情景模拟演练对提高严重产后出血患者救治能力的分析

目的分析情景模拟演练培训对提高救治严重产后出血患者能力及降低死亡率的效果。 方法2018年7月和2019年9月对广东省某地级市产科医护人员(共228人次)分别进行为期3 d的严重产后出血情景模拟培训，通过理论授课、单项操作培训、团队急救演练、团队急救小组示范等形式，进行产后出血急救理论知识、技能操作、人员分工及站位管理等培训；应用"产后出血团队急救演练培训效果评价表"，对受训人员培训前后的团队协作、急救技能操作和操作时间三个方面共14项评分变化进行对比分析；根据资料类型采用均数±标准差、百分比、独立样本t检验、Wilcoxon配对符号秩和检验等方法进行描述和分析。 结果(1)急救操作评分：两次培训前后人员产后出血量估计评分[2018年(2.56±1.54)分与(4.56±1.87)分，2019年(3.56±1.54)分与(4.56±1.68)分]；及时呼救评分：[2018年(4.12±0.58)分与(4.72±1.12)分，2019年(4.32±0.68)分与(4.92±1.35)分]；生命体征管理评分：[2018年(4.28±0.58)分与(4.58±0.58)分，2019年(4.46±0.78)分与(4.78±1.23)分]；产后出血原因分析评分：[2018年(4.25±1.65)分与(4.55±1.98)分，2019年(4.35±1.32)分与(4.55±1.98)分]；处理和输血治疗评分：[2018年(3.25±1.78)分与(4.25±1.85)分，2019年(3.85±1.18)分与(4.25±1.85)分]；5项评分与培训前比较均明显提高，差异有统计学意义(P<0.05)；(2)团队协作方面评分：分工明确[2018年(2.24±0.68)分与(4.14±1.21)分，2019年(3.24±1.18)分与(4.14±1.21)分；人员站位合理[2018年(2.56±1.57)分与(4.16±1.47)分，2019年(3.56±1.42)分与(4.36±1.24)分]；迅速有序[2018年(3.78±1.56)分与(4.25±1.68)分，2019年(4.18±1.04)分与(4.55±1.67)分]；沟通报告[2018年(3.25±0.89)分与(4.55±1.68)分，2019年(3.89±1.23)分与(4.85±1.85)分]；4个方面培训后评分均有明显改善，差异有统计学意义(P<0.05)；(3)操作时间评分：总抢救时间[2018年(1865±89.57)s与(1665±96.32)s，2019年(1796±58.57)s与(1565±87.32)s]；呼救开始时间[2018年(162±34.47)s与(113±52.68)s，2019年(154±57.47)s与(112±45.68)s]；针对产后出血原因处理时间[2018年(287±56.87)s与(217±47.56)s，2019年(252±58.87)s与(215±48.36)s]；有效静脉通路建立时间[2018年(182±39.57)s与(162±65.84)s，2019年(156±34.65)s与(120±35.68)s]；开始进行容量管理时间[(2018年(198±65.78)s与(168±48.95)s，2019年(156±25.89)s与(122±41.32)s]均明显缩短，培训后与培训前评分比较，差异有统计学意义(P<0.05)。(4)2017年至2019年该市产后出血发生率分别为3.37%、2.57%、1.90%，死亡率分别为2.38/10万、0、0，呈逐年下降的趋势。 结论加强对产科医护人员产后出血情景模拟培训，能够显著提高医护人员的救治水平和严重产后出血的救治成功率，降低死亡率。     

阶梯式亚专科培训模式在重症孕产妇救治中的效果评估

目的借助国家脱贫攻坚政策，在毕节示范区实施重症孕产妇救治阶梯式亚专科培训模式，评估该模式对当地重症孕产妇救治的临床效果。 方法2020年6月，以广州医科大学附属第三医院为依托，在贵州省毕节市开展重症孕产妇救治阶梯式亚专科培训，培养市级产科重症救治骨干，并持续深入到各县各乡镇的所有助产机构。观察和了解该培训模式前后受训人员考核成绩与孕产妇临床相关质控指标及各项产科质控指标的变化。 结果(1)培训前学员的平均理论成绩为(62.9±3.2)分，培训后的理论成绩为(81.8±4.0)分，差异有统计学意义(t＝-15.748，P<0.001)；培训前技能成绩为(57.5±3.8)分，培训后的平均技能成绩为(75.1±2.7)分，差异具有统计学意义(t＝-16.292，P<0.001)。(2)毕节市2020年上半年的产后出血率、严重产后出血率、子痫发生率、羊水栓塞率、孕产妇死亡率分别为：34.66‰、8.39‰、8.58/万、7.22/万、1.455/10万；下半年对应数据分别为：31.92‰、4.65‰、5.55/万、0.61/万、1.069/10万，毕节全市2020年下半年的产后出血率、严重产后出血率、子痫发生率、羊水栓塞率、孕产妇死亡率明显低于上半年；下半年的危重症孕产妇发生率较上半年无明显降低。 结论采用重症孕产妇救治阶梯式亚专科培训模式对改善危重症孕产妇的妊娠结局可能有积极影响。     

