Authors: Haven Frazier, Leanne Free, Shana Miles, Matthew Vanbaaren, Adam Levy
Categories: Original Publication, Abortion, Dilation and Evacuation, OB/GYN, Simulation, Women's Health, Clinical/Procedural Skills Training, Gynecologic Surgery
Source: MedEdPORTAL : the Journal of Teaching and Learning Resources
Authors: Haven Frazier, Leanne Free, Shana Miles, Matthew Vanbaaren, Adam Levy
In the US, one in four women will have an abortion, and most OB/GYN physicians have had patients who required abortion care. Most second-trimester abortions in the US (95%) are performed via dilation and evacuation (D&E), which requires provider skill and competency. Barriers to obtaining abortion training include opt-in residency programs, location-based legal restrictions, and religiously affiliated institutions. Our D&E simulation is a cost-effective, realistic model.
D&E models were assembled using juice containers, Cornish hens, and Sopher forceps. Thirty-five participants (medical students and OB/GYN residents) completed presimulation surveys and received a brief lecture about abortion demographics, techniques, and complications, followed by the hands-on simulation; 27 completed postsimulation surveys. Participants assessed their comfort levels in performing D&Es and recognizing postabortion complications, and their likelihood of performing D&Es in future clinical practice.
Comfort levels significantly improved pre- to postsimulation, increasing from 32% to 55% (p < .001) for participants reporting feeling somewhat comfortable or extremely comfortable performing D&Es, and increasing from 46% to 63% (p < .01) for participants reporting feeling somewhat comfortable or extremely comfortable recognizing postabortion complications after receiving the introductory lecture. Overall, participants indicated that the simulation was realistic (92%) and increased their knowledge (100%) and ability to perform D&Es (96%).
Our affordable and simple D&E model can be easily replicated and implemented for training in second-trimester D&E. This model can serve as a valuable and realistic tool for providers with restricted access to clinical abortion who need adjunct training, improving physician education and competency.
By the end of this activity, learners will be able 1.Discuss abortion demographics in the US.2.Discuss the types of abortion training in graduate and undergraduate medical education.3.Discuss barriers to abortion training in the US.4.Describe the pros and cons of medical versus surgical abortion in the second trimester.5.Consent a patient for dilation and evacuation (D&E).6.List the indications for D&E.7.Describe how to prepare for and perform D&E.8.Practice a key component of D&E manual skills (fetal evacuation) on simulation models.9.Describe and demonstrate methods of handling forceps during D&E.10.List postabortion complications.11.Define postabortion hemorrhage and discuss the management of this complication.12.Discuss methods of post-D&E contraception.
Abortion care is an essential and common part of reproductive health care. In the US, one in four women have an abortion in their lifetimes, and almost all OB/GYN physicians have had patients who required some sort of uterine evacuation.^1,2^ Although 90% of abortions occur in the first trimester, 95% of those that occur at later gestational ages in the US are performed via D&E, which requires more provider skill and competency to perform.^3,4^ When compared to medical management, surgical management is often faster, associated with fewer complications, more cost-effective, and more often preferred by patients undergoing second-trimester abortion.^4^
Providers often face barriers when it comes to obtaining abortion training, including opt-in residency programs, legal restrictions based on location of practice, and institutions with religious affiliations.^5^ In order to become certified with the American Board of Obstetrics and Gynecology, OB/GYNs must complete, at a minimum, the equivalent of two 4-week blocks of family planning during residency, which should include structured curriculum and clinical experiences in contraception, surgical sterilization, patient counseling about medical and surgical abortions, and management of abortion complications. Augmenting clinical experiences with simulation is encouraged.^6^ Despite this, only four in 10 US OB/GYN physicians reported providing routine abortion care for their patients, and only 64% of OB/GYN residency program directors reported providing routine abortion training for their residents.^2^ The American College of Obstetricians and Gynecologists supports increasing the pool of abortion providers to include family medicine physicians and advanced practice clinicians, as well as integrating routine abortion training into resident and medical student education.^5^
Most existing abortion simulation models are designed for first-trimester abortions; fewer exist for developing skills in D&E in the second trimester. To our knowledge, one other D&E simulation model has been published in MedEdPORTAL;^7^ this model requires D&E simulation using a high-fidelity birthing mannequin, among other pieces of specialty medical equipment. While this design simulates clinical scenarios and postabortion complications, it may also be impractical or inaccessible for providers outside of an academic setting. A lower-fidelity D&E simulation model similar to ours was published in 2022;^8^ however, this model uses less realistic materials for the products of conception. Additionally, the model was part of a multiphase study introducing D&E to the community, and descriptions of the simulation model itself are limited.^8^ Another D&E simulation model employs large plastic bottles for the uterus, but the fetal parts and endometrium were found to be less realistic by study participants.^9^
Our simulation was originally designed in 2020 and the responses were universally positive among the University of Nevada, Las Vegas (UNLV) and Mountain View Hospital OB/GYN residents. It employs a low-budget (approximately “8 per model and “92 for bulk supplies), easy to assemble (approximately 30 minutes), and realistic design developed for learners and providers to practice D&Es, despite any legal or institutional barriers they may face. These features accommodate institutions with limited resources, time, or budgets, while also providing realistic tactile sensation to simulate D&E procedures.
