VIRTUAL MASS-CASUALTY INCIDENT SIMULATION

Frederick Friedman Jr., MD; Ceyda Oner, MD; G. Alex Trivette, MD Icahn School of Medicine at Mount Sinai

ABSTRACT:

Introduction: Due to the declining usage of forceps and vacuums in assisting vaginal deliveries, many centers have resorted to simulations to train their house staff. We previously described the success of a didactic program for simulating operative vaginal deliveries. We now report on the recorded pressures on the brachial plexus during forceps-assisted vaginal deliveries (FAVDs) as compared to vacuum-assisted vaginal deliveries (VAVDs) using a mannequin. Method: This study was approved by the Mount Sinai Institutional Review

Board with a waiver of consent. The residents in an academic Obstetrics and Gynecology program were recruited for participation. Baseline survey data including year of training, demographics, and prior experience with operative vaginal deliveries (OVDs). Following an educational session reviewing appropriate usage and techniques, a hands-on practical was conducted using a pelvic model whose matching baby contained a force monitor in its neck. Forces generated during the simulated deliveries were recorded. Result: A total of 22 residents completed the study. During this study, 20 of the 22 residents exerted more force on the baby mannequin’s neck during

VAVDs as compared to FAVDs (P<.001). Whether evaluated by year of residency training or reported experience, there appeared to be greater forces exerted during VAVDs than with FAVDs. Conclusion: During this educational study, the forces exerted on a baby mannequin’s neck were greater during VAVDs than they were during

FAVDs. Whether this is an artifact of the study or similar to in vivo results was not tested. Additional studies are currently underway.

INTRODUCTION:

The frequency of operative vaginal deliveries has been declining throughout the United States. According to the CDCs National Vital Statistics report on births, the frequency of OVDs decreased from 9.4% to 4.8% from 1995 to 2018. Several efforts are underway to reverse this trend and to support residents with sufficient training of a highly technical, but low frequency, procedure. OVDs are beneficial as they can, in the appropriate clinical context, reduce the rate of cesarean sections and improve outcomes. One of these methods to improve training is simulation, and we previously described a successful didactic program for simulating operative vaginal deliveries.

For this study, we report the recorded pressures on the brachial plexus during forceps-assisted vaginal deliveries (FAVDs) as compared to vacuum-assisted vaginal deliveries (VAVDs) in a simulated delivery using a mannequin. The force exerted on a neonate’s brachial plexus during delivery is of great importance, as excessive force can result in permanent neurological sequela such as Erb palsy. Operative vaginal deliveries have been associated with increased risk of such injuries.

METHODS :

Mount Sinai OB/GYN residents were recruited to participate in the simulation study during the 2019-2020 academic year, a total of 22 residents participated. The study was approved by the Mount Sinai IRB with a waiver for consent.

The simulation study began with a baseline survey to obtain demographics, assess resident knowledge and experience with OVDs. After this the residents underwent an educational session which was in lecture format. Two operative vaginal delivery (Figure 1). Finally, a post simulation survey was administered.

Our previous study demonstrated success in improving resident’s knowledge and skill with OVDs. They also found the session to be worthwhile and enjoyable. For this project we focused on the force generated on the brachial plexus of the neonate during the simulation. This was recorded in Newtons using the PROMPT force monitor. The force generated was recorded throughout the resident’s delivery using both the forceps and the vacuum, and this data was documented for analysis.

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Average of Net Forceps Average of Net Vacuum

Figure 2. Overall average net force of simulated forceps vs vacuum delivery

RESULTS:

Of the residents recruited, 22 in total participated; 20 of the 22 residents (91%) exerted more force on the neonate mannequin’s neck during VAVDs as compared to FAVDs (P<.001). The force exerted was measured in Newtons. An average of 32 N was noted when residents used forceps and an average of 68 N was noted when residents used a vacuum during the simulated operative vaginal deliveries (Figure 2). This was seen regardless of reported experience or year of residency training.

CONCLUSIONS:

This simulation study involving OB/GYN residents at The Mount Sinai Hospital demonstrated that the force exerted on a neonate mannequin’s neck was greater during VAVDs than they were during FAVDs. Whether this is an artifact of the study itself or is also similar to live vaginal births was not tested in this study. Additional studies attempting to answer this would be beneficial for clinical management.

REFERENCES:

1. Operative Vaginal Delivery Skills for Residents using Simulation Training. Frederick Friedman, Jr., MD. Ceyda Oner, MD. G Alex Trivette, MD. SASGOG 2020 Annual Meeting. 2. National Vital Statistics Reports, Vol. 67, No. 8, November 7, 2018