急救模拟培训在产科临床实践中的意义

产科急救模拟培训可提高产科医务工作者处理复杂危急重症的临床综合技能、增强临床处理信心、提高团队沟通能力,有效降低相关不良母儿结局的发生,但培训效果会随着间隔时间延长逐渐减弱。因此,强调急救模拟培训在产科危急重症处理(肩难产、脐带脱垂、产后出血、子痫)中的运用,并要注重定期、重复培训。     

10年间阴道助产术的临床应用回顾性分析

目的:分析2007~2016年10年期间四川省妇幼保健院分娩产妇中的阴道手术助产率、剖宫产率以及母婴结局的变化,探索提高阴道助产技术,降低剖宫产率的方法和途径。方法:回顾性分析2007~2016年分娩的51199例产妇病历资料,比较经过全面阴道助产培训后的5年(2012~2016年)与全面培训前的5年(2007~2011年)全院的分娩情况及近期母婴预后,并分析培训后5年分娩产妇的阴道助产率、剖宫产率、新生儿窒息率的变化趋势。结果:(1)培训前的5年,分娩产妇的阴道手术助产率是1.11%,剖宫产率是58.52%,Ⅲ度以上会阴裂伤率是0.56%,新生儿窒息率是5.88%。而培训后的最近5年,分娩产妇的阴道助产率是3.16%,剖宫产率是46.42%,Ⅲ度以上会阴裂伤率是0.23%,新生儿窒息率是3.21%。培训前后两个阶段的指标比较,差异均有统计学意义(P0.05)。(2)经过培训后近五年我院分娩产妇的阴道助产率逐年上升,而剖宫产率则逐年下降,新生儿窒息率和产妇的会阴损伤率也逐年下降。结论:通过对我院产科医护人员进行阴道助产模拟培训和临床实践培训,可以提高阴道助产技术的临床应用,降低剖宫产率,并改善母婴结局,阴道助产模拟培训模式值得推广运用。     

肩难产紧急处理16例分析

目的分析肩难产发生特点，降低相关母儿并发症。 方法回顾性分析2013年1月至2018年12月陆军军医大学第一附属医院产科收治的紧急发生肩难产病例16例的临床资料，分析指标包括肩难产高危因素、诊断、助娩方式及母儿结局。 结果6年内经阴道分娩共16 252例，肩难产16例，发生率0.1%。高危因素分布为巨大儿3例，妊娠期糖尿病4例，器械助产5例，4例患者无高危因素。7例肩难产确诊表现为胎头娩出后胎肩嵌顿，9例表现为胎头娩出胎肩嵌顿并合并有"乌龟征"的临床表现。16例肩难产病例运用3～5种经阴道最终娩出。母儿结局：产后出血1例，会阴侧切11例，软产道损伤9例，无严重会阴裂伤；14例新生儿健康状况良好，1例新生儿3月龄时发现眼睑下垂，1例失访。 结论肩难产仍是无法预测的产科急症，需要正确判断肩难产的发生，掌握肩难产救治流程，快速施救，从而降低母儿并发症。     

