The Journal of Maternal-Fetal & Neonatal Medicine

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Training needs in operative obstetrics for maternal-fetal medicine fellows Kacey Y Eichelberger, Angela M Bengtson, Sue Tolleson-Rinehart & M. Kathryn Menard To cite this article: Kacey Y Eichelberger, Angela M Bengtson, Sue Tolleson-Rinehart & M. Kathryn Menard (2015) Training needs in operative obstetrics for maternal-fetal medicine fellows, The Journal of Maternal-Fetal & Neonatal Medicine, 28:12, 1467-1470, DOI: 10.3109/14767058.2014.957669 To link to this article: http://dx.doi.org/10.3109/14767058.2014.957669

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Date: 25 October 2015, At: 12:36

http://informahealthcare.com/jmf ISSN: 1476-7058 (print), 1476-4954 (electronic) J Matern Fetal Neonatal Med, 2015; 28(12): 1467–1470 ! 2014 Informa UK Ltd. DOI: 10.3109/14767058.2014.957669

ORIGINAL ARTICLE

Training needs in operative obstetrics for maternal-fetal medicine fellows Kacey Y Eichelberger1, Angela M Bengtson2, Sue Tolleson-Rinehart3, and M. Kathryn Menard4 Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Greenville Health Systems, Greenville, SC, USA, 2Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA, 3Department of Pediatrics and the Health Care and Prevention MD-MPH Program, University of North Carolina, Chapel Hill, NC, USA, and 4MPH Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of North Carolina, Chapel Hill, NC, USA

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1

Abstract

Keywords

Objective: To define residual operative obstetric training needs for first-year maternal-fetal medicine (MFM) fellows. Methods: We administered a web-based survey to all 100 first-year fellows. We used descriptive statistics to report frequency data for 13 procedures, and logistic regression to estimate odds ratios for comfort in doing and teaching selected procedures. Results: Response rate was 86% (n ¼ 86). Fellows who completed residency in the Northeast/ Midatlantic (n ¼ 26) were less likely to report comfort doing or teaching low forceps deliveries (OR 0.21, 95% CI 0.05, 0.78; and 0.20, 95% CI 0.04, 0.85, respectively), while those completing fellowship in the West (n ¼ 13), reported more comfort performing breech extraction of a second twin (OR 6.84, 95% CI 1.24, 51.50); fellows completing residency in the Southeast formed the referent group. Fellows reporting completion of the three selected procedures 45 times each during residency were significantly more likely to report comfort doing and teaching them as fellows. Type of residency program (community/academic) was not significantly associated with reported comfort. Conclusion: The wide range of operative obstetric experience fellows reported gaining in residency varies by region. Additional research is needed to understand competency and teaching ability for procedural skills, and many MFM fellows may need additional procedural experience.

Breech extraction, cesarean hysterectomy, forceps, MFM fellow, operative obstetrics, surgical training

Introduction In the modern obstetric landscape in which one in three babies is born via cesarean, one in eight preterm, and one in 30 as part of a multiple gestation [1], an obstetrician’s ability to perform antepartum and intrapartum surgery skillfully is frequently nothing short of life-saving. While expertise in performing operative obstetric procedures remains a key learning objective for competency in Maternal-Fetal Medicine (MFM) [2], the extent to which incoming fellows feel sufficiently trained to either perform or teach these procedures as they begin fellowship remains largely unknown. Indeed, factors affecting one’s self-reported ‘‘surgical competency’’ in general remain incompletely defined, but include the individual learning curve for each given procedure, the method and quality of prior training,

Address for correspondence: Kacey Eichelberger, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Greenville Health Systems, 890 West Faris Road, Suite 470. Greenville, SC 29605, USA. Tel: +919 357 8633. Fax: +864 569 0390. E-mail: [email protected]

History Received 4 April 2014 Revised 14 July 2014 Accepted 20 August 2014 Published online 10 September 2014

reported comfort of the instructor, and volume of cases to which a learner has been exposed [3–5]. We sought to characterize residual training needs in operative obstetrics among first-year MFM fellows. Our primary objective was to determine the frequency with which 13 operative obstetric procedures were performed by incoming MFM fellows during their preceding residency training, as well as the fellows’ self-reported comfort with performing and teaching these procedures during their fellowship. Our secondary objective was to identify factors associated with increased comfort performing and teaching these procedures.

