European Journal of Obstetrics & Gynecology and Reproductive Biology 159 (2011) 72–76

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European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Self-perceived impact of simulation-based training on the management of

real-life obstetrical emergencies
Ana Reynolds a,*, Diogo Ayres-de-Campos a,b, Mariana Lobo b
a
Simulation Centre, Department of Obstetrics and Gynecology, Faculty of Medicine, University of Porto, Portugal
b
INEB – Institute of Biomedical Engineering, University of Porto, Portugal

A R T I C L E I N F O A B S T R A C T

Article history: Objective: To evaluate the self-perceived impact of attending a simulation-based training course on the
Received 14 March 2011 management of real-life obstetrical emergencies.
Received in revised form 28 June 2011 Study design: A prospective follow-up study was conducted. Obstetric nurses and obstetricians (n = 54)
Accepted 11 July 2011
from a tertiary care university hospital participated in a simulation-based training course for the
management of four obstetric emergencies. One year after the last session of the course, participants
Keywords: were asked to complete a questionnaire evaluating the self-perceived impact it had on their knowledge,
Simulation
technical skills, and teamwork skills during experienced real-life situations. A five-point Likert grading
Training programs
scale was used. The x2 test with one degree of freedom or the Fisher’s exact test were used to compare
Obstetrics
Patient care team groups of participants. The t-test for independent samples was used to compare mean scores between
Emergencies groups.
Results: A total of 46 healthcare professionals answered the questionnaire: 27 obstetricians and 19
obstetric nurses. Of these, 87% perceived an improvement (scores 4 or 5) in their knowledge and skills
during real emergencies. Obstetric nurses expressed a significantly higher improvement than
obstetricians in their ability to diagnose or be aware of obstetrical emergencies (p = 0.002), in their
technical skills (p = 0.024), and in their ability to deal with teamwork related issues (p = 0.005).
Participants who had experienced in real-life situations all four simulated scenarios rated the impact of
training significantly higher than others (p = 0.049), and also reported a better improvement in their
knowledge of management guidelines (p = 0.006).
Conclusions: Healthcare professionals who participated in a simulation-based training course in
obstetrical emergencies perceived a substantial improvement in their knowledge and skills when
witnessing real-life emergencies. Improvements seem to be particularly relevant for obstetric nurses and
for those who witness all trained obstetrical emergencies.
ß 2011 Elsevier Ireland Ltd. All rights reserved.

1. Introduction ‘‘Managing Obstetric Emergencies and Trauma (MOET)’’ course

Structured simulation-based training courses in obstetrical
emergencies were developed and implemented in the 1990s. The
‘‘Advanced Life Support in Obstetrics’’ (ALSO) course was
introduced in the United States in 1991, to enhance obstetrical
emergency skills for clinicians who provided low-risk and/or
low-intervention maternity services [1]. It included standardized
lectures with management protocols, and hands-on sessions
with custom-design mannequins. In the United Kingdom, the
* Corresponding author at: Departamento de Ginecologia e Obstetrı́cia,
Faculdade de Medicina da Universidade do Porto, Al. Prof. Hernâni Monteiro,
4200-319 Porto, Portugal.
E-mail address: reynolds@med.up.pt (A. Reynolds).
was introduced in 1998, to teach advanced skills to obstetricians
and anesthetists [2]. More recently, the ‘‘Practical Obstetric
Multi-Professional Training (PROMPT)’’ course was developed in
the United Kingdom, as a training package for obstetricians,
midwives and anesthetists, allowing the implementation of
courses at individual maternity units [3].
Multidisciplinary simulation-based team training in obstetrical
emergencies was introduced in Portugal in 2006, at the Biomedical
Simulation Centre of the Porto Medical School. National curricula
for this course have now been developed with the support of the
College of Obstetrics and Gynecology, the Society of Obstetrics and
Maternal–Fetal Medicine and the Association of Obstetric Nurses,
and are currently being used across all simulation centers in the
country. Arguments favoring the implementation of such courses
were a need to acquire and maintain management skills in