肩难产45例临床分析

目的:探讨肩难产发生的高危因素和母婴并发症及处理方法。方法:回顾性分析四川省安县妇幼保健院2000年10月至2010年10月45例肩难产的临床资料,根据肩难产时母婴并发症的发生率与新生儿体重、助产手法及娩肩时间的关系进行分组,并进行分析。结果:①肩难产发生的高危因素主要有巨大儿(62.2%),子宫收缩乏力(15.6%),妊娠期糖尿病(11.1%)。②肩难产母婴并发症主要有:母体会阴裂伤(17例,37.8%),产后出血(7例,15.6%),新生儿窒息(29例,64.4%)。巨大儿组的母婴并发症发生率高于正常体重儿组(P<0.05);母亲并发症发生率与助产手法及娩肩时间无明显关系(P>0.05),而新生儿并发症发生率随助产手法种类的增加及娩肩时间的增加而增加(P<0.05)。③助产手法:采用屈大腿法成功分娩10例(22.2%),屈大腿法+压前肩法成功16例(35.6%),屈大腿法+压前肩法+旋肩法成功12例(26.7%),屈大腿法+压前肩法+旋肩法+牵后臂法成功7例(15.6%)。结论:巨大儿是肩难产发生的首要高危因素。母体会阴裂伤、产后出血及新生儿窒息是肩难产的常见并发症,母亲并发症主要与胎儿体重有关,新生儿并...     

SimMom模拟人在产科医师培训中的作用

产科是一门实践性强、应急性高、对团队合作要求高的临床医学。在患者安全性要求更高的今天,产科医生需要通过模拟训练来提高临床操作技能和团队合作能力以应对各种急危重症。现对SimMom模拟人在产科医师培训中的研究进展进行讨论。     

辅助生殖专科护士培养模式及实践效果分析

目的探讨辅助生殖专科护士临床培训模式,以进一步提高专科护士胜任能力。方法根据《浙江省专科护士培训方案》,结合辅助生殖护理专科特点,制定培训形式、培训内容和考核方法。第一期辅助生殖专科护士培训共招收26名学员,进行为期4个月全脱产系统培训,其中理论授课1个月,临床实践技能培训3个月。培训结束后,进行理论与实践考核评价。结果 26名学员通过培训,理论、临床实践技能及专家答辩等各项考核均合格,培训前、后所有学员专科理论成绩明显提高,平均成绩分别为(37.48±12.20)分、(87.36±3.58)分,差异具有统计学意义(P=0.000);具备英文文献检索能力由培训前的15.4%提高至69.2%,差异具有统计学意义(P=0.000);培训结束后,综述、开题报告和个案护理专家答辩成绩平均(90.56±2.16)分。结论以专科理论、专科技能、科研能力为核心的临床培养模式,可全面提升辅助生殖专科护士核心胜任能力。     

情景模拟教学模式在妇产科规范化培训中的实践效果分析

目的 评估情景模拟教学模式应用于妇产科住院医师、规培生、实习生规范化培训中的实践价值。方法 选取100名进行培训的妇产科住院医师、规培生、实习生为研究对象,按照不同培训方式分为对照组与观察组,每组50名。对照组给予传统教学方法,观察组给予情景模拟教学模式。对比两组课程成绩和对课程的满意度。结果 观察组理论成绩（92.53±5.23）分和技能成绩（93.14±4.26）分高于对照组的（85.52±3.15）、（83.51±3.15）分,差异有统计学意义（P<0.05）。观察组学生对课程的满意度高于对照组,差异有统计学意义（P<0.05）。结论 为妇产科住院医师、规培生、实习生规范化培训提供情景模拟教学模式展现较高的可行性,能获得良好的教学效果,提高学生教学满意度。     

“四肢着床”(趴位)操作法处理肩难产的临床应用观察

目的:探讨四肢着床(趴位)操作法处理肩难产的疗效。方法:回顾性分析自2008年1月至2010年4月于我院经阴道分娩因巨大儿发生肩难产5例患者的临床资料。结果:均在第二产程因巨大儿发生肩难产,应用McRobert操作法加耻骨上加压失败后,改用四肢着床(趴位)操作法安全、快速地将胎儿娩出,其中2例新生儿发生重度窒息,经有效的新生儿心肺复苏治疗后,新生儿均能恢复自主呼吸,Apgar评分10分。2例新生儿发现臂丛神经麻痹,未发现锁骨或肱骨骨折等并发症。结论:四肢着床(趴位)操作法是处理肩难产的安全、快速而有效的操作法。     

