Introduction
In obstetrics, a change in professional practice style and patient
characteristics may affect the main obstetrical skills including breech
assisted vaginal delivery due to lack of training of obstetricians. This
has an impact on Cesarean delivery rate which has increased worldwide
reaching a rate as high as 40.5% in Latin America, 25% in
Europe,19.2% in Asia, and 7.3% in Africa with a difference between
low- and high-income countries 1
Moreover, The Term Breech Trial in 2000 showed better neonatal outcomes
in terms of morbidity and mortality in planned CD versus planned
assisted vaginal delivery in breech presentation without any changes in
maternal outcomes. This led to a steady decline in the rate of breech
assisted vaginal delivery and to fewer opportunities for training and
mastering vaginal breech deliveries for future generations of clinicians2.
The mode of delivery is registered through the Robson classification of
cesarean sections (the ten-group classification system) endorsed by
World Health Organization (WHO) since 2015 as the best tool for cesarean
classification. Among the ten groups, group 6 refers to nulliparous
women who delivered a singleton fetus with breech presentation, and
group 7 refers to multiparous women who delivered a singleton fetus in
breech presentation regardless of the previous mode of delivery3.
Given these facts, the role of simulation is getting more important to
build specific skills in obstetrics and specifically in breech assisted
vaginal deliveries as it previously showed benefit in maintaining
obstetrical skills.
Worldwide many simulation programs were attempted and evaluated.
A systematic review in 2018 has shown that simulation-based training has
led to better clinical performance and quality of patient care
especially in obstetrical emergencies 4.
Another systematic review in 2019 showed that operative vaginal delivery
simulation sessions are associated with improvement in the knowledge,
competencies, and skills of healthcare professionals and better patient
outcomes 5.
A simulation training for vaginal breech delivery for resident doctors
is associated with better performance and skills and more comfort that
last for 10-26 weeks and this improvement declines over time6,7.
In the United Kingdom (UK), the Practical Obstetric Multi-Professional
Training (PROMPT) is an evidence based multi-professional obstetric
emergencies training package adopted as a local obstetric emergency
training program in Bristol and showed significant improvements in
obstetrical and neonatal outcomes compared in the 4 years before and 4
years after its introduction (neonatal hypoxic brain injuries, reduction
in injuries after shoulder dystocia and in emergency cesarean section).
According to Draycott in 2015, training for obstetric emergencies may
not be always generalized and effective 8. It depends
on the nature of clinical and non-clinical outcomes measured, the
setting where the simulation is conducted (simulation center/
on-site..). Bergh et al. suggested that local training of teams at their
unit using their own tools and supplies made them more familiar to their
setting and led to the most effective training. This implies the
integration of local clinical, medical, environmental and human factors9.
In Australia the implementation of the PROMPT for the management of
postpartum hemorrhage led to improvements in clinical skills and
non-technical skills concerning confidence, leadership, communication
and teamwork with no significant impact on all clinical parameters10,11.
To our knowledge the maternity department at the Rafic Hariri University
Hospital is the only department in the middle east to follow the Train
the Trainers” program and to adopt it as a training program for all
maternity staff and one of the first maternity to adopt the Robson
classification.
Given the plethora of evidence supporting the benefit of simulation in
obstetrics and after the implementation of the PROMPT to our maternity
staff, the aim of our study is to evaluate its effect on the attitude of
the obstetricians to perform assisted vaginal delivery for breech
presentation measured by the changes observed in the Robson
classification (groups R6 and R7) and on the neonatal outcomes measured
by the Apgar score and admission to the neonatal intensive care unit.