Cardiac arrest is a rare event during pregnancy [
Simulation has also been shown to improve competence in obstetric emergency decision-making, leadership, and individual and team performance [
The objective of this study was to improve the knowledge, competence, confidence, and crisis resource management (CRM) skills of a team of obstetrical residents in the management of maternal cardiopulmonary arrest through the implementation of a simulation-based curriculum.
Nine residents from our institution’s Obstetrics & Gynecology (OBGYN) residency program were recruited for the study based on their availability to participate in all four simulations. Residents were evenly assigned to one of two study groups based on their level of training. The residents not part of the study were involved in the educational experience as part of a nonresearch group. Simulations were scheduled during protected time for weekly resident education. The study was considered exempt by the Institutional Review Board.
Participants completed a 7-question confidence survey (CS) utilizing a 5-point Likert scale and a 20-question multiple-choice knowledge test (KT) in a pretest/posttest approach. Competence was assessed by video review of obstetrical residents’ management as a team of a simulated maternal cardiac arrest in a similar pretest/posttest fashion. An expert panel composed of a Maternal Fetal Medicine (MFM) attending, an Emergency Medicine (EM) attending, and an Obstetrician/Gynecologist graded the pre- and postintervention simulations using a modified score sheet with items from both TeamSTEPPS® and the American Heart Association® (AHA) Megacode Checklist (see the following checklist).
Ensures high-quality CPR at all times. Assigns team member roles. Ensures that team members perform well.
Recognizes VF. Clears before ANALYZE and SHOCK. Immediately resumes CPR after shocks. Appropriate airway management. Appropriate cycles of drug-rhythm check/shock-CPR. Administers appropriate drug(s) and doses.
Activates protocol for an emergency cesarean delivery as soon as cardiac arrest is identified. Performs manual left uterine displacement. Performs chest compressions slightly higher on the sternum than normally recommended. Uses bag-mask ventilation with 100% O2 before intubation is done. Attempts to identify common and reversible causes of cardiac arrest in pregnancy. Delivers infant by emergency cesarean section. Delivers infant no more than 5 minutes after cardiac arrest ensues.
Identifies ROSC. Ensures BP and 12-lead ECG are performed and O2 saturation is monitored, verbalizes need for endotracheal intubation and waveform capnography, and orders laboratory tests. Considers therapeutic hypothermia.
The medical simulation staff, two senior level OBGYN residents, and the Director of the MFM department at our institution jointly designed a four-case simulation based curriculum. Educational objectives were modeled after the current AHA guidelines for the management of maternal cardiac arrest (see Figure
Maternal cardiac arrest algorithm.
All simulations were based on presentations that could lead to maternal cardiac arrest [
All simulations were performed in the simulation laboratory of Summa Health System. A confederate nurse and real time patient feedback were used in all simulations to facilitate information gathering and scenario flow. A digital monitor displaying dynamic vital signs was readily available and modified based on case progression. Cases were ended at the faculty member’s discretion once 10 minutes after maternal cardiac arrest had elapsed.
Gaumard’s NOELLE Maternal and Neonatal Birthing Simulator was used for all simulations. To enable the performance of an emergent perimortem cesarean section, the simulator was fitted with a disposable abdominal wall and amniotic sac unit. The amniotic sac was emulated by a red biohazard bag, the NOELLE infant model (basic), water, and food coloring. The simulator electrical and mechanical systems were deactivated and protected by plastic liners. The amniotic sac unit was placed in the abdomen of the NOELLE simulator. This unit was then covered by flank steak to simulate the fascia and muscle layers of the abdomen. These two layers were then protected by two-inch model foam to serve as the subcutaneous fat. To hold the layers of the abdomen in place, an iodoform band was attached from the pelvis to the breast line of the model. The skin was recreated by flesh-colored duct tape keeping the abdominal layers secure (see Figure
Modified Gaumard’s NOELLE® Maternal and Neonatal Birthing Simulator. (a) Disposable abdominal wall and amniotic sac unit covered by flank steak, emulating fascia, and muscle layers. (b) Subcutaneous fat later made from two-inch model foam. (c) Internal layers held in place by an iodoform band. (d) Skin recreated from flesh-colored duct tape.
Individual CS, KT, and simulation team performance scores were analyzed using SPSS 22.0.
