulation training programs on midwives' knowledge and performance, both variables related to postpartum hemorrhage care were significantly improved after training. However, to adequately assess the effectiveness of simulation training, the long-term effects on performance, knowledge, and clinical outcomes in the care of obstetric complications should be studied . Research findings indicate that simulation training is critical for healthcare professionals in managing postpartum hemorrhage.
Eclampsia refers to the occurrence of at least one generalized seizure among patients who have criteria for preeclampsia and who do not have other neurological diseases . It is a rare and potentially life-threatening obstetric emergency, occurring in 2 to 3% of women with severe preeclampsia who do not receive prophylaxis . Training healthcare professionals who provide obstetric care is vital for the care of eclampsia, which is a major cause of maternal and perinatal morbidity and mortality. Deering et al.  demonstrated that simulation training was more effective than traditional learning in the management of eclampsia . Ellis et al.  published a randomized clinical trial examining the effects of simulation training on the clinical effectiveness of teams. In the study, simulation demonstrated that teams completed basic tasks in preeclampsia intervention at a higher rate, magnesium sulfate administration was completed in a shorter time, and better teamwork and higher performance . The study results show that simulation training is necessary for healthcare professionals in preeclampsia management.
Cases of shoulder dystocia are rare and difficult to predict. However, there are evidence-based guidelines on the management of this emergency, which carries major long-term complications, such as hypoxic-ischemic encephalopathy and brachial plexus injuries . In a randomized clinical trial, Daniels et al.  showed that simulation training was more effective than traditional training in managing shoulder dystocia . The use of simulation to address the effects of shoulder dystocia is probably one of the best-studied areas of obstetric simulation. In a quasi-experimental study, Kordi et al.  compared the impact of simulation-based training and oral technique on midwives' skills in managing shoulder dystocia. The results showed improvements in midwife performance . In a randomized clinical study, Fransen et al. (2015) reported increased performance of multidisciplinary obstetric teams and reduced shoulder dystocia trauma . These results showed that simulation training could be used effectively in managing shoulder dystocia.
Maternal cardiac arrest
Cardiac arrest is defined as a sudden and unexpected event, with loss of consciousness following impaired blood flow through the coronary artery, which is diverted to the brain . Studies of cardiac arrest in the general adult population show that it may be possible to improve patient outcomes in the event of cardiac arrest . The care of a pregnant patient experiencing cardiac arrest is different from that of a general adult, as the team must take into account the specific physiology of pregnancy and the status of the fetus during resuscitation . Studies on the management of maternal cardiac arrest demonstrate that simulation has a beneficial effect on improving the skills of healthcare professionals. Fisher et al.  conducted a study to determine the effects of simulation training in managing maternal cardiac arrest on the performance, knowledge, and confidence of 19 maternal-fetal healthcare professional participants. According to the study results, participants showed statistically significant improvement in the timely establishment of cardiopulmonary resuscitation and delivery by perimortem cesarean section . Lipman et al.  evaluated 18 simulation case videos involving maternal amniotic fluid embolism and subsequent cardiac arrest. Although all participants were certified according to American Heart Association recommendations for advanced resuscitation care, inadequacies were found in the practice of cardiopulmonary resuscitation during simulated arrests. In the study, the teams performed 56% of adequate compressions and 50% of ventilations in a timely manner . Since maternal cardiac arrest and perimortem cesarean section are rare, appropriate interventions for the mother and newborn are directly related to the preparedness and familiarity of the healthcare team. With simulation training, the obstetric team will be able to practice and evaluate outcomes.
Umbilical cord prolapse
Umbilical cord prolapse can be occult or overt. It occurs when a fragment of the umbilical cord advances along or in front of the fetal presentation. This makes it susceptible to compression by the presenting part, which can lead to fetal asphyxia. This event occurs in 0.18% of live births . A study carried out in a large maternity hospital in the United Kingdom showed that the application of a simulated umbilical cord prolapse management protocol was effective. This was associated with significantly reducing the mean time from diagnosis to delivery . The results of the study showed that simulation training can be effective and reliable in preventing maternal-fetal mortality and morbidity associated with umbilical cord prolapse.
