Faculty Bibliography

Objectives: To evaluate the effect of a pelvic model simulation on performance of sacrospinous ligament fixation (SSLF) and to develop and validate a reliable Objective Structured Assessment of Technical Skills (OSATS) to measure the necessary surgical skills to perform SSLF. Methods: After developing a pelvic model for SSLF, we enrolled OB/GYN residents as well as experts who routinely perform the procedure. Baseline resident knowledge on SSLF was evaluated using a written test. All residents underwent a didactic session pertinent to SSLF and were then randomized to simulation training vs. no training. During the simulation, participants were taught to perform the procedure in a systematic fashion on a pelvic model that permitted the trainees to visualize spatial relationships and understand the procedure in a 3-dimensional space. All residents were then evaluated using a modified OSATS which consisted of a global rating scale (GRS) to examine performance during the entire testing process and a task-specific checklist (TSC). The GRS was comprised of 5 domains related to surgical performance graded on a 5-point scale from 1 to 5 (poor to excellent performance). The TSC consisted of an 8 item surgical check list and was graded on a 3-point scale from 0-2. Two blinded experienced independent raters used the OSATS scale for SSLF to evaluate each individual performance. After completion, knowledge was reassessed using a written post-test and participants were asked to evaluate the training session. Construct validity was measured by comparing OSATS scores between experts and trainees. Data collected included year of residency and self-reported number of prior procedures. Written test scores (paired t- test) and OSATS scores (Wilcoxon signed rank test) between the groups were compared. A p-value < 0.05 was considered significant. Results: The trainee group consisted of 20 residents, 11 of whom underwent simulation training and 9 who did not. 4 subjects were included in the expert group (3 urologists and 1 gynecologist). After simulation, OSATS mean total GRS scores (18.4+/-0.9 vs. 11.1+/-0.5, p=0.0005) and mean total TSC scores (12.6+/-1.4 vs. 6.1+/-0.6, p=0.0003) were significantly better for the simulation group vs. the traditional learning group. Mean time required to complete the procedure was also significantly different between the two resident groups (p=.0006). Results were still significant when adjusting for year of residency and number of prior procedures. There was improvement in mean written post-test scores in all the trainees (p=0.0005); however, there was no difference in scores between the two randomized groups. Experts had higher total GRS scores (25+/-0.7 vs. 15.1+/-0.8, p=0.006) and TSC scores (13.7+/-0.6 vs. 9.7+/-1.2, p=0.02) as well as higher scores in each subscale. Experts also required less time to complete the procedure than trainees (p=0.02). All participants agreed that the pelvic model was useful for learning SSLF and felt it would improve their ability to perform the procedure in vivo. Conclusions: Simulation for urogynecologic procedures like our SSLF model can be useful in improving skills and confidence in trainees. Additionally, the OSATS scale demonstrated validity in differentiating novices from experts

Background: Complete separation of the vaginal vault from the uterus is a rare complication of cesarean delivery, requiring assistance with a vaginal hand. Case: A 24-year-old nulliparous woman at 40 weeks plus 3 days of gestation experienced arrest of the second stage of labor, and a vaginal hand was required during cesarean delivery to disimpact a deeply engaged fetal head. Results: Following delivery, complete detachment of the vaginal vault from the cervix was noted without disruption of the uterine vessels. Normal anatomy was surgically restored without complications. The neonate was treated for respiratory distress, and examined for sepsis and hyperbilirubinemia, requiring phototherapy. He was discharged 6 days and was healthy at a 2-week follow-up. Conclusions: Complete separation of the uterus and vaginal vault is a previously unknown complication resulting from elevation of an impacted fetal head vaginally. Simple reattachment of the uterus to the vaginal cuff represents a reasonable alternative to peripartum hysterectomy. 2013, Mary Ann Liebert, Inc