The OB/GYN residency program at UNLV is a combined civilian and military program with a total of 16 civilian residents and eight military residents. Clinical education primarily takes place at a private hospital and the university-associated hospital and outpatient clinics, with occasional clinical duties performed at Nellis Air Force Base. The UNLV OB/GYN residency program is a participating institution in the Kenneth J. Ryan Training Program in Abortion and Family Planning, which was designed to help residency programs integrate family planning (including abortion care) into resident education.^2^ Family planning rotations at UNLV are longitudinal across all 4 years, and abortion care training is opt-out. Residents spend approximately 2 weeks at the family planning clinic during each year of residency, where they take part in providing medication abortion, procedural abortion, contraception, and management of abortion-related complications. During this study period, most residents participated in full-spectrum abortion care and no residents opted out. They had opportunities to start performing parts of D&Es during their first year of residency, and later performed D&Es fully during the remainder of their residency training. Third- and fourth-year medical students can elect to rotate at the family planning clinic, where they also learn full-spectrum family planning care.
This study received an institutional review board exempt status from the UNLV Office of Research Integrity–Human Subjects. Our D&E simulation was held during a single 1-hour didactics session for the OB/GYN residents and the third- and fourth-year medical students who were completing their OB/GYN clerkship at that time. The D&E models were assembled ahead of time (Appendix A) and Sopher forceps were borrowed from the family planning clinic and the university hospital operating room. Each D&E model was set up on an absorbent pad on a flat, narrow table. Gloves and Sopher forceps were available at each of these stations.
The following materials were required to create the D&E simulation models (assembled ahead of time; Appendix A) and to complete the •Plastic juice carton (1 gallon), with neck opening measuring approximately 1.5 inches (3.8 centimeters) in diameter•Utility knife•Tape measure•Carpet foam (or similar spongy material)•Scissors•Double-sided tape•Duct tape•Cornish hen (raw)•Sopher forceps•Gloves (recommended)•Absorbent pad or plastic sheet (recommended)•Flat surface
To start the activity, residents and medical students completed a presimulation survey (Appendix B) on the Qualtrics platform. The survey assessed their preexisting knowledge surrounding second-trimester abortion and also asked participants to indicate their comfort level with performing D&Es and being able to recognize postabortion complications, with response options of extremely uncomfortable, somewhat uncomfortable, neither comfortable nor uncomfortable, somewhat comfortable, and extremely comfortable.
Next, participants received a brief introductory lecture (Appendix C), which outlined abortion demographics in the US, second-trimester abortion techniques including D&Es, and complications of procedural abortions. This was followed by dividing the participants into pairs at each D&E station. One of the participants practiced the D&E technique while the other held and secured the simulation model in place from the opposite side of the table. Throughout the simulation activity, family planning faculty were present to instruct on technique, although instruction can also be received from OB/GYN generalists or maternal-fetal medicine specialists who perform D&Es as a part of their clinical practice.
The following methods for practicing D&E technique (Appendix D) were •The person performing the D&E should stand in front of the neck of the carton and use grasping forceps to methodically remove the hen (and loose foam) in pieces.•Another person should stand at the base of the carton to firmly hold it in place against the table.•Introduce the forceps into the carton. ○Forceps are generally introduced and opened in an anterior-posterior direction, so both jaws can be visualized on transabdominal ultrasound. They may also be opened horizontally; however, both jaws cannot be visualized simultaneously on ultrasound in this orientation.^10,11^○Drop your hands if needed to match the angle of the uterus, if positioned anteriorly.^10^○Grasp tissue and rotate prior to pulling to reduce complications involving the uterine wall.○[Optional] Hanson's Maneuver: When ultrasound is not available, place one hand on the uterine fundus (base of the carton) and do not allow the forceps to pass your hand (this has limited utility in obese patients).^12^•Once all of the hen (and loose foam) has been removed, the inside of the carton should be examined to evaluate for any pieces of adhered carpet foam that have been removed. This would simulate injured uterine tissue.