Methods In November 2011, we administered a web-based survey using Qualtrics software (Provo, UT) during the annual Maternal-Fetal Medicine Fellows’ Retreat. The retreat is a three day-long event in Palisades, NY to which all first year MFM fellows have been invited since its inception in 2010. Prior to survey distribution, we received exemption from the University of North Carolina’s Institutional Review Board, and then tested the survey model with seven chief residents

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and four MFM faculty at our institution, both for ease of use and conceptual concerns. The final survey was distributed twice via an embedded email link to all first-year fellows (n ¼ 100), regardless of their attendance at the retreat. The 13 operative obstetric procedures included in the survey were based on two criteria: first, that they were included in ABOG’s Guide to Learning in Maternal-Fetal Medicine as procedures for which graduating fellows should demonstrate ‘‘experience sufficient to perform the procedure independently’’ (e.g. cesarean hysterectomy, transvaginal cervical cerclage, operative vaginal deliveries, episiotomy and vaginal laceration repair, and management of the nonvertex second twin) [2]; and second, that these procedures may have been performed by the first-year fellow as lead surgeon during their preceding residency training (thus the exclusion of in utero fetal procedures from our survey). Transabdominal cervical cerclage (via open laparotomy or robotic approach) did not meet the two criteria above, but was included for completeness of the cerclage data set. We used descriptive statistics to analyze frequency data for all 13 operative obstetric procedures and sociodemographic information for all MFM fellows. For the 13 operative obstetric procedures of interest, first-year fellows were asked to estimate the number of times they had performed the procedure during their preceding residency training, with response options of cardinal numbers ranging from zero to ‘‘greater than 25’’. Prior to administering the survey, we identified comfort with doing and teaching four of the 13 procedures as the primary outcome variables: vacuum delivery, low forceps delivery, cesarean hysterectomy, and breech extraction of a second twin. These four were selected in particular as they are each of public health interest in the setting of increasing cesarean delivery rates. We used exact logistic regression to estimate the odds of a fellow being comfortable performing or teaching these four procedures when compared to a referent of those uncomfortable performing or teaching the same procedure, with separate models for performing and teaching. In the survey, fellows were asked to identify their current comfort with performing and teaching each of the 13 procedures by selecting one of three options per procedure: ‘‘I am NOT comfortable performing and I am NOT comfortable teaching’’ (option 1); ‘‘I am comfortable performing but I am NOT comfortable teaching’’ (option 2); and, ‘‘I am comfortable performing and I am comfortable teaching’’ (option 3). Finally, for the four procedures chosen a priori for bivariate analysis, we performed exact logistic regression to estimate the odds of a fellow being comfortable performing the procedure (options 2 and 3 combined), when compared to those not comfortable performing (option 1). Similarly, we estimated the odds of a fellow being comfortable teaching the procedure (option 3), when compared to those not comfortable teaching (options 1 and 2 combined). Variables of interest included: region where residency and fellowship were performed; residency affiliation (community- versus university-based); number admitted to the residency program per class; number of annual deliveries at residency and fellowship hospitals; and number of times other obstetric procedures had been performed during residency. All variables were categorized as shown in Tables 1 and 2

J Matern Fetal Neonatal Med, 2015; 28(12): 1467–1470

and modeled using indicator variables. Due to the limited sample size, we only estimated the bivariate (unadjusted) association between each variable and an outcome of comfort with performing or teaching each of the four outcomes. A p value 0.05 was considered statistically significant. All statistical analyses were conducted using Stata 11 (StataCorp, College Station, TX).