Cesarean section is a very common procedure that can lead to serious complications, especially when an abdominal incision is involved or when it is performed under emergency circumstances . Therefore, training with cesarean section simulation may be useful for healthcare professionals. Vellanki et al.  compared a simulated cesarean section model and usual training in the training of new interns in a randomized clinical trial. According to the result of the study, it was shown that medical students trained with the simulation were better able to identify the cesarean section act phases. In addition, the students had greater well-being during the act . Simulation training can be used to eliminate the identified barriers and reduce the intervention time in emergency cesarean section, as well as allow the team to hone their skills.
Interdisciplinary clinical simulation in obstetrical emergencies
Numerous efforts to improve outcomes in obstetrics have focused on techniques and increasing medical knowledge. However, it has been recognized that many complications and morbidity arise from ineffective team interventions, not individual failures. The lack of teamwork dynamics is a crucial factor contributing to about 75% of preventable medical errors . Gum et al.  conducted a qualitative study to investigate how simulation training improves maternal emergency care and team development. The study’s results reported that participants highlighted how simulation facilitated reflection and evaluation of team leadership skills, in addition to reviewing the role of leadership in emergency settings. The study noted that the training allowed participants to have a common goal (patient safety), which fostered mutual respect, increased trust among team members, and allowed them to learn from each other . Similarly, Hernandez et al. (2021) conducted a study to analyze the impact and the effects of multidisciplinary group obstetric emergency simulation training. The study results showed that the participants' skill levels and satisfaction improved . Reeves et al.  reported that standardized simulations for obstetric emergency management and patient safety training were beneficial in improving the reactivity and skills of team members, as well as patient outcomes . In a study involving midwives, nurses, and obstetricians, we investigated whether simulation training was related to perceived changes in self-efficacy and collective efficacy in managing postpartum hemorrhage. The results revealed a significant increase in the participant group’s self-efficacy and collective efficacy levels after training . In another study involving medical and midwifery students, which assessed interprofessional attitudes and clinical knowledge after simulation training, the results evidenced an improvement in interprofessional attitudes .
In research conducted by Walker et al. , which covered obstetric hemorrhage, shoulder dystocia, preeclampsia/eclampsia, and neonatal resuscitation scenarios, 450 healthcare professionals were trained in interdisciplinary teams, with a significant increase in knowledge and self-efficacy of both physicians and nurses in each area . Inadequate management of obstetric emergencies can result in severe trauma and death of the mother, fetus, and newborn. The interdisciplinary approach in simulation training improves team performance and ensures quality care by increasing patient safety.
Strengths and limitations
One of the strengths of this study lies in the diversity of data sources collected, including different types of research and the participation of various countries. However, it is important to note that we did not carry out a quality assessment of the included studies. This decision was congruent with our objectives but simultaneously limited our results' applicability. In addition, the methods used to synthesize the data did not take into consideration the possible differences among the study samples nor the quality of the methodology used in the studies. It is also relevant to note that our inclusion criteria were specific and may have excluded the incorporation of articles that could have been relevant to the research topic. This includes the possibility of not having considered studies conducted with other healthcare professionals who provide emergency care in contexts different from those addressed in this study.
The findings of this review have the potential to offer guidance to educators and researchers who are planning, developing, evaluating, or implementing clinical simulation-based training programs, whether in the context of obstetric emergencies or in other fields of application.
It is essential to continue research into this essential aspect of simulation training. Future high-quality research will strengthen the evidence on best practices in clinical simulation training in obstetric emergencies.
The results of this study provided conclusive evidence that clinical simulation training in the management of obstetric emergencies was effective in developing the skills of healthcare professionals and preparing teams to respond to emergencies adequately. Its applications correlated with improved performance. Therefore, implementing simulation training for managing obstetric emergencies should be considered a promising strategy to improve maternal and neonatal health care delivery.
However, simulation interventions can be time-consuming and resource-intensive. Educators and researchers should be aware of these challenges when approaching simulation training strategies. Despite the eventual limitations associated with simulation, this training strategy was considered positive for healthcare professionals' learning process in managing obstetric emergencies.