0301-2115/$ – see front matter ß 2011 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ejogrb.2011.07.022
 A. Reynolds et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 159 (2011) 72–76
obstetrical emergencies, because of the rarity of these events, and
the ethical/legal dilemmas related to the management of such
situations by novices.
The United States Joint Commission on Accreditation of
Healthcare Organizations [4], the United Kingdom Maternity
Clinical Negligence Scheme for Trusts [5,6], and the European
Resuscitation Council [7] all advise the regular training of
obstetrical emergencies, based on current disparities found in
the management of these situations.
It is hoped that simulation-based training improves subsequent
management of real-life situations (transferability), leading to a
reduction in the incidence of adverse obstetric outcomes. This
latter aspect has been demonstrated in some observational studies
with historical controls [8–10], albeit the several biases that may
affect this study design. This study aimed at evaluating transfer-
ability, by assessing the self-perceived impact of a simulation-
based course on knowledge, technical skills, and teamwork skills,
experienced during real-life situations.
2. Materials and methods
The study was conducted in the labor ward of a tertiary care
university hospital, with an average of circa 2800 deliveries per
year. All obstetricians and obstetric nurses working in the labor
ward who had participated, at least one year previously, in a
simulation-based obstetrical emergencies course were approached
for participation.
Fig. 1. Study population flowchart.
73
A total of 16 courses were run between April 2006 and
December 2007, with the participation of 15 specialists, 15
residents in Obstetrics and Gynecology, and 27 obstetric nurses.
Fig. 1 displays the population flowchart (Fig. 1). The course
instructors (three specialists and two obstetric nurses), and the
staff who had moved to other healthcare facilities (two residents
and one obstetric nurse) were not approached to fill in the
questionnaire. Eight course participants (one specialist and seven
obstetric nurses) did not complete the questionnaire.
The simulation-based course was run in one of the labor ward
suites. Each course lasted 4 h and featured four training scenarios:
acute fetal hypoxia, shoulder dystocia, post-partum hemorrhage,
and eclampsia. A full body delivery simulator (NoelleTM, Gaumard
Inc., Miami, USA) was used in the first three scenarios and a patient
actor in the fourth. After a 10-min introduction to explain the
training objectives and course methodology, participants were
divided into two teams of one or two obstetricinas and one or two
obstetric nurses. One team was assigned to manage the clinical
scenario, while the other filled in a performance evaluation
checklist. The latter was developed based on local management
guidelines and evaluated knowledge, technical skills and team-
work related issues, such as communication, task distribution,
team support, and plan sharing. A 10-min presentation of the
management guideline followed the first resolution of the
scenario, after which the scenario was repeated as teams changed
their roles. Teams alternated in their order of scenario resolution
and a facilitator was present at all times to aid trainees if the
74 A. Reynolds et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 159 (2011) 72–76

scenario was not progressing. A short debriefing session followed
the second resolution of the scenario, and teams discussed their
performances based on the checklist report.
The study questionnaire was anonymous and included ques-
tions about the trainee’s age, gender, profession and years of
experience. It also enquired whether they had witnessed one or
more of the trained obstetric emergencies during the year that
followed the last training course, and whether they had witnessed
other obstetrical emergencies (listed in Table 2). This was followed
by ten questions related to their self-perceived performance
during real-life situations and, as a result, course usefulness (listed
in Tables 3 and 4). All these questions were rated using a 5-point
Likert scale (1 – totally disagree, 2 – disagree, 3 – no opinion, 4 –
agree, 5 – totally agree). Additional free text commentaries and
suggestions were welcomed.
A formal evaluation of the study protocol by the institution’s
Ethics Committee was judged to be unnecessary, as no patient-
identifiable data was evaluated and the questionnaire was
anonymous and answered voluntarily.
2.1. Statistical analysis
The Statistical Package for Social Sciences (v.15 SPSS Inc, Chicago,
USA) was used for statistical analysis. Internal consistency of the
questionnaire was evaluated using Cronbach’s alpha coefficient. A
binomial test was applied to check whether responses were
significantly different from the neutral value (Likert score of 3).
As the majority of answers (87.6%) lay between ‘‘agree’’ or ‘‘totally
agree’’ (Likert score of 4 or 5) the Likert scale was simplified into two
levels: ‘‘totally agree’’ (Likert score = 5) or ‘‘the rest’’ (Likert
score  4). The x2 test with one degree of freedom was used to
compare the percentages of ‘‘totally agree’’ answers (Likert
score = 5) between groups: obstetric nurses versus obstetricians
and, participants who had witnesses all four trained emergencies in
real life versus others. If test assumptions could not be met, Fisher’s
exact test was used. Based on its summative properties, the Likert
scale was transformed into a single continuous overall rating score,
ranging from 10 to 50, to perform a global analysis. The Kolmogorov–
Smirnov test was used to confirm that the overall rating score
variable was normally distributed, and consequently the parametric
t-test for independent samples was chosen to compare mean scores
between groups. Significance of tests was set at p < 0.05. The
Cohen’s d effect size [11,12] was calculated to complement
inferential statistics.
3. Results
A total of 57 healthcare professionals attended the obstetric
emergencies course (15 specialists, 15 residents and 27 obstetric
nurses), corresponding to 74% of the labor ward staff (excluding
the five involved in training). Two residents and one obstetric
nurse had moved on to other healthcare facilities. Forty-six course
participants (85%) answered the questionnaire (14 specialists, 13
residents and 19 obstetric nurses).
Analysis of the main characteristics of questionnaire respon-
ders versus all course participants still working in the labor ward is
displayed in Table 1, and revealed no significant differences
between the two groups.
The number and percentage of questionnaire responders who
witnessed real-life emergencies, are displayed in Table 2. An
average of 6.3 different types of obstetrical emergency situations
was witnessed (291 reported emergencies/46 responders). Similar
experiences with obstetrical emergencies were reported by
obstetric nurses (123/19 = 6.5), all obstetricians (168/27 = 6.2),
specialists only (90/14 = 6.4), and residents only (78/13 = 6.0).
Responders witnessed an average of 2.6 (120/46) of the four