Results Eighty-six fellows completed the survey (86% response rate), and demographic data on the respondents is presented in Table 1. Fellows were asked to identify the state(s) in which they completed their residency and are receiving their fellowship training. They were also asked to provide information regarding the size and affiliation of their residency program (university- versus community-based), and the size of their fellowship program. The majority of responding MFM fellows completed their residencies in the Northeast/Midatlantic and Southeast (n ¼ 52; 60.4%), and identified their residencies as university-based (n ¼ 71; 82.6%). Similarly, the majority of respondents are completing their fellowships in the Northeast/Midatlantic and Southeast (n ¼ 47; 54.7%). Frequency data for the 13 operative obstetric procedures of interest are presented in Table 2 in the categories used for bivariate analysis; median number of times performed per procedure is presented in Table 3. Fellows completing residency in the Northeast/Midatlantic were 80% less likely to report comfort in both performing and teaching low forceps deliveries when compared to those

Table 1. Demographic data for survey respondents. Demographic variable Region where residency was completed Southeast Northeast/Midatlantic Midwest West Residency affiliation University based Community based Number admitted to residency program per year 55 5–9 10 Number of deliveries per year at residency hospital(s) 52000 2000–3999 4000–5999 6000 Region where fellowship is being completed Southeast Northeast/Midatlantic Midwest West Missing Number of deliveries per year at fellowship hospital(s) 52000 2000–3999 4000–5999 6000 Missing

n (%) 26 26 21 13

(30.2) (30.2) (24.4) (15.1)

71 (82.6) 15 (17.4) 15 (17.4) 57 (66.3) 14 (16.3) 11 32 19 24

(12.8) (37.2) (22.1) (27.9)

16 31 18 20 1

(18.6) (36.1) (20.9) (23.3) (1.2)

8 27 17 15 19

(9.3) (31.4) (19.8) (17.4) (22.1)

Operative obstetric training needs for MFM fellows

DOI: 10.3109/14767058.2014.957669

Table 2. Frequency of procedures performed during residency.

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Procedure Cesarean hysterectomy 55 5–9 10–25 Breech extraction of a second twin 55 5–9 10–25 McDonald cerclage 55 5–9 10–14 15–25 Shirodkar Cerclage Never 55 5–9 10–25 Cervico–isthmic cerclage (vaginal approach) Never 1 Abdominal cerclage Never 1 1 Robotic cerclage Never 1 Forceps: outlet 55 5–9 10–14 15–25 Forceps: low Never 55 5–9 10–25 Forceps: rotational Never 55 5 Forceps: Pipers Never 55 5 Vacuum delivery 59 10–14 15–19 20–25 Repair of a fourth degree laceration 55 5–9 10–14 15–19 20–25

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66 (76.7) 13 (15.1) 7 (8.1)

deliveries when compared to those who had performed fewer breech extractions or cesarean hysterectomies (OR 4.69, 95% CI 1.23, 22.51; OR 5.04, 95% CI 1.20, 30.51). With regard to breech extraction of a second twin, fellows completing their fellowships in the West were significantly more likely to report comfort performing that procedure when compared to those completing fellowships in the Southeast (OR 6.84, 95% CI 1.24, 51.50), though they were not significantly more likely to report comfort in teaching the procedure (OR 3.92, 95% CI 0.84, 21.11). With regards to cesarean hysterectomy, no residency or fellowship demographic was significantly associated with increased comfort performing the procedure, and only fellowship hospital size was significantly associated with increased comfort teaching the procedure, with fellows at hospitals completing 4000–5999 deliveries per year 91% more likely to report being comfortable teaching cesarean hysterectomy than fellows at hospitals performing 52000 deliveries per year (OR 0.09, 95% CI 0.01, 0.87). Finally, the data on comfort performing and teaching vacuum delivery was so skewed, with so few respondents uncomfortable with the procedure, that cell size was too small for meaningful bivariate analysis.