Resident participation was 45% (9 of 20). Average participant age was
Residents confidence and knowledge scores before and after intervention.
Test scores | Before intervention | After intervention | Change in score |
|
---|---|---|---|---|
Knowledge (%) | ||||
Mean (SD) | 58.9 (8.94) | 72.8 (6.18) | 13.9 (11.93) | 0.016 |
Median | 65 | 75 | 10 | |
Min–Max | 45–70 | 65–80 | 0–35 | |
|
||||
Self-reported confidence | ||||
Mean (SD) | 22.2 (6.42) | 29.9 (3.41) | 7.7 (4.82) | 0.007 |
Median | 24 | 32 | 7 |
Note:
Residents team competence scores (paired) before and after intervention.
Critical performance steps (area of competency/posttest competency) | Pretest competency | |||
---|---|---|---|---|
Not competent | Competent |
| ||
Team leader | ||||
Ensures high-quality CPR at all times | Not Competent | 9 (100%) | NA | |
Competent | ||||
Assigns team member roles | Not Competent | 9 (100%) | NA | |
Competent | ||||
Ensures that team members perform well | Not Competent | 5 (55.6%) | 0.134 | |
Competent | 4 (44.4%) | |||
|
||||
VF management | ||||
Recognizes VF | Not Competent | 5 (55.6%) | 0.134 | |
Competent | 4 (44.4%) | |||
Clears before ANALYZE and SHOCK | Not Competent | NA | ||
Competent | 9 (100%) | |||
Immediately resumes CPR after shocks | Not Competent | NA | ||
Competent | 9 (100%) | |||
Appropriate airway management | Not Competent | 0.008 | ||
Competent | 9 (100%) | |||
Appropriate cycles of drug-rhythm check/shock-CPR | Not Competent | 0.008 | ||
Competent | 9 (100%) | |||
Administer appropriate drug(s) and doses | Not Competent | 9 (100%) | NA | |
Competent | ||||
|
||||
BLS/ACLS modifications for pregnancy | ||||
Activates protocol for an emergency cesarean delivery as soon as cardiac |
Not Competent | 0.134 | ||
Competent | 4 (44.4%) | 5 (55.6%) | ||
Positions patient in left-lateral tilt or performs manual uterine displacement | Not Competent | 0.008 | ||
Competent | 9 (100%) | |||
Performs chest compressions slightly higher on sternum than normally |
Not Competent | 0.074 | ||
Competent | 5 (55.6%) | 4 (44.4%) | ||
Uses bag-mask ventilation with 100% O2 before intubation is done | Not Competent | 0.074 | ||
Competent | 5 (55.6%) | 4 (44.4%) | ||
Attempts to identify common and reversible causes of cardiac arrest in |
Not Competent | 0.008 | ||
Competent | 9 (100%) | |||
Delivers infant by emergency cesarean section | Not Competent | NA | ||
Competent | 9 (100%) | |||
Delivers infant no more than 5 minutes after cardiac arrest ensues | Not Competent | 0.074 | ||
Competent | 5 (55.6%) | 4 (44.4%) | ||
|
||||
Postcardiac arrest | ||||
Identifies ROSC | Not Competent | 0.074 | ||
Competent | 5 (55.6%) | 4 (44.4%) | ||
Ensures BP and 12 lead ECG are performed and O2 saturation is monitored, |
Not Competent | 9 (100%) | NA | |
Competent | ||||
Considers therapeutic hypothermia | Not Competent | 9 (100%) | NA | |
Competent |
Note:
In our study we noted a significant improvement in the critical performance steps of airway management, adherence to advanced cardiovascular life support (ACLS) treatment algorithm, manual left uterine displacement, and identification of common causes of maternal cardiac arrest. There was also improvement of KT scores from baseline. This trend was also demonstrated in the increase in CS from the initial evaluation to the postintervention stage. This is likely a result of the focused, interactive learning environment afforded in the simulation laboratory and the expert debriefing following all simulations.