At the conclusion of the activity, the residents and medical students completed a postsimulation survey (Appendix E). The total duration of the lecture and simulation was approximately 1.5 hours. Results were analyzed using descriptive statistics and chi-squared tests.
In total, 35 people completed the presimulation survey and participated in the simulation activity, and 27 completed the postsimulation survey. Simulation participants included third-year medical students, fourth-year medical students, and residents at all four training levels (Table 1). Of all simulation participants, 66% reported having participated in a D&E simulation in the past, while 34% had not. Similarly, 66% of participants reported having performed D&Es in an outpatient or inpatient clinical setting in the past, while 34% had not.
Participants’ comfort level in their ability to perform D&Es increased significantly pre- to postsimulation, with participants indicating a comfort level of somewhat comfortable or extremely comfortable increasing from 32% to 55% (p < .001). Moreover, participants reported feeling more comfortable recognizing postabortion complications after receiving the introductory lecture, increasing from 46% to 63% of participants (p < .01; Table 2).
Participants were also asked if they were more likely to perform D&Es in future practice if they were to receive more simulated training during residency. Students who did not intend to pursue a specialty in OB/GYN chose not applicable. The percentage of participants who responded yes to indicate they were likely to perform D&Es in future if given more simulated training increased from 60% to 67% pre- to postsimulation, and the percentage who responded no or unsure decreased from 40% to 33% pre- to postsimulation (p = .62). When asked if they were more likely to perform D&Es in future practice if they were to receive more clinical training (as opposed to simulated training) during residency, the percentage of participants who responded yes increased from 62% to 67%, and the percentage who responded no or unsure decreased from 38% to 33% (p = .94). These response changes from pre- to postsimulation were not statistically significant (Table 3).
After completion of the simulation, the participants were asked their opinions on the simulation experience. Overall, most participants felt that the simulation was realistic (92%) and increased their knowledge (100%) and their ability to perform D&Es (96%; Table 3).
It is imperative for OB/GYN physicians to become competent in D&E. Unfortunately, with increased legal restrictions and institutional barriers based on location of practice, there is increasingly limited opportunity to use and practice this skill set until it becomes medically indicated, at which point the clinical scenario may be urgent or emergent. The simulation presented is a low-budget and realistic model that can be easily implemented for supplemental training in D&E.
Our D&E model can be easily replicated, unlike other models which are cost-prohibitive or require advanced equipment. The model is easily assembled with few supplies, some of which are a one-time purchase (utility knife, scissors, juice containers), while others can be purchased in bulk for multiple uses (carpet foam, gloves, absorbent pads). Cornish hens (or similar poultry products) are available at most grocery stores. Obtaining Sopher forceps proved to be somewhat more challenging; however, these can be either obtained through a one-time purchase for multiple uses or, depending on local resources, borrowed from nearby facilities.
Existing D&E simulations, endorsed by American College of Obstetricians and Gynecologists and Innovating Education in Reproductive Health, range from low-fidelity models such as our own to high-fidelity models that simulate emergency scenarios. These low-fidelity pelvic models are made from melons, glass jars, plastic bottles, or neoprene, and the fetal models include a variety of objects including dried pasta, pepperoni sticks, mushrooms, eggs, ping-pong balls, cat toys, modeling clay, washcloths, facial tissue, and velcro.^13–16^ While study participants have found plastic bottles to be more realistic compared to other models, there have been varied responses to the tactile sensation of removing these aforementioned products and how well they simulate removing fetal parts.^9^ The use of Cornish hens in our model addresses these concerns by providing a more realistic tactile sensation and requires participants to disarticulate the hen prior to removing it from the container.
Overall, the simulation was successful in increasing learner knowledge and confidence in performing D&Es. Limitations to this simulation include a lack of full postsimulation survey participation (27 of 35 participants completed the second survey), and the large proportion of participants who were medical students who may not practice in a specialty that provides abortion care.
While simulation training does not entirely replace clinical experience, this model could serve as a valuable adjunct tool for physicians and other providers with restricted access to clinical abortion training. This is especially important for residency programs that only offer opt-in training or programs that do not offer any abortion training, as these physicians are still likely to encounter indicated terminations even if they reside in restrictive states. Incorporating D&E simulation