83 (96.5) 3 (3.5)

Discussion

n (%) 65 (75.6) 15 (17.4) 6 (7.0) 53 (61.6) 16 (18.6) 17 (19.8) 18 20 24 24

(20.9) (23.3) (27.9) (27.9)

47 (54.7) 28 (32.6) 7 (8.1) 4 (4.7) 82 (95.4) 4 (4.7)

25 12 19 30

(29.1) (14.0) (22.1) (34.9)

32 20 14 20

(37.2) (23.3) (16.3) (23.3)

65 (75.6) 15 (17.4) 6 (7.0) 61 (70.9) 17 (19.8) 8 (9.3) 9 11 9 57

(10.5) (12.8) (10.5) (66.3)

50 (58.1) 18 (20.9) 7 (8.1) 5 (5.8) 6 (7.0)

from the Southeast (OR 0.21, 95% CI 0.05, 0.78; OR 0.20, 95% CI 0.04, 0.85). Respondents reporting performing five or lesser forceps deliveries during residency were significantly more likely to report comfort performing low forceps deliveries as a fellow when compared to those who had never performed the procedure (OR 47.16, 95% CI 6.64, 635.83), but fellows who had performed 410 breech extractions or 5–9 cesarean hysterectomies were also significantly more likely to report comfort performing low forceps

Our data identify significant residual training needs in many operative obstetric procedures for MFM fellows, particularly cesarean hysterectomy, forceps deliveries, breech extraction of a second twin, and non-McDonald cervical cerclage. We chose to measure operative obstetric training needs among incoming MFM fellows for two practical reasons: one, they represent a small (n ¼ 100), well-defined cohort, and are therefore easier to sample en masse; and two, one may intuit that by choosing this subspecialty, the subjects plan to continue to practice obstetrics in some form. That said, operative obstetrics is certainly not the sole domain of MFMs, and our data cannot contribute to a larger discussion of operative obstetric training needs for other recent residency graduates. These training needs are of particular concern given the groundswell of public health interest in decreasing the national cesarean delivery rate. In response to a 26.5% cesarean delivery rate among low risk primiparous women in the United States (US), the Society for Maternal-Fetal Medicine, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the American College of Obstetricians and Gynecologists convened a joint two-day workshop in February 2012 entitled ‘‘Preventing the First Cesarean Delivery’’. Among the modifiable risk factors for first cesarean identified during the workshop, one particular area of concern was diminishing skill in and use of operative vaginal delivery. Indeed, in the recently published workshop summary, the committee concludes that, ‘‘given the current (cesarean delivery) rates, it is critical that training and experience in operative vaginal delivery are augmented and encouraged [6]’’. All surveys have an inherent risk of sampling bias and imprecision. Given the small population we were surveying and the specificity of other demographic data we requested,

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J Matern Fetal Neonatal Med, 2015; 28(12): 1467–1470

Table 3. Self-reported comfort with performing and teaching operative obstetric procedures (n ¼ 85, completed surveys).

Procedure

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Cesarean hysterectomy Breech extraction of a second twin Forceps: outlet Forceps: low Forceps: rotational Forceps: Pipers Vacuum delivery Cerclage: McDonald Cerclage: Shirodkar Cerclage: cervico-isthmic (vaginal approach) Cerclage: abdominal Cerclage: robotic 4th degree laceration repair

Times performed during residency; Median (IQR) 3 (1–4) 3 (1–5) 10 (3–15) 2 (0–7) 0 (0–0) 0 (0–1) 22 (13– 25) 10 (5–14) 0 (0–2) 0 (0–0) 0 (0–0) 0 (0–0) 3 (2–5)

