June 2014

OB Basics - a University of Calgary Needs Based Educational Day for Incoming Residents

OB Basics is a full day interactive multiple station workshop to improve the competence and confidence of

incoming residents as they enter their obstetrical experience. The skill set included was based on an informal

needs assessment by family medicine obstetrical educators in 2013.

Simple simulation is a fun and inexpensive solution to skill enhancement, and encourages a non-threatening

learning environment.

The curriculum was developed by Heather Baxter for the University of Calgary Family Medicine residency

program. I would like to extend sincere appreciation to Vicki Van Wagner, RM for her willingness to share some

of her model designs. The reference for her excellent article is listed below. I would also like to thank Anne

Biringer MD, and Jeanine Robinson and Marianna Hofmeister for their assistance and support.

This is certainly a work in progress. A new workshop is being developed focussing on interprofessional

communication for 2014. If you have any other innovations or new curriculum please share it with us.

Thanks for your interest in this curriculum.

Heather Baxter MD CCFP FCFP

Associate Clinical Professor

Director Master Teacher Program

Faculty of Medicine

University of Calgary

habaxter@ucalgary.ca

Reference:

Van Wagner V. Using Simple Simulation to Teach Midwifery Skills. Canadian Journal of Midwifery Research and

Practice 2012; 11 (1)

Preceptor Notes for OB Basics Day 2014

Thank you very much for offering to assist with the OB basics day for the new family medicine residents.

This day is the result of the suggestions from your colleagues to improve the quality of the educational experience

for the family medicine residents and the preceptors alike. The residents have completed ALSO (Advanced Life

Support in Obstetrics) in year one of the residency for the past few years. This has helped to improve the

confidence and competence of the residents in emergency obstetrical situations. As family doctors have increased

their role in the obstetrical education of our residents, the lack of some basic obstetrical skills has been

highlighted. The residents come from any one of the 17 medical schools across Canada with variable obstetrical

experiences and often little hands on experience in their clerkship. Many will never have had an opportunity to

do a vaginal exam of an obstetrical patient, much less do a vaginal delivery. The last obstetrical experience may

have been almost 2 years ago as well. Policies and procedures also differ across Canada, and so we hope to orient

them to the expectations and procedures used in Calgary.

Thus the idea for this OB Basics day was born. It is meant to assist all 79 new residents to develop, or review and

renew their basic obstetrical skills before starting their OB rotation. This is a very hands-on skills based workshop,

hopefully lots of fun for all involved. The program anticipates that the residents will be more prepared to start

their rotation and will thus gain the competencies expected faster.

Teaching of obstetrical skills comes with a number of challenges. Obstetrical training is opportunistic, dependent

on which patients and which clinical circumstances occur when a given resident is on call. Patient and learner

safety and well being also need to be assured and this often limits our learner’s experience. Much of maternity

care also occurs “in the dark” thus requiring repeat confirmatory exams. This day will offer the opportunity for

each resident to experience a variety of obstetrical procedures in a supportive, simulated setting. Our goal is for

both the residents and preceptors to be more confident in the competence of the resident’s emerging skills.

The residents will complete ALARM either later in July if their obstetrical rotation is in 2014, or in December if

their rotation is in 2015.

This day was a great success last year, and with your assistance I am sure it will be again. I hope you enjoy meeting

and mentoring our new residents.

Station #1 – Normal Delivery

By the end of this workshop residents will be able to

1. Demonstrate the technique a normal vaginal delivery

2. Demonstrate the somersault manoeuvre for tight nuchal cord

3. Demonstrate delivery of placenta

4. Describe technique for delayed cord clamping

At this station each of the students should have the opportunity to use a pelvis and neonate mannequin to

practice a normal vaginal delivery and delivery of the placenta. I would suggest reviewing the cardinal stages of a

normal delivery as well. A set of photos of the cardinal stages will be at your station. Please also review how to

check for a nuchal cord, deliver through a nuchal cord and avoid pulling it over the head, and the somersault

manoeuvre. I would suggest spending 10 minutes or so demonstrating and using the remaining 40 minutes for

the students to practice. Each preceptor should have their own mannequin and 4-5 students per session. Please

also discuss early vs delayed cord clamping. I have included 3 recent resources regarding delayed cord clamping

for your convenience.