Recurrent obstetric management mistakes identified by simulation

OBJECTIVE: To develop a simulation-based curricular unit for labor and delivery teams involved in obstetric emergencies to detect and address common mistakes. METHODS: A simulation-based curricular unit for hands-on training of four obstetric emergency scenarios was developed using high-tech mannequins and low-tech simulators. The scenarios were eclamptic seizure, postpartum hemorrhage, shoulder dystocia, and breech extraction. The obstetric teams consisted of at least one resident and two midwives. Checklists of actions expected from the teams were handed out to the course's tutors who observed the "event." All sessions were videotaped and then reviewed and analyzed by the trainees themselves, who were guided by two experienced tutors. We identified the most commonly occurring mistakes by summing up checklists and by watching the recorded sessions. RESULTS: Between February 2004 and April 2006, 60 residents in obstetrics and gynecology and 88 midwives underwent the simulation-based course. Forty-two labor and delivery teams completed all four sessions. The most common management errors were delay in transporting the bleeding patient to the operating room (82%), unfamiliarity with prostaglandin administration to reverse uterine atony (82%), poor cardiopulmonary resuscitation techniques (80%), inadequate documentation of shoulder dystocia (80%), delayed administration of blood products to reverse consumption coagulopathy (66%), and inappropriate avoidance of episiotomy in shoulder dystocia and breech extraction (32%). Eighteen trainees were invited for repeated sessions at least 6 months after the first training day, and their scores were significantly higher in the latter sessions (79.4+/-4.3 versus 70+/-5.3 for the second and first simulated eclampsia sessions). CONCLUSION: A curricular unit based on simulation of obstetric emergencies can identify pitfalls of management in labor and delivery rooms that need to be addressed.     

Shoulder Dystocia and Postpartum Hemorrhage Simulations: Student Confidence in Managing These Complications

Introduction: Simulation is an effective teaching strategy for educating health professionals. However, little is known about the effectiveness of simulations in midwifery education. The purpose of this project was to determine whether the use of high‐fidelity simulations for the obstetric emergencies of shoulder dystocia and postpartum hemorrhage increases student confidence in managing these complications. Methods: The participants were registered nurses enrolled in a graduate midwifery education program in the Southeastern United States. Student confidence in learning to manage shoulder dystocia and postpartum hemorrhage was studied in 2 groups of students. The control group (n = 10) received standard teaching methods consisting of discussion, watching a video, and low‐fidelity teaching methods. The intervention group (n = 18) received a high‐fidelity simulation learning experience. Student confidence was measured before and after each learning experience using a validated, 8‐item, Likert‐type scale. Results: In the control group, student confidence did not significantly increase after a classroom discussion or low‐fidelity simulation experience. Student confidence increased significantly (P < .01) after the high‐fidelity simulation learning experiences. When the differences between the pretest and posttest scores were compared for the control and intervention groups, there was a moderate effect size (0.54) for the intervention group for the shoulder dystocia simulations and a large effect size (1.68) for the postpartum hemorrhage simulations. Conclusion: High‐fidelity simulations for shoulder dystocia and postpartum hemorrhage significantly increased student confidence in managing these complications.     

Emergency Birth Hybrid Simulation with Standardized Patients in Midwifery Education: Implementation and Evaluation

Structured simulations have become a critical part of health professions education at every level, particularly for high‐risk, low‐incidence scenarios. This article describes the implementation and evaluation of a hybrid simulation of emergency birth situations in a graduate midwifery program. In the fall of 2011 and spring of 2012, nurse‐midwifery students twice participated in 2 simulated emergencies—shoulder dystocia and postpartum hemorrhage—using hybrid simulation (a standardized patient paired with a birth task trainer). Students found the simulations to be realistic. The use of best practices (ie, repetitive practice, team learning, small group debriefing, and large group debriefing) enhanced the quality of the simulation experience and the learners’ reflection about their professional skills, strengths, weaknesses, and confidence in managing these 2 obstetric emergencies. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health.     

Effect of obstetric team training on team performance and medical technical skills: a randomised controlled trial