we opted not to ask the respondents for their gender, as this would make individual survey results potentially identifiable. That said, Bonar and colleagues reported that males are significantly more likely to perform forceps deliveries during residency than are females [7], and we were unable to test this hypothesis in our own data set. Similarly, while we asked new first-year fellows to report the number of times they had performed procedures during their preceding residencies, we neglected to ask them whether they had spent time in practice post-residency and pre-fellowship. It is possible, then, that this subset of fellows would have higher rates of reported comfort performing and teaching procedures than their raw residency frequency data would suggest, rendering our results less accurate as a picture of their overall comfort. Unfortunately, we neglected to inquire about external cephalic version (of a singleton or second twin), and therefore our dataset on operative obstetric procedures remains incomplete. Finally, and perhaps most importantly, the practice of operative obstetrics is certainly not limited to maternal-fetal sub-specialists, and our survey does not define residual training needs for recent graduates pursuing other areas of practice. In part, the way forward for increased training in operative obstetrics for MFM fellows has already begun. As outlined in the now iconic ‘‘Putting the ‘M’ back in maternal-fetal medicine’’, ABOG recently modified MFM fellowship requirements to include two months of dedicated Labor and Delivery service, during which fellows can hone needed surgical skills [8]. Solt and colleagues reported a significantly increased resident forceps training rate with the addition of a single proactive laborist faculty member at their teaching hospital [9]. Finally, Nitsche and Dupuis have reported significant utility of simulators in teaching cerclage and forceps, respectively, to residents and MFM fellows [10,11]. If, as many suggest, subspecialty training for MFMs should continue to prepare fellows for a broader scope of care than prenatal diagnosis and outpatient consultation alone, our data identify a substantial need for additional procedural training. Further research is needed to better characterize what factors

Not comfortable doing or teaching; N (%) 20 33 28 43 80 63

(24) (39) (33) (51) (94) (74) 1 (1) 1 (1) 56 (67) 80 (94) 75 (88) 81 (95) 11 (13)

Comfortable doing but not teaching; N (%) 36 11 11 11

(42) (13) (13) (13) 3 (4) 12 (14) 1 (1) 14 (17) 17 (20) 4 (5) 7 (8) 3 (4) 18 (21)

Comfortable doing and teaching; N (%) 29 41 46 31

(34) (48) (54) (36) 2 (2) 10 (12) 83 (98) 70 (82) 11 (13) 1 (1) 3 (4) 1 (1) 56 (66)

contribute to a learner’s perceived comfort with and competency in operative obstetrics.

Declaration of interest The authors report no declarations of interest.

References 1. Martin JA, Hamilton BE, Ventura SJ, et al. Births: Final data for 2010. National Vital Statistics Reports Aug 2012; 61(1). Available from: www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_01.pdf [last accessed 11 Mar 2013]. 2. American Board of Obstetrics & Gynecology, Inc. Guide to Learning in Maternal-Fetal Medicine 2007. 3. Faurie C, Khadra M. Technical competence in surgeons. ANZ J Surg 2012;82:682–90. 4. Beasley SW, McBride C, Pearson ML. Use of the operative logbook to monitor trainee progress, and evaluate operative supervision provided by accredited training posts. Surgeon 2011;9:S14–15. 5. Papanna R, Biau DJ, Mann LK, et al. Use of the Learning CurveCumulative Summation test for quantitative and individualized assessment of competency of a surgical procedure in obstetrics and gynecology: fetoscopic laser ablation as a model. Am J Obstet Gynecol 2011;204:218 e1–9. 6. Spong CY, Berghella V, Wenstrom KD, et al. Preventing the first cesarean delivery: summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists workshop. Obstet Gynecol Nov 2012;120:1181–93. 7. Bonar KD, Kaunitz AM, Sanchez-Ramos L. The effect of obstetric resident gender on forceps delivery rate. Am J Obstet Gynecol 2000;182:1050–1. 8. D’Alton ME, Bonanno CA, Berkowitz RL, et al. Putting the ‘M’ back in maternal-fetal medicine. Am J Obstet Gynecol 2013;208:442–8. [Epub ahead of print]. doi:10.1016/ j.ajog.2012.11.041. 9. Solt I, Jackson S, Moore T, et al. Teaching forceps: the impact of proactive faculty. Am J Obstet Gynecol 2011;448:e1–4. 10. Nitsche JF, Brost BC. A cervical cerclage task trainer for maternalfetal medicine fellows and obstetrics/gynecology residents. Simul Healthc 2012;7:321–5. 11. Dupuis O, Moreau R, Pham MT, Redarce T. Assessment of forceps blade orientations during their placement using an instrumented childbirth simulator. BJOG 2009;116:327–32.

Training needs in operative obstetrics for maternal-fetal medicine fellows.

To define residual operative obstetric training needs for first-year maternal-fetal medicine (MFM) fellows...
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