I expect that the level of confidence and competence in vaginal deliveries will be variable. I am assuming there

will be lots of questions and discussion. Other skills you may want to demonstrate include the somersault

manoeuvre for snug nuchal cords, and methods of protecting the perineum.

Resources – picture of cardinal stages of normal delivery -see attached, available at each station

3 articles on early cord clamping

http://onlinelibrary.wiley.com/doi/10.1002/146518 Cochrane review on delayed cord clamping

http://www.who.int/elena/titles/cord_clamping/en/index.html WHO April 2013 delayed cord clamping

recommendations

http://www.jogc.com/abstracts/full/201206_Obstetrics_2.pdf JOGC 2012 re delayed cord clamping

Station #2A – Obstetrical Equipment

By the end of this workshop residents will be able to

1. List components of an obstetrical delivery tray

2. List what equipment counts are required at the end of the procedure

3. List 3 types of sutures and one advantage of each

4. Demonstrate how to appropriately drape for a vaginal delivery

5. Describe safe management and disposal of sharps

This station is meant to be an orientation to the equipment and set-up for a normal vaginal delivery. Please

review how to open an obstetrical tray in a sterile manner, review of the instruments and their use, how the

instruments are usually laid out, what instrument and sponge counts the medical practitioner is responsible for at

the end of the procedure. Please review chromic, vicryl and PDS sutures and their uses. The ethicon ppt and basic

suturing notes may be good resources to review. These sutures will be available for the students to feel the

difference in the filaments. Please also demonstrate how draping should be done for a normal vaginal delivery.

Resources - basic suturing notes for students

ethicon ppt

Resources at Station: basic suturing notes for students

Station #2B – Cervical Exam

By the end of this workshop residents will be able to

1. Demonstrate the technique for a gender sensitive vaginal exam

2. Demonstrate the assessment of cervical dilatation, effacement and station.

3. Demonstrate the determination of fetal position by assessing suture lines

This is a very hands on station, with lots of opportunity for the students to develop their skill in assessing

dilatation, effacement and station. Please discuss how to accomplish gender sensitive exams, and techniques to

assist women to relax during vaginal exams. Various models will be available and will be reviewed at the

orientation. A pelvic mannequin will be available to review station and please have the students practice

palpating for the spines. Fetal mannequins and other models for determining suture lines and fontanelles will also

be available.

Resources at station:

fetal head diameter photo, cranial sutures photo

There will be numerous models to allow the residents to determine dilatation, effacement and

sutures/fontanelles.

Station #3 – Knot Tying

By the end of this workshop residents will be able to

1. Demonstrate technique for 1 hand knot tying

2. Demonstrate technique for instrument tie

The residents will likely have variable competence at knot tying. This is their chance to practice both the one hand

tie and instrument tie. They should have reviewed the videos listed below prior to the session. They need to

ensure they are making square knots. Once they have the mastered the basics of the skill the progression to

challenge should be

1. Knot with string

2. Knot with suture (vicryl and chromic will both be available for them to feel the difference)

3. Add wearing gloves

4. Add muko to the gloves to simulate blood and mucus making it more slippery

5. Have them do the one hand tie with their eyes closed to simulate knot tying deep in the vaginal vault

6. To add interest and fun they can have “races”.

Resources - http://www.youtube.com/watch?v=wvNsWdcgQrw– good one hand tie video with audio

– students will have for pre-reading and will have available at station http://www.youtube.com/watch?v=wbpQhiNDxvo – instrument tie, brief, shows appropriate suture

technique as well. Students will have this for pre-reading

Station #4 – Episiotomy and Perineal Tear Repair

By the end of this workshop residents will be able to

1. Demonstrate technique for performing a midline and medio-lateral episiotomy

2. Demonstrate technique for repair of a midline episiotomy or first/second degree tear

Resources –

http://www.aafp.org/afp/2003/1015/p1585.html - AAFP article plus the following 3 resources the students should have reviewed

Info pages on basic suturing and perineal tears

http://www.youtube.com/watch?v=R4o4KSY4MMY – video of sponge 2nd degree tear

http://www.youtube.com/watch?v=1ZJnh5zIQDU –video of real repair of 2nd degree tear

This station is a chance to develop their competence in performing an episiotomy and basic perineal tear repairs

using a tissue model – pig rectums. This is actually a fairly good model for the human perineum. A demonstration

will be done at the orientation.