Please cite this paper as: Fransen A, van de Ven J, Merién A, de Wit-Zuurendonk L, Houterman S, Mol B, Oei S. Effect of obstetric team training on team performance and medical technical skills: a randomised controlled trial. BJOG 2012;119:1387-1393. Objective To determine whether obstetric team training in a medical simulation centre improves the team performance and utilisation of appropriate medical technical skills of healthcare professionals. Design Cluster randomised controlled trial. Setting The Netherlands. Sample The obstetric departments of 24 Dutch hospitals. Methods The obstetric departments were randomly assigned to a 1-day session of multiprofessional team training in a medical simulation centre or to no such training. Team training was given with high-fidelity mannequins by an obstetrician and a communication expert. More than 6?months following training, two unannounced simulated scenarios were carried out in the delivery rooms of all 24 obstetric departments. The scenarios, comprising a case of shoulder dystocia and a case of amniotic fluid embolism, were videotaped. The team performance and utilisation of appropriate medical skills were evaluated by two independent experts. Main outcome measures Team performance evaluated with the validated Clinical Teamwork Scale (CTS) and the employment of two specific obstetric procedures for the two clinical scenarios in the simulation (delivery of the baby with shoulder dystocia in the maternal all-fours position and conducting a perimortem caesarean section within 5?minutes for the scenario of amniotic fluid embolism). Results Seventy-four obstetric teams from 12 hospitals in the intervention group underwent teamwork training between November 2009 and July 2010. The teamwork performance in the training group was significantly better in comparison to the nontraining group (median CTS score: 7.5 versus 6.0, respectively; P?=?0.014). The use of the predefined obstetric procedures for the two clinical scenarios was also significantly more frequent in the training group compared with the nontraining group (83 versus 46%, respectively; P?=?0.009). Conclusions Team performance and medical technical skills may be significantly improved after multiprofessional obstetric team training in a medical simulation centre.     

Improving resident competency in the management of shoulder dystocia with simulation training

OBJECTIVE: To determine whether a simulation training scenario improves resident competency in the management of shoulder dystocia. METHODS: Residents from 2 training programs participated in this study. The residents were block-randomized by year-group to a training session on shoulder dystocia management that used an obstetric birthing simulator or to a control group with no specific training. Trained residents and control subjects were subsequently tested on a standardized shoulder dystocia scenario, and the encounters were digitally recorded. A physician grader from an external institution then graded and rated the resident's performance with a standardized evaluation sheet. Statistical analysis included the Student t test, chi(2), and regression analysis, as appropriate. RESULTS: Trained residents had significantly higher scores in all evaluation categories, including timelines of their interventions, performance of maneuvers, and overall performance. They also performed the delivery in a shorter time than control subjects (61 versus 146 seconds, P =.003). CONCLUSION: Training with a simulation-training scenario improved resident performance in the management of shoulder dystocia. LEVEL OF EVIDENCE: I     

Effectiveness of team training in managing shoulder dystocia: a retrospective study

Objectives: To evaluate the effectiveness of simulation team training for the management of shoulder dystocia. Primary outcome measures were the number of reported cases of shoulder dystocia, as well as fetal injury that occurred from it. Secondary outcome is documentation of manoeuvres used to alleviate shoulder dystocia.

Methods: Retrospective cohort study in a teaching hospital in the Netherlands, in a 38 month period before and after implementation of team training.

Results: We compared 3492 term vaginal cephalic deliveries with 3496 deliveries before and after team training. Incidence of shoulder dystocia increased from 51 to 90 cases (RR 1.8 (95% CI: 1.3–2.5)). Fetal injury occurred in 16 and eight cases, respectively (RR 0.50 (95% CI: 0.21–1.2)). Before team training started, the all-fours manoeuvre was never used, while after team training it was used in 41 of 90 cases (45%). Proper documentation of all manoeuvres used to alleviate shoulder dystocia significantly increased after team training (RR 1.6 (95% CI: 1.05–2.5)).

Conclusions: Simulation team training increased the frequency of shoulder dystocia, facilitated implementation of the all-fours technique, improved documentation of delivery notes and may have a beneficial effect on the number of children injured due to shoulder dystocia.     

Shoulder dystocia: Simulation and a team-centered protocol

Shoulder dystocia is an obstetric emergency that has been reported to occur in 0.2–3% of all vaginal deliveries. Several characteristics of shoulder dystocia make it a particular challenge to manage effectively. It is relatively infrequent, the diagnosis cannot be made according to a single objective criterion that can be recognized to exist by all members of the care team who are present, it is unpredictable, and there is the need for coordinated actions of all members of the health care team who have come together on the day of the delivery and may not have worked together before or specifically during a shoulder dystocia. In general, there is evidence from different medical disciplines that checklists/protocols and simulation may be used to enhance team performance. There is also some evidence, albeit limited, that such techniques may be used to improve shoulder dystocia outcomes.     

产房内危重症的处理

日常工作中产房发生急救事件较多，其中肩难产、子宫破裂、产后出血、脐带脱垂、子痫、羊水栓塞、胎盘早剥是较常见的一些危重症。为了达到良好的救治效果，产房必须具备技术过硬、反应快速的团队以及随时可用的设备，平时危重症急救的演练是提高产房危重症急救能力的有效措施。