Discussion
Main findings
To our knowledge, this is the first study that compared the rate of assisted vaginal delivery in breech presentation according to Robson’s classification before and after the simulation-based training course. In assisted vaginal delivery for breech presentation, the simulation sessions for obstetricians seem to give more confidence to the obstetrician to try assisted vaginal delivery in the category R6, with no significant effect in the category R7. The introduction of a simulation-based course improved the management of vaginal breech deliveries and led to the presence of a more senior physician during the assisted vaginal delivery of breech presentation (attending physician and senior resident). The effect of simulation is time-related and this is explained by the increase of the rate of cesarean deliveries in the groups R6 and R7 to reach the same rates as before the simulation, so repeated simulation sessions are needed to maintain the same level of performance.
In our study no significant changes were noted in neonatal outcomes in terms of admission to the NICU and the Apgar score in the vaginal delivery and cesarean groups. The main reason for unfavorable neonatal outcomes was prematurity. We could conclude that breech assisted vaginal delivery, after simulation sessions, in some well selected cases could lead to maternal and neonatal favorable outcomes.
Strength and limitations
The strength of this study is that it evaluated, for the first time, the effect of simulation in the trend to deliver breech presentation vaginally and the changes emerged according to the Robson’s classification in a low-income setting in Lebanon. Our results highlight the importance of simulation to decrease the cesarean rate in the group R6 in particular. Due to the small number of patients included in the study (92 patients) done at a public hospital, it is unclear whether we can extend the results of our study to general population and to private hospitals that contributes to a considerable proportion of institutional deliveries.
Interpretations
Our conclusion that a simulation-based training led to better outcomes and more confidence in the management of breech assisted vaginal delivery aligns with previous findings by Hardy et al.12.
The retention of skills is time related. Stone et al. showed a decrease in retained skills in breech deliveries 10-26 weeks after the training, but the level of comfort was not affected by the time6.
Predictive criteria for a higher risk unsuccessful breech vaginal delivery include according to the Royal College to Obstetricians and Gynaecologists in 2017: hyperextended neck on ultrasound, high estimated fetal weight (>3,8kg), low estimated fetal weight (<10th percentile), footling presentation and antenatal fetal compromise. The presence of skilled experienced obstetrician leads to a safe breech vaginal delivery13.
This is where the role of simulation could be beneficial.
According to the new guidelines of the Collège National des Gynécologues et Obstétriciens Français (CNGOF) in 2020 the risk of neonatal complications is low in vaginal delivery or elective cesarean in term breech pregnancies 14.
The implementation of an evidence -based training programme (PROMPT) in obstetric emergencies adapted to the local settings with collaborative collective efforts is generative of safety and high performance in local maternities leading to better maternal and neonatal outcomes.
Obstetric simulation is a cornerstone in cases of high-acuity, low-frequency obstetric events.
Conclusion:
The prevalence of breech assisted vaginal delivery increased after implementation of a simulation-based training especially in the group R6 of the Robson classification, without increasing neonatal adverse effects.
Contribution to authorship
Inaam Hatoum and Amina Krounbi collected and analysed the data
Inaam Hatoum, Charlotte El Hajjar and Janoub Khazaal wrote the manuscript.
George Yared revised the manuscript before the submission.
Disclosure of interests
The authors disclose no conflict of interest.
Ethics approval
Our study was approved by the Institutional Review Board (IRB) at Rafic Hariri University Hospital.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Figure and table legends
Table 1: Prevalence of vaginal delivery in breech presentation according to Robson’ classification and the status of simulation
Figure 1: Prevalence of cesarean delivery in R6 and R7 between 2016 and June 2020