Please start with a demonstration of how to cut a midline and medio-lateral episiotomy protecting the fetal scalp

and using a single cut. Please discuss indications for an episiotomy, how to predict significant perineal tears eg

tissue edema and blanching. Each student should have a chance to complete a midline episiotomy as this will be

the model for their repair as well.

Afterwards please demonstrate the basics of a repair. Students should be aware that there are many different

ways to repair a second degree tear (or episiotomy) and the 2 videos do highlight some of the potential

differences. Feel free to use your usual repair technique or adopt a technique similar to one of the videos.

Station #5 – Basic Obstetrical Procedures

By the end of this workshop residents will be able to

1. Demonstrate a safe technique for artificial rupture of membranes

2. Demonstrate application of a fetal scalp electrode

3. Demonstrate how to clamp and cut a tight nuchal cord

4. Demonstrate how to clamp, strip and then cut a cord to minimize body fluid exposure for the team

5. Demonstrate the collection of an arterial cord gas sample

6. Demonstrate the technique for sterile glove and gowning (optional)

This station is a chance for the students to develop competence in the above skills. Models will be available for

each skill. A demonstration of the models will be done at the orientation. Most of the skills will involve a stem of

a case presentation for the student to review to consider the indications and contra-indications of each

procedure.

ARM – This station will have a case presentation. Please ensure that residents are aware of the importance of

confirming the station (+2 or lower) before ARM, and how to attempt to ballot the head, as well as checking

membranes for vessels suggesting vasa previa. Please discuss the risks of fetal scalp lacerations if membranes

tight to head. There will be 2 independent study models for the students to review as well, both with cases for

cord prolapse and vasa previa.

Fetal scalp electrode –This station has a case presentation. Please review the importance of ensuring vertex

presentation, avoiding fontanelles, appropriate application technique, and how to remove the device.

Cutting a tight nuchal cord – there will be a model of an umbilical cord that can be wrapped tightly around a fetal

mannequin’s neck to allow the students to clamp and cut the cord. Please review how to manage snug nuchal

cords by delivering through and that cutting the cord prior to delivery of the shoulders is a last resort with

significant potential risk if delivery of the infant is delayed. They will be taught how to manage shoulder dystocia

in ALARM later this month or later in the year.

Please also discuss and demonstrate and allow the students to practice clamping a cord and stripping the cord to

minimize blood exposure for the health care team. There will be a model to simulate this. It would be useful for

the students to practice using a Kelly clamp with both hands.

Arterial cord gas sample – please review how to identify the vessels of umbilical cord (2 arteries and one vein) and

how to get the sample, need to remove any air in sample and label appropriately. ALARM/SOGC recommends

taking both an arterial and venous sample partially to ensure that one sample is arterial however this policy is not

supported by AHS and not utilised by all practitioners.

Some students last year requested a review of the technique for donning sterile gloves and gowns. Please

demonstrate and allow the students an opportunity to practice the technique. It may be beneficial to discuss

extra tips for assisting in the OR, what the expectations of a surgical assist are from a nursing/patient

management point of view.

Artificial Rupture of Membranes

Vasa Previa

Fetal Scalp Electrode

Tight Nuchal Cord

Cord Gas

STEM – A.R.M.

Ms. Nguyen is a 23 year old G2P0

at 41 weeks gestation.

She had an uncomplicated

prenatal course.

She had the spontaneous onset of

labour but has been progressing

slowly.

At 3 PM she was 5 cm. It is now 6

PM and the nurse calls you to

reassess as she is 6 cm.