Table 1
Comparison of demographic data between course participants (CP) and responders to the questionnaire (R). Statistical analysis between groups (p).

Obstetric nurses Specialists Residentsa

CP R p CP R p CP = R

N 26 19 15 14 13
Average age (years) (range) 42 (30–55) 40 (30–54) 0.229 43 (31–57) 42 (31–55) 0.700 29.3 (26–35)
Female participants (n) (%) 25 (96.2) 18 (94.7) 1.000 13 (86.7) 13 (92.9) 1.000 13 (100)
Average experience (years) (range) 7.7 (1–24) 5.6 (1–21) 0.253 8.7 (1–23) 7.8 (1–23) 0.736 3.1 (1–6)
a
All residents that participated in the course responded to the questionnaire.

Table 2
Number (n) and percentage (%) of responders who attended each real-life obstetrical emergency during the year that followed the last course. The first four emergencies were
part of the simulation-based course scenarios.

Obstetrical emergency Obstetric nurses (n = 19) Obstetricians (n = 27) Overall (n = 46)

n (%) n (%) n (%)

Acute fetal hypoxia 17 (90) 24 (89) 41 (89)

Shoulder dystocia 12 (63) 21 (78) 33 (72)
Post-partum hemorrhage 11 (58) 18 (67) 29 (63)
Eclampsia 9 (47) 8 (30) 17 (37)
Cord prolapse 10 (53) 14 (52) 24 (52)
Uterine hyperstimulation with fetal distress 17 (90) 19 (70) 36 (78)
Retention of the aftercoming head 0 (0) 1 (4) 1 (2)
Placental abruption 8 (42) 12 (44) 20 (43)
Hemorrhage due to placenta praevia 7 (37) 11 (41) 18 (39)
Placental retention 14 (74) 17 (63) 31 (74)
Uterine rupture 1 (5) 5 (19) 6 (13)
Abortion with profuse hemorrhage 7 (37) 12 (44) 19 (41)
Disseminated intravascular coagulation 1 (5) 2 (8) 3 (7)
Maternal cardio-respiratory arrest 2 (11) 1 (4) 3 (7)
Amniotic fluid embolism 3 (16) 2 (7) 5 (11)
Other 4 (21) 1 (4) 5 (11)
Total 123 168 291
 A. Reynolds et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 159 (2011) 72–76 75

Table 3
Overall Likert score ratings for each item of the questionnaire. Number (n) and percentage (%) of responders (n = 46).

Totally Disagree No opinion Agree Totally

disagree n (%) n (%) n (%) agree n
n (%) (%)

1 ‘‘My knowledge of management guidelines in obstetrical emergencies improved’’ 0 1 (2.2) 0 19 (41.3) 26 (56.5)
2. ‘‘My ability to diagnose or to be aware of emergency situations improved’’ 0 1 (2.2) 0 21 (45.7) 24 (52.2)
3. ‘‘My technical skills for performing obstetrical maneuvers improved’’ 0 4 (8.7) 1 (2.2) 21 (45.7) 20 (43.5)
4. ‘‘I dealt more easily with teamwork related issues’’ 0 0 3 (6.5) 25 (54.3) 18 (39.1)
5. ‘‘My communication skills improved’’ 0 2 (4.3) 2 (4.3) 32 (69.6) 10 (21.7)
6. ‘‘My support of other team members improved’’ 0 3 (6.5) 8 (17.4) 27 (58.7) 8 (17.4)
7. ‘‘I felt that communication skills among team members improved’’ 0 5 (11) 11 (23.9) 23 (50) 7 (15.2)
8. ‘‘I felt support from the other team members’’ 0 0 4 (8.7) 34 (73.9) 8 (17.4)
9. ‘‘I felt a greater sharing of the plan by the team members’’ 0 3 (6.5) 9 (19.6) 26 (56.5) 8 (17.4)
10. ‘‘I felt the training course to be a useful experience’’ 0 0 0 9 (19.6) 37 (80.4)

