Faculty Bibliography

BACKGROUND:Skilled performance of cesarean deliveries is essential in obstetrics and gynecology residency. A computer-enhanced visual learning module (CEVL Cesarean) was developed to teach cesarean deliveries. METHODS:An online module presented cesarean deliveries as a series of components using text, audio, video and animation. First-year residents used CEVL Cesarean and were evaluated intra-operatively by trained raters, then provided feedback about surgical performance. Clinical outcomes were collected for approximately 50 cesarean deliveries for each resident. RESULTS:From 2010 to 2011, 12 first-year residents participated in the study. About 406 unique observed cesarean deliveries were analyzed. Procedures up to each resident's 70th case were analyzed by grouping cases in 10 s (cases 1-10 and 11-20), or deciles. Resident performance significantly improved by decile [χ(2)(6) = 47.56, p < 0.001]. When examining each resident's performance, surgical skill acquisition plateaued by cases 21-30. Procedural performance, independent of resident, also improved significantly by decile [χ(2)(6) = 186.95, p < 0.001], plateauing by decile 4 (cases 31-40). Throughout the observation period, operative time decreased by 3.84 min (p = 0.006). CONCLUSIONS:Pre-clinical teaching using computer-based modules for cesarean sections is feasible to develop. Novice surgeons required at least 30 procedures before performing the procedure competently. When residents performed competently, operative time and complications decreased.

OBJECTIVE:To estimate the association between obstetric forceps volume and severe perineal lacerations or adverse neonatal outcomes. METHODS:This is a retrospective cohort of forceps deliveries performed at a tertiary care hospital. Obstetricians were grouped by quartile of forceps volume over the study time period. Severe (third- or fourth-degree) perineal lacerations and adverse neonatal outcomes were compared across quartiles. Individual patient characteristics were controlled for using multilevel multivariable analysis. This study had 90% power to detect a twofold difference in severe perineal lacerations between the first and fourth quartiles. Additional analyses were performed using physician years in practice or year of residency of the involved resident physicians. RESULTS:One hundred eighteen attending physicians (2,369 forceps deliveries) were included. The median (interquartile range) annual number of forceps per quartile was 1.3 (1.0-1.8), 3.8 (3.0-4.3), 6.3 (5.5-6.8), and 11.5 (9.8-17.3). The frequency of severe perineal lacerations from lowest to highest quartile was 29.9%, 27.5%, 33.3%, and 36.9% (P=.013). After adjusting for confounders, the relationship between volume quartile and severe perineal lacerations became nonsignificant. Although not powered to this outcome, the frequency of composite adverse neonatal outcome was not associated with volume quartile in either bivariate or multivariable analysis. Similarly, neither physician years of practice nor resident year was associated with severe perineal laceration. However, more experience as a resident was associated with a reduced odds of composite adverse neonatal outcomes. CONCLUSIONS:After controlling for patient factors, neither attending forceps volume nor physician years in practice was associated with severe perineal lacerations or composite neonatal injury. LEVEL OF EVIDENCE/METHODS:II.

OBJECTIVES/OBJECTIVE:To describe obstetric outcomes in women with a prior obstetric anal sphincter injury (OASIS) and to identify risk factors for recurrence. METHODS:A retrospective chart review of women who sustained an OASIS between November 2005 and March 2010 at a tertiary care hospital was performed to identify risk factors for recurrence. RESULTS:One thousand six hundred twenty-nine patients had an OASIS. Of these, 758 patients (90%) subsequently delivered during the aforementioned timeframe; 685 patients had a subsequent vaginal delivery. Of the women, 3.2% had a recurrent OASIS. Recurrence was associated with larger birth weight (27% ≥4000 g vs 11.6% <4000 g; P = 0.04) and delivery mode (25.0%, 12.5%, and 2.7% for forceps-assisted, vacuum-assisted, and spontaneous deliveries, respectively (P = 0.0001)), whereas a history of fourth-degree laceration, prior wound complication, or episiotomy at subsequent delivery were not (P = 0.5, P = 0.5, and P = 0.4, respectively). CONCLUSIONS:Recurrent OASIS occurred in a small percentage of women (3.2%) who subsequently delivered vaginally. Recurrent OASIS was associated with operative vaginal delivery and birth weight 4000 g or greater. Neither episiotomy at first delivery nor at subsequent delivery conferred an increased recurrence risk.

Annual surgeon case volume has been linked to patient outcome in a variety of surgical fields, although limited data focus on gynecologic surgery performed by general gynecologists. Herein we review the literature addressing the associations between intraoperative injury, postoperative morbidity, and resource use among surgeons performing a low vs high volume of hysterectomies. Although study design and populations differ, individual and composite morbidity outcomes consistently favored high-volume surgeons. Given the growing emphasis on competency-based evaluation in surgery, gynecology departments may soon consider volume requirements a component of privileging.