She is requesting you rupture her

membranes.

STEM – CORD PROLAPSE

Ms. Taylor is a 32 year old G5P3

who was followed for diet

controlled gestational diabetes.

A recent ultrasound showed EFW

3.5 kg infant, BPP 8/8, AFI=27.

She had the spontaneous onset of

labour at 39 weeks and is now 7

cm.

Her membranes just ruptured and

the nurse calls you to review the

fetal monitoring strip.

STEM – FSE APPLICATION

Ms. Running Water is an 18 year

old First Nations patient, with a

pregnancy complicated by a high

BMI and 60 lbs of weight gain but

otherwise uncomplicated.

There was meconium with SROM

and continuous fetal monitoring

was commenced.

The nurse calls as she is struggling

to get an adequate assessment as

the patient wants to be up walking

and changing position.

STEM – VASA PREVIA

Ms. Singh is a 34 year old G3P1 at

37 weeks. She has had an

uneventful pregnancy.

Her 18 week ultrasound showed a

low lying placenta with a

succenturiate lobe.

Repeat ultrasound at 30 weeks

showed the placenta >2 cm away

from the os, again with a

succenturiate lobe.

She presented to triage with a 3

hour history of contractions.

Procedural Skill Teaching

Six Step model

• Demonstrate – the whole procedure with minimal discussion –

“big picture context”

• Demonstrate again, with commentary, broken into steps

• both these steps could be done with a video as pre-reading

• Student demonstrates, talking it through

• Ask for the student’s feedback

• Give your feedback

• Allow supervised practice under increasingly realistic conditions

Graded guidance as the learner improves in his skill set.

For Knot Tying a potential progression is

1. With thick cord

2. With suture

3. Add gloves

4. Add muko (simulates blood)

5. Do it with eyes closed or in the dark

AGENDA - OBSTETRIC SKILLS DAY - University of Calgary, Family Medicine, 2014

P R E C E P T O R S R E S I D E N T S

Start Finish Location Start Finish Location

8:00 8:15 breakfast - provided

G384 HMRB Atrium -- -- --

8:15 8:30 Group Orientation G384 8:15 8:30 Registration

Theatre __

8:30 8:45 travel to ATSSL travel 8:30 9:00 Lecture - Pre-test, Curric, Intro to day, Group Assign

Theatre __

8:45 9:30 hands on Orientation ATSSL 9:00 9:30

break / washroom; 2 groups: Class 4/6 - UME, Wet Lab - G500

9:30 9:40 travel to ATSSL: 2 groups ATSSL

9:40 9:50 get all Rs settled in their stations 9:40 9:50 get all Rs settled in their stations ATSSL

9:50 10:40 Concurrent Sessions 1 ATSSL Concurrent Sessions 1 ATSSL

10:40 11:30 Concurrent Sessions 2 ATSSL Concurrent Sessions 2 ATSSL

11:30 12:20 Concurrent Sessions 3 ATSSL Concurrent Sessions 3 ATSSL

12:20 13:20 Lunch - provided G384 on own ... HRIC Atrium

13:20 14:10 Concurrent Sessions 4 ATSSL Concurrent Sessions 4 ATSSL

14:10 15:00 Concurrent Sessions 5 ATSSL Concurrent Sessions 5 ATSSL

15:00 15:50 Concurrent Sessions 6 ATSSL Concurrent Sessions 6 ATSSL

15:50 Post-test, evaluation ATSSL

Equipment List for Obs Skills Day

EQUIPMENT 2014; TOTAL REQD

Session 1 - Knot Tying

Session 2 - Episiotomy

& Tear Repair

Session 3a -

Equip Orient

Session 3b -

Cervical Assessm

ent

Session 4 -

Normal Delivery

Session 5a - Artificial Rupture of Membranes

Session 5b - Fetal

Scalp Electrode

Session 5c -

Cord...