trained emergencies, with similar experiences being reported by
obstetric nurses (49/19 = 2.6), all obstetricians (71/27 = 2.6),
specialists only (39/14 = 2.8), and residents only (32/13 = 2.5).
Cronbach’s alpha coefficient for questionnaire results was
0.866, indicating a good internal consistency, as a value higher
than 0.70 is considered acceptable for this purpose [13].
Responders rated 87.6% of all questions as ‘‘agree’’ or ‘‘totally
agree’’ (Likert score of 4 and 5). The scores for each questionnaire
item are shown in Table 3. There were no statistically significant
differences in overall rating between obstetric nurses with more
than five years experience and others (p = 0.679) or between
specialists and residents (p = 0.574). Obstetric nurses assigned a
maximum rating more often than obstetricians, but overall ratings
were not statistically different (p = 0.053). Differences reached
statistical significance in questions two (p = 0.002), three
(p = 0.024) and four (p = 0.005), where obstetric nurses expressed
a higher improvement than obstetricians in their ability to
diagnose or be aware of emergency situations, in their technical
skills and in their ability to deal with teamwork related issues.
Responders who had witnessed all four of the trained situations
(four specialists, one resident, and three obstetric nurses)
attributed maximum ratings more frequently than others
(p = 0.049), and also reported a greater improvement in their
knowledge of management guidelines (p = 0.006). These results
are shown in detail in Table 4.
Cohen’s d for the overall rating difference between obstetric
nurses and obstetricians was 0.5, and for responders who had
witnessed all four trained emergencies versus others was 0.8,
suggesting that the groups are different for both comparisons.
Regarding the perceived usefulness of training, 80.4% of all
responders attributed a maximum rating (84% of the obstetric
nurses and 78% of the obstetricians). Twenty four (52.2%)
healthcare professionals provided additional comments or sugges-
tions. The most frequent suggestion was that training should be
repeated on a regular basis and/or with other scenarios (87.5%).
4. Comment
Healthcare professionals who had participated in a simulation-
based training course in obstetrical emergencies perceived a
substantial improvement in their knowledge and skills when
witnessing real-life emergencies. Improvements seem to be
particularly relevant for obstetric nurses and for those who
witness all trained obstetrical emergencies. The utility of the
course received maximum rating by a large majority of partici-
pants.
Possible limitations of this study include a relatively small
sample size, mainly as a consequence of training being limited to
one maternity unit. The need to keep questionnaires anonymous
led to the impossibility of tracking down non-responders and thus
increasing response rate. A larger sample size might have led to the
finding of significant differences between obstetric nurses and
obstetricians in their overall perception of improvement, as
suggested by the Cohen’s d effect size measurement. It could also

Table 4
Number (n) and percentage (%) of obstetric nurses versus obstetricians as well as those who had witnesses all four trained emergencies in real life (‘‘witnessed all
emergencies’’) versus others with maximum rating of each questionnaire item (Likert score of 5). Statistical analysis between groups (p).

Obstetric Obstetricians ‘‘witnessed Others (n = 38)

nurses (n = 27) all emergencies’’
(n = 19) (n = 8)

