Cesarean Section (CS) is one of the first surgical procedures trainees learn during their residency in Obstetrics and Gynecology and 20% of children in Denmark are delivered by CS every year.
CS is characterized by being the most frequent open surgical procedure but is also a lifesaving intervention and demands a high level of collaboration among several healthcare providers with different educational backgrounds. Furthermore, the patient is awake during the procedure both in elective and very acute cases. All these factors require that the leading surgeon has good technical - and non-technical skills to avoid complications during and after the procedure. The outcome of the operation is directly correlated to the technical skills of the surgeon. Infection and bleeding are known complications after performing CS, which again is associated with increased morbidity and mortality for both mother and child.
Traditionally, surgical skills are taught by the apprenticeship model where the residents first observe, then perform the procedure under supervision of a senior college and finally, operate independently. It requires a high number of CS to become independent. It is estimated that residents have to perform between ten to forty supervised CS, before operating independently depending on their former experience. Currently the WHO recommends reducing the CS rate. At the hospital Southern Jutland (SHS), the rate of CS is 12%, amounting to approx. 200 CS pr. year. This leads to few chances for the resident to train the CS procedure, since only around 25% of the CS are elective and thus relevant for training junior residents. With three doctors in 1st year of resident training and two doctors later in obstetric training per year at SHS, this is not sufficient to obtain the necessary competency to be able to perform a CS independently.
However, the number of CS alone might not a good predictor for the competency of the resident to perform CS independently. It is more important to accurately assess the competencies of the residents, as some residents might acquire these competencies with fewer CS than others. The level of the competencies can be evaluated by using an assessment tool, provided that the assessment tool is able to accurately assess the competencies of the resident ability to perform a CS independently.
Furthermore, the number of CS needed to acquire the required competencies might be reduced by simulation-based training. Studies from other surgical procedures suggest that simulation training plays an important part when teaching and training technical and non-technical surgical skills.
Simulation based training can improve trainees' surgical skills, prepare them for learning in the operating theater and potentially improve their CS learning curve. Improving trainees' surgical skills could in the end lower the risk of post partem complications, which would be beneficial for all obstetric departments and particularly for the patients.
Several courses in simulation-based training are offered to surgical residents in Denmark, but so far not in performing CS. Currently a pilot course, integrating technical and non-technical skills, is running at the hospital of Southern Jutland, Aabenraa, with CS performed on a simulation doll in a life-like surgical set-up.
The effects of simulation-based training on technical skills is being investigated by scoring the participants on an assessment tool. The most used tool for scoring the competency of the residents' technical skills is OSATS (Objective Structured Assessment of Technical Skills). This tool was initially created to assess the resident's surgical skills and is used in different areas of surgical fields inclusive for Gynecology and Obstetrics for CS skill rating. Preliminary conclusions of the first course round from the Simulation-based training in Aabenraa were, that OSATS was not good enough to assess the technical skills of the residencies, since it was easy to get a high score on OSATS even when only parts of the CS operation were performed like suturing the fascia and skin.
It has been suggested to develop an OSATS specifically designed for assessment of a CS. This has already been done for several procedures including obstetric ultrasound skills, laparoscopic skills, vacuum extraction etc.
When developing a new assessment tool, it is important to use an appropriate framework for the validation process to ensure that evidence supporting validity is explored sufficiently. The framework suggested by Kane is accepted within medical education, as it outlines a set of requests to secure good practice of gathering evidence when developing an assessment tool.
A single assessment does not fully capture the development of a skill. Learning curve studies have shown to be a suitable method to investigate the development in acquired skills during a learning process in CS. A learning curve is a graphical representation visualizing the rate of learning with time or number of procedures that trainees have to perform to attain a certain skill level. To evaluate the effect of a training course, the continuous skill development after the course must be monitored, and compared with those of a control group.
In summary, there is a need to investigate the effect of simulation training of CS, including development of a new assessment tool, evaluating the learning curve for CS, and monitor the development of competencies for CS among residents during their internship.
Collaborating researchers and departments
Department of Gynecology and Obstetrics, Hospital of Southern Jutland
- Obstetric Consultant, MD, Kamilla Gerhard Nielsen.
Focused Research Unit in Emergency Medicine, University Hospital of Southern, Professor in Emergency Medicine
- Ph.D., MHM, Christian, Backer Mogensen.
CAMES, Rigshospitalet, Professor, Head of Research
Department of Gynecology and Obstetrics, Hvidovre Hospital, and Copenhagen Academy for Medical Education and Simulation, Capital Region
- MD, Ph.D. Ebbe Thinggaard.