Session 5d -

Gloving, Gowning

Session 6 - Interprof Consultati

on

amniohooks 4 - - - - - 4 - - - -

ball, sock, box, red cathetar - vasa previa 1 - - - - - - - 1 - -

ball, sock, box, yarn - cord prolapse 1 - - - - - - - 1 - -

balloons (w air, glove, saran) 100 - - - - - 100 - - - -

balls, socks, boxes for cervix dilation examples: thin, thick, long, var cm 0 - - 10 - - - - - -

biohazard box 0 - - 1 - - - - - - -

blue pads - for under pig rectums 0 - 100 - - - - - - - -

boxes to obscure cervix - ARM, FSE 6 - - - - - 3 3 - - -

cervix dilation board (H.Baxter got from PLC) 0 - - 1 - - - - - - -

cord ph (Arterial Blood Sampler - Ref 956-622) 20 - - - - - - - 20 - -

cord pH (Needle - 22G x 1 1/2 - Ref 305900) 20 - - - - - - - 20

corduroy or jean material - cover infant head some - - - - - - 1 - - -

delivery record - with STAMP to show where documentation goes 10

fetal scalp electrodes (reuseable for our purpose) 10 - - - - - 10 - - -

forceps - Kelly 5 1/2", curved, MH7-38 (FM=20) 16 - 16 - - - - - - - -

forceps - tissue 1x2 5" non-sterile (FM=20) 16 - 16 - - - - - - - -

gloves - L 0 30 30 - - - - - - - -

gloves - M 0 30 30 - - - - - - - -

gloves - S 0 50 50 - - - - - - - -

gloves - sterile (S,M,L,XL) 150 - - 2 - - - - - 150 -

gloves - XL 0 30 30 - - - - - - - -

gown pack 1 - - - - - - - - 1

infant in pelvis/box - tight nuchal cord 2 - - - - - - 2 - - -

infant model in pelvis for position/sutures 0 - - - 1 - - - - - -

infant models in pelvis - FSE 6 - - - - - 3 3 - - -

jar lids with dilation written top 0 - - - 35 - - - - - -

kelly clamps 5 - - - - - - 2 3 - -

muko - packets 1 1 - 1 - - - - 1 - -

needle drivers - Mayo-Hegar, 6 1/4", MH8-44 0 16 16 - - - - - - - -

pelvic birthing models / task trainers 5 5

pelvic models (UG FM) (Juan's) for physical exam 0 - - - 2 - - - - - -

photography release form - Residents & Preceptors 80

pig rectum (male) - if no perineal models 0 - 100 - - - - - - - -

plastic table covering 16 8 8 2 3 8 2 2 2 2 -

prenatal record 2 - - 2 - - - - - - 2

saran wrap 1 - - - - - 1 - - - -

scissors - Mayo straight - 2 per table in Episiotomy & Knot 6 16 16 - - - - 2 4 - -

sharps container - red or yellow 0 - 4 - - - - - - - -

sharps container - red 0 - - 1 - - - - - - -

suture - Ethicon Boards 0 15 - - - - - - - - -

suture - Ethicon ppt printouts to tape up 4 - - 4 - - - - - - -

sutures - chromic 2.0, #811, CT-1, 27" 0 - 200 6 - - - - - - -

sutures - chromic 3-0, #810, CT-1, 27" 0 - 200 - - - - - - - -

sutures - PDS (polydioxanone), 11, #Z339, CT-1, 27" 0 - - 2 - - - - - - -

sutures - Vicryl 2.0 J345, CT-1 - 36" 0 200 200 6 - - - - - - -

tape - masking 2 - - 1 - - - - - - -

tape - packing 2 - - - - - 1 - - - -

tray - cervical repair tray - PLC - see xls file saved 2013 0 - - 2 - - - - - - -

tray - gown - Sterile Delivery Pack - Cardinal Health 4 - - - - - - - - 4 -

tray - OB instrument trays - see xls Set Delivery MCC 0 - - 2 - - - - - - -

umbilical cord models - 2 tight nuchal cord 2 - - - - - - 2 - - -

umbilical cord models - yarn - red, blue, white 4 - - - - - - - 4 - -

umbilical cords - small french red catheters 12 - - - - - - - 12 - -