n (%) n (%) p n (%) n (%) p

1. ‘‘My knowledge of management guidelines in obstetrical 12 (63%) 14 (52%) 0.446a 8 (100%) 18 (47%) 0.006b
emergencies improved’’
2. ‘‘My ability to diagnose or to be aware of emergency 15 (79%) 9 (33%) 0.002a 6 (75%) 18 (47%) 0.247b
situations improved’’
3. ‘‘My technical skills in performing obstetrical maneuvers 12 (63%) 8 (30%) 0.024a 5 (63%) 15 (40%) 0.267b
improved’’
4. ‘‘I dealt more easily with teamwork related issues’’ 12 (63%) 6 (22%) 0.005a 5 (63%) 13 (34%) 0.232b
5. ‘‘My communication skills improved’’ 7 (37%) 3 (11%) 0.067b 3 (38%) 7 (18%) 0.344b
6. ‘‘My support of other team members improved’’ 5 (26%) 3 (11%) 0.246b 3 (38%) 5 (13%) 0.129b
7. ‘‘I felt that communication skills among all team members 5 (26%) 2 (7%) 0.107b 3 (38%) 4 (11%) 0.089b
improved’’
8. ‘‘I felt support from the other team members’’ 5 (26%) 3 (11%) 0.246b 3 (38% 5 (13%) 0.129b
9. ‘‘I felt a greater sharing of the plan by all team members’’ 5 (26%) 3 (11%) 0.246b 3 (38%) 5 (13%) 0.129b
10. ‘‘The training course was useful’’ 16 (84%) 21 (78%) 0.716b 7 (88%) 30 (79%) 1.000b
Overall rating (mean  SD) 43.5  5.16 40.9  3.96 0.053c 44.9  4.22 41.3  4.53 0.049c
a
Statistical analysis using chi-square test with one degree of freedom.
b
Statistical analysis using the Fisher’s exact test.
c
Statistical analysis using t-test for independent samples.
76 A. Reynolds et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 159 (2011) 72–76
have uncovered differences related to participants’ years of
experience. There was a trend towards lower scores in the
majority of questions related to teamwork skills (questions 5–9),
than in those concerning cognitive or technical skills (questions 1–
4), but this failed to reach statistical significance. Obstetric nurses
and responders who had witnesses all four trained situations also
tended to report higher improvements in teamwork skills, but
again differences did not reach statistical significance.
Training took place over a period of 20 months, so that the time
elapsed between taking the course and responding to the
questionnaire varied between 12 and 32 months. This aspect
created some heterogenicity in the experience accumulated after
the course, but the anonymity of the questionnaires precluded an
evaluation of its effect.
The voluntary nature of the course raises the possibility of
selection bias with the participants. Indeed, almost all junior
obstetricians and obstetric nurses attended, while senior obste-
tricians constituted the majority of absentees. Therefore, the
conclusions of this study cannot be safely applicable to the latter
group.
While self-evaluation of knowledge, technical skills and
teamwork skills has inherent limitations for assessing transfer-
ability into the real domain, other consensual and validated forms
are lacking and envisioned alternatives are associated with great
practical difficulties. Significant increases in trainee’s self-confi-
dence after attending a simulation-based training course in
obstetrical emergencies have been reported by others, and these
appear to be maintained at 12 months [14] or when measured 9–
15 months after training [15]. Training has also been associated
with an enhancement of cognitive knowledge [16], and an
improvement of management skills, with retention of these skills
at 6 and 12 months after training [17–20].
Our training course was held inside the labor ward, but
scheduled outside normal working hours to avoid overlapping
activities. One study evaluating the implementation of obstetric
drills in the labor ward [21], reported difficulties in running them
in busy units, as service provision was adversely affected, and there
were problems in maintaining staff concentration. On the other
hand, training of obstetrical emergencies in a simulation centre has
been associated with lesser benefits than training in the delivery
ward [16,22].
Obstetric nurses reported a higher improvement than obste-
tricians in their ability to diagnose or be aware of obstetrical
emergencies, as well as in their technical skills and ability to deal
with teamwork related issues. It is possible that there were more
knowledge gaps in this group, perhaps as a consequence of
previous training and/or experience and less participation in the
development of management guidelines. It is also possible that this
group has a greater predisposition to learning with simulation, and
a greater awareness of the importance of teamwork skills.
Obstetric nurses are frequently at the front line of obstetrical
emergencies, and it is therefore likely that such improvements will
translate into benefits for patient outcome.
Participants who had witnessed real-life incidents of all four
trained scenarios reported an overall higher improvement of skills,
and a better knowledge of management guidelines, than the
remaining responders. These findings suggest a cognitive rein-
forcement and improvement in overall skills, when faced with
real-life situations, as a consequence of simulation-based training.
Poor knowledge, lack of technical skills and inadequate team
interactions have been shown to play an important role in
obstetrical adverse events [6,23], but the demonstration that
simulation-based training is able to change this picture is a much
more complex task. The results of this study suggest a transfer-
ability of knowledge and skills to real-life situations, as perceived
by the healthcare professionals themselves. Retrospective studies
have shown a significant decrease in the incidence of some adverse
neonatal outcomes after training [8–10]. However, a prospective
trial is needed to establish unequivocally the impact of such
courses on obstetric outcomes.
Acknowledgements
The authors would like to thank the training staff of the
obstetrical emergencies course, Mariana Guimarães (obstetrician),
Maria José Lemos (obstetric nurse) and Alexandra Amaral
(obstetric nurse); and all trainees who voluntarily participated
in the course and filled in the questionnaire.
Funding and conflicts of interest: No external funding was
provided and there are no conflicts of interest to declare.
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