OBJECTIVES: Educators of trainees in procedure-based specialties need focused assessment tools that are valid, objective, and assess technical skills in a realistic context. A framework for hybrid assessment using standardized patient scenarios and bench skills testing might facilitate evaluation of competency. METHODS: Seven PGY-1 obstetrics and gynecology residents participated in a hybrid assessment that used observed structured clinical examination (OSCE) by a standardized patient who had sustained a vaginal laceration during vaginal delivery. The residents elicited a history and counseled the patient, and then completed a laceration repair on a pelvic model. The residents were rated on their performance in the scenario, which included issues of cultural competency, rapport-building, patient counseling. The technical skills were videotaped and rated using a modified global assessment form by 2 faculty members on a 3-point scale from "not done" to "partly done" to "well-done." Residents also completed a subjective assessment of the station. RESULTS: Mean technical performance of the residents on the technical skills was 55% "well-done," with a range of 20%-90%. The assessment identified 3 residents as below the mean, and 1 resident with areas of deficiency. Subjective assessment by the residents was that juggling the technical, cognitive, and affective components of the examination was challenging. CONCLUSIONS: Technical skills can be included in a case-based assessment using scenarios that address a range of cognitive and affective skills required of physicians. Results may help training programs assess individuals' abilities as well as identify program needs for curricular improvement. This framework might be useful in setting standards for competency and identifying poor performers.

BACKGROUND: Reflective practice may help physicians identify and connect with what they value and find meaningful in their work. There are many practical obstacles in teaching narrative skills and reflection to residents in surgical subspecialties. We aimed to assess the feasibility of designing and implementing a writing workshop series within an obstetrics and gynecology curriculum. MATERIALS AND METHODS: Between 2008 and 2009, a reflective writing workshop series was introduced into the didactic curriculum of an obstetrics and gynecology residency program. The course included reading fiction and creative writing. Workshops focused on topics residents identified. Residents answered a subjective questionnaire and also completed the Maslach Burnout Inventory and Interpersonal Reactivity Index to assess burnout and empathy. RESULTS: Six 1-hour reflective writing workshops took place within the dedicated didactic time for residents. Of the 20 residents in the program, 10 junior residents and 8 senior residents evaluated the workshops. Ten residents participated in more than one workshop, an average of 3.6 workshops. Residents felt that the workshops were enjoyable, and some felt that they influenced their experience of residency, but few felt that it affected their work with patients. Trends in Maslach Burnout Inventory and Interpersonal Reactivity Index scores did not show statistical significance. CONCLUSION: A practical curriculum for introducing reflective practice to obstetrics and gynecology residents is described. This model may be useful to educators looking to incorporate reflective practice into residency curricula and lead to collaborative work that may assess the impact of this work on the experience of residents and their patients.

OBJECTIVE: To evaluate contemporary perinatal and cardiac outcomes of pregnancies in women with major structural congenital heart disease. METHODS: Obstetric, neonatal, and cardiac outcomes were abstracted retrospectively from medical records of all women with congenital cardiac disease delivering at our institution from 2000-2007 and compared by type of structural defect. Predictors of adverse cardiac or obstetric events were identified. RESULTS: Over the 7-year study period, 74 deliveries occurred in 69 women with congenital heart disease, median age 28 years. There were three right-obstructive defects, 14 left-obstructive defects, four right-regurgitant defects, 19 conotruncal defects, 19 shunts, and four miscellaneous lesions. There were 21 adverse cardiac events in 15 pregnancies (20.2%); these were defined as maternal death, congestive heart failure, myocardial infarction, stroke, the need for urgent cardiac intervention, or arrhythmia requiring treatment. There were 44 adverse obstetric events in 34 pregnancies (45.9%), defined as preterm delivery, stillbirth, preeclampsia, small for gestational age, or neonatal intensive care unit admission. Patients with shunt morphology were more likely to experience adverse obstetric and cardiac outcomes. CONCLUSION: Pregnancy in women with underlying major congenital heart defects poses increased risks to both mother and fetus. Nonetheless, favorable maternal and neonatal outcomes occur in the majority of patients.

