ASSOCIATION OF PROFESSORS OF GYNECOLOGY AND OBSTETRICS

Learning Outcomes 

This clinical skills module provides a standardized framework for teaching management of normal vaginal delivery. Following participation in this module, students should demonstrate the following learning outcomes:

1. Describe the three stages of labor
2. Describe the cardinal movements of labor
3. Describe the various types of fetal position
4. Describe the steps of a normal vaginal delivery
5. Properly assess fetal station and position
6. Deliver the fetal head
7. Assess for nuchal cord
8. Deliver the remainder of the body
9. Deliver the placenta
10. Identify cervical and/or perineal lacerations
11. Properly document the delivery procedure

These learning objectives can be met through a combination of self-directed learning and didactics.

Best Practices 

Reliance upon clinical experience as a “gold-standard” for training in vaginal delivery can be limited by several factors, namely, inadequate patient availability, unpredictable emergencies, and lack of standardization of training. The alternative to clinical practice is structured skills training using an obstetrical birth simulator. Simulation allows students to learn, make mistakes, and receive feedback in a safe setting (1,2). Although investigations describing the efficacy of these models are limited, available evidence suggests that training novices with these models results in better overall performance and higher levels of confidence in their skills to perform vaginal deliveries (3,4).

Therefore we suggest that birth simulators be used to teach vaginal delivery skills to medical students.

A number of models for training in vaginal delivery can be purchased from commercial vendors. It is important to note that more realistic (high-fidelity) simulators do not necessarily provide better skills attainment as compared to less-realistic (low-fidelity) simulators (1). Therefore, the selection of an appropriate simulation model should be based on the scope of the learning objectives. For the purpose of medical student training, a low-fidelity simulator is expected to produce equivalent learning outcomes to high-fidelity simulators.

Following completion of appropriate didactic or self-directed background learning, students should participate in a mentored hands-on practice session/lab.

Case Scenario

A 26-year-old gravida 3 para 2 @ 40 2/7 weeks has presented to the triage room on Labor and Delivery. The fetal heart rate is 150 beats per minute. The estimated fetal weight is 3.15 kg (7 lb). The women states she has a strong desire to push and is leaking clear fluid. She has had an uncomplicated prenatal course. She has had 2 vaginal deliveries of 3.6-kg (8 lb) infants.

The student tasks are to:

1. Perform a vaginal exam to determine initial fetal station and position
2. Manage delivery of the infant
3. Manage delivery of the placenta
4. Initiate warming and drying of infant
5. Examine the cervix and perineum for lacerations
6. After completing the delivery, complete a delivery note

Checklist 

The following checklist may be used as a component of the training session and/or as a component of a performance assessment as part of an objective structured clinical examination.

Sample Delivery Note
NSVD of a live female infant, 3000 gm and Apgars 9/9. Delivered LOA, no nuchal cord, clear fluid. Head delivered atraumatically, body delivered without difficulty. Cord clamped and cut. Baby handed to nurse. Placenta delivered via continuous cord traction. Fundus firm, minimal bleeding. Perineum and vagina inspected – small 2nd degree perineal laceration repaired under local anesthesia with 2-0 and 3-0 vicryl-rapide suture in the usual fashion. Placenta appears intact and grossly normal with 3 vessel cord. Hemostasis noted. EBL 350 cc.  No complications.

Performance Assessment

Once adequate practice has been obtained, both with the birth simulators and actual patient encounters, a formal assessment of knowledge and skills can be conducted using the checklist.

This session should include the following components:

1. Standardized case scenario with skills assessment using birth simulator model
2. Materials for student to document delivery procedure note

Practical Tips

We recommend that vaginal delivery skills training be introduced to students during the third-year clinical clerkship in Obstetrics and Gynecology. The training/practice session can best be conducted as a skills lab, followed by immediate performance assessment using the checklist. Continued practice should be encouraged during the clerkship. Consideration can be given to conducting a performance assessment as part of an objective structured clinical examination at the end of the obstetrics and gynecology clerkship or at the end of the third year.

Resources

The following is a list of resources that may be helpful in augmenting your didactic presentations in these areas:

The following table lists some of the available simulation models and their relative cost:

1. DeStephano C, Chou B, Patel S, Slattery R, Hueppchen N. A randomized controlled trial of birth simulation for medical students. Am J Obstet Gynecol. 2015; 213:91.e1-7.
2. Deering S, Auguste T, Lockrow E. Obstetric simulation for medical student, resident, and fellow education. Seminars in Perinatology. 2013; 37:143-5.
3. Deering S, Bowen J, Hodor J, Satin AJ. Simulation training and resident performance of Singleton vaginal breech delivery. Obstet Gynecol. 2006; 107(1): 86-89.
4. Jude DC, Gilbert GG, Magrane D. Simulation training in the obstetrics and gynecology clerkship. Am J Obstet Gynecol. 2006; 195:1489-92.