1. Number of Simulation Sessions and Vaginal Delivery Performance in Medical Students Joshua F. Nitsche, MD, PhD, Timberly Butler, Alison Witkowski, Sha Jin, Brian C. Brost, MD Department of Obstetrics and Gynecology, Wake Forest School of Medicine Objective To determine the optimal number of simulation sessions needed for the majority of medical students to competently perform a vaginal delivery. Introduction Along with a Pap smear, breast exam, and labor cervical exam the vaginal delivery is a procedure that defines a medical student ’ s OB/GYN clerkship. These procedures are important because they are central to the practice of OB/GYN and students will likely have few exposures to these skills outside of their OB/GYN clerkship. Unfortunately, training opportunities are decreasing, such that many medical students graduate having performed few if any vaginal deliveries. Simulation can compensate for this by allowing students to practice vaginal delivery skills in a safe learning environment, better prepare them for their first real-life opportunity, diminish their anxiety with the procedure, and potentially increase a woman ’ s willingness to have such a trainee participate in the birth of her child. Simulation has been used in a several medical disciplines including OB/GYN 1,2 and has been successfully employed in medical 3 and nursing students 4. Surprisingly, there is very little information about the use of simulation in vaginal delivery training and how to best integrate it into the medical curriculum. Studies involving small numbers of medical students have shown that trainee self-assessed confidence 5,6 and participation in real-life deliveries was increased with the use of simulation 7. In a prior study of vaginal delivery simulation, we saw 85% of medical students achieve competence after 5 1-hour simulation session (unpublished observations). Given the large amount of instructor time required to conduct simulations we sought to illustrate the dose response curve of vaginal delivery simulation and determine if competence could be achieved after fewer than 5 sessions. Methods The number of vaginal delivery simulation sessions were varied during the first 4 OB/GYN clerkships of the academic year. Third year students received either 2, 3, or 4 vaginal delivery simulation sessions using the Noelle® birthing simulator. At the end of each clerkship all students participated in a hybrid vaginal delivery simulation using a standardized patient and a PROMPT® simulator to provide for a novel testing environment. Student performance was scored using a standardized procedural checklist, with a score of 26 or greater designated a satisfactory score. Checklist score and percentage of student with a satisfactory score were compared between groups using a one- way ANOVA with a Tukey’s post-test or a chi-square goodness of fit test. Results The data on student vaginal delivery performance based on number of training sessions is provided in Table 1. Checklist score and the percentage of students receiving a satisfactory score in the groups that had 3, 4, or 5 sessions were significantly higher than students that received only 2 training sessions (*p<0.05). Checklist scores and percentage of students receiving a satisfactory score in the groups that had 4 and 5 sessions were also higher than students that received only 3 sessions. This comparison approached but did not reach significance (†p<0.10). Discussion Students who received 3, 4, or 5 sessions performed significantly better that students that received only 2 simulations sessions. Although the comparison of performance of students that received 4 and 5 sessions was higher than those students who received 3 sessions the comparison approached, but did not achieve significance. However, with the relatively low numbers of students in the current analysis it is likely that significance would be reached with a larger sample size. The student performance in the present study was very similar to our previous findings comparing students that received 1 or 5 simulation sessions 7. Students in the prior study that received 5 simulation sessions and the students in the present study that received 4 or 5 sessions performed very well with high checklist scores and the great majority of students achieving a satisfactory score. However, students in the prior study that received 1 simulation session and the students in the present study that received 2 sessions performed rather poorly. In addition, students in the present study that received 3 sessions showed intermediate performance demonstrating a clear dose response of vaginal delivery simulation. As only 17% of students who received 2 simulation sessions achieved a satisfactory score on the final assessment, this small number of sessions does not adequately prepare students for a real-life delivery. There was significantly better performance in those students who had 3 sessions, but even then only 60% of students achieved a satisfactory score. As it is unclear what level of vaginal delivery skill should be expected of students after completion of the clerkship, some may argue that the performance of the student that received 3 sessions were adequately prepared for a real-life delivery. However, in that group of students still had a sizeable amount of ill-prepared students (40%) lending support for the argument that 4 sessions should be included in the clerkship so that the great majority of students do complete the rotation adequately prepared for real life deliveries. Conclusions Two simulation sessions are not sufficient to properly prepare students for real-life vaginal deliveries While students that received 3 sessions had significantly better performance than students who had only 2 sessions, 4 or 5 sessions may be required to properly prepare the vast majority of students for real-life deliveries. Depending on the goals of the clerkship three or four vaginal delivery simulation sessions likely provides the best balance between faculty resources and student performance Additional students should be added to the study in order to distinguish if 4 vaginal delivery simulation sessions provides additional benefit to students over just 3 sessions. References 1. Cook DA, Brydges R, et al. Comparative effectiveness of technology- enhanced simulation versus other instructional methods: a systematic review and meta-analysis. Simulation in healthcare : journal of the Society for Simulation in Healthcare. 2012;7(5):308-20. Epub 2012/10/04. 2. Cook DA, Hatala R, et al. Technology-Enhanced Simulation for Health Professions Education A Systematic Review and Meta-analysis. Jama-J Am Med Assoc. 2011;306(9):978-88. 3. Deering SH, Hodor JG, et al. Additional training with an obstetric simulator improves medical student comfort with basic procedures. Simulation in healthcare : journal of the Society for Simulation in Healthcare. 2006;1(1):32-4. Epub 2006/04/01. 4. Partin JL, Payne TA, Slemmons MF. Students' perceptions of their learning experiences using high-fidelity simulation to teach concepts relative to obstetrics. Nursing education perspectives. 2011;32(3):186-8. 5. Dayal AK, Fisher N, et al. Simulation training improves medical students' learning experiences when performing real vaginal deliveries. Simulation in healthcare : journal of the Society for Simulation in Healthcare. 2009;4(3):155-9. Epub 2009/08/15. 6. Jude DC, Gilbert GG, Magrane D. Simulation training in the obstetrics and gynecology clerkship. American journal of obstetrics and gynecology. 2006;195(5):1489-92. Epub 2006/07/19. 7. Shumard K, Fino N, Denney J, Quinn K, Bailey J, Jijon R, Huang C, Kesty K, Whitecar P, Grandis A, Brost B, Nitsche J, Effects of vaginal delivery simulation in novice providers, in preparation. ©Creative Communications Wake Forest Baptist Medical Center creative@wakehealth.edu Permission is granted for use when printed by Creative Communications. All other uses strictly prohibited. ©Creative Communications Wake Forest Baptist Medical Center creative@wakehealth.edu Permission is granted for use when printed by Creative Communications. All other uses strictly prohibited. Table 1. Student Vaginal Delivery Performance # of Sessions 2 (n=12) 3 (n=15) 4 (n=15) 5 (n=13) Checklist Score 22 ± 2.926 ± 4.0*28 ± 2.1*†28 ± 1.8*† % Passing Score 17%60%*87%*†92%*†