OBJECTIVE(S): To determine whether operator-dependent obstetric complications occur at higher rates in July at teaching hospitals using a large, nationwide sample of deliveries. STUDY DESIGN: Data for this study were obtained from an administrative dataset, the Nationwide Inpatient Sample, for the years 1998 to 2002. Singleton deliveries and singleton livebirth admissions among Medicaid patients at teaching hospitals with OB/GYN residents working on the Labor and Delivery ward were identified. Outcomes for various complications for these patients in the month of July were compared to those occurring in the months from August to June. RESULTS: The 26,546 women in our cohort who delivered in July were compared to the 272,584 women delivering during August to June. There were no statistically significant differences in the rates of cesarean delivery, urethral/bladder injury, third or fourth degree lacerations, wound complications, postpartum hemorrhage, transfusion, shoulder dystocia, chorioamnionitis or anesthesia-related complications. The 26,175 singleton livebirth admissions in July were compared to 266,158 such admissions in August to June. There were no statistically significant differences in the rates of brachial plexus injury (0.2 vs 0.2%, P=0.824) or birth asphyxia (0.1 vs 0.1%, P=0.643). CONCLUSION(S): This study shows no increased rate of operator-dependent complications of delivery at teaching hospitals nationwide in the month of July.

OBJECTIVE: The purpose of this study was to assess the maternal morbidity associated with attempted vaginal birth after cesarean (VBAC) in twin gestations using a large, nationwide sample of deliveries. STUDY DESIGN: Data for this study were obtained from an administrative dataset, the Nationwide Inpatient Sample, a representative sample of discharges from non-Federal hospitals, for the years 1993 to 2002. Patients admitted nonemergently for the delivery of twin gestations who had a history of previous cesarean delivery were selected. Patients that either delivered vaginally or who had discharge codes that indicated labor before cesarean delivery were defined as the trial of labor group, while patients who had a cesarean delivery without discharge codes that indicated labor were defined as the elective cesarean group. Various complications of delivery were analyzed for each group. RESULTS: We identified 4705 women who underwent an elective cesarean delivery and 1850 women who underwent a trial of labor. For women who had a trial of labor, 836 (45.2%) delivered vaginally. The rate of uterine rupture was higher in the trial of labor group than in the elective cesarean group (0.9% vs 0.1%, P < .001), and the rate of wound complications was lower (0.6% vs 1.3%, P < .02). The rates of other complications including hysterectomy, transfusion, major postpartum infection, thromboembolism, uterine dehiscence, and pelvic hematoma were not significantly different between the 2 groups. CONCLUSION: Our study showed a significantly higher rate of uterine rupture in the trial of labor group that is similar to the rates reported for trial of labor after cesarean in singleton pregnancies.

New neurons continue to be generated in the dentate gyrus throughout adulthood. Previous studies have shown that a significant proportion of new granule cells labeled with the thymidine analogue bromodeoxyuridine (BrdU) are lost from the adult dentate gyrus within 2 weeks. How long this loss continues and the extent to which it represents cell death, as opposed to dilution of label, is unclear. To address these questions, adult rats were injected with BrdU, and BrdU labeling in the dentate gyrus was compared at several survival time points. Double labeling with BrdU and the cell cycle marker Ki-67 showed that BrdU is detectable for up to 4 days in some cells that continue to divide, indicating that any decrease in the number of BrdU-labeled cells after 4 days is likely to reflect cell death rather than BrdU dilution. Death of new cells in the granule cell layer occurred at a steady rate between 6 and 28 days after labeling, resulting in loss of 50% of BrdU-labeled cells over this 22-day period. New granule cells that survived this first month lived for at least 5 additional months. In contrast, 26% of the granule cells labeled with BrdU at the peak of dentate gyrus development on postnatal day (P) 6 died between 1 and 6 months after labeling. These findings suggest that granule cells born during adulthood that become integrated into circuits and survive to maturity are very stable and may permanently replace granule cells born during development.