Cardiopulmonary arrest in pregnancy is a high-risk, low frequency scenario and as such requires continued training and preparation to maintain an appropriate skill level to manage these complex patients [
Despite the training intervention, groups did not demonstrate a significant improvement in team leader specific tasks of ensuring high-quality cardiopulmonary resuscitation (e.g., minimizing disruptions in chest compression) and role assignment. During the debriefing sessions team leaders expressed difficulty assigning roles and determining a team leader because, in some instances, there were multiple senior level residents in the teams. This varies greatly from their normal call schedule. We used this opportunity to emphasize the importance of having a clearly defined leader, how to choose a team leader among peers, and how those “would be leaders” can be an asset to the team by being the first follower [
The critical performance steps that did not show improvement, pertaining to CRM (e.g., team leadership), likely need continued longitudinal training throughout residency to achieve competence. Consistent with current ACLS training literature regarding skill decay, our belief is that the lack of consideration of therapeutic hypothermia, as well as the areas where residents remained noncompetent, was likely due to the expected decline in knowledge and psychomotor skill retention after ACLS certification [
Residents performed a perimortem cesarean section during all simulations. However, we observed an unexpected trend with almost all groups choosing to perform a Pfannenstiel skin incision and a low transverse uterine incision, contrasting with the current practice guidelines that favor a midline vertical incision (see Figure
Residents performing emergent perimortem cesarean section.
Our study had several limitations including a small sample size and residents from one concentration (obstetrics and gynecology) from a single institution. We hope to further strengthen our simulation-based curriculum by providing a true interprofessional learning environment. In future simulation scenarios, ideally we would include multiple disciplines and levels of training to help the assignment of team roles and execution of tasks feel more appropriate for the learner. Based on our study, further practice with these scenarios is needed to solidify the important concepts pertaining to cardiovascular collapse. In our institution, we plan to do this by utilizing these scenarios starting with the incoming interns’ initial “boot camp” and repeating this training through all four years to track progress, decrease skill decay, and solidify concepts with which the learner may not be regularly faced. For other groups attempting a similar study or for obstetrics and gynecology learners in general, our project demonstrated the need to enforce early and often the key changes for maternal cardiac arrest management. It also demonstrated that further training and enforcement of team leader skills is crucial to improve the confidence and performance of the team.
This simulation-based study demonstrated improved OBGYN resident knowledge, confidence, and competence in several areas of the management of third trimester maternal cardiac arrest. Several skills, however, will likely require more longitudinal curricular exposure and training to develop and maintain proficiency.
Crisis resource management
Obstetrician/Gynecologist
Confidence survey
Knowledge test
Maternal Fetal Medicine
Emergency Medicine
American Heart Association
Cardiopulmonary resuscitation
Advanced Cardiac Life Support.
There is no conflict of interests regarding the publication of this paper.
(i) Study conception and design were done by Jacquelyn Adams, Jose R. Cepeda Brito, Lauren Baker, Patrick G. Hughes, M. David Gothard, Michele L. McCarroll, Jocelyn Davis, Angela Silber, and Rami Ahmed. (ii) Acquisition of data was done by Jacquelyn Adams, Jose R. Cepeda Brito, Lauren Baker, Patrick G. Hughes, Michele L. McCarroll, and Rami Ahmed. (iii) Analysis and interpretation of data were done by Jacquelyn Adams, Jose R. Cepeda Brito, M. David Gothard, Michele L. McCarroll, and Rami Ahmed. (iv) Drafting of the paper was done by Jacquelyn Adams, Jose R. Cepeda Brito, Michele L. McCarroll, Jocelyn Davis, and Rami Ahmed. (v) Critical revision was done by Jacquelyn Adams, Jose R. Cepeda Brito, Lauren Baker, Patrick G. Hughes, M. David Gothard, Michele L. McCarroll, Jocelyn Davis, Angela Silber, and Rami Ahmed.
Several people were instrumental in the completion of this pilot study and the authors would like to acknowledge them here. They would like to thank the staff of the Virtual Care Simulation Laboratory, especially S. Scott Atkinson, for his role in the development of the modifications to the birthing simulator so that the participants could perform a life-like cesarean section and Alma Benner for her technical support during all the simulations. They would also like to thank the Akron City Hospital’s Labor and Delivery nursing staff for their role as support staff during all the simulations, and Jennifer Frey for her valuable guidance through the submission and preparation process. Finally, they would like to thank their faculty, Dr. Edward Ferris, Dr. Thomas Mendise, and Dr. Susan Shondel who very graciously donated their time to further their residents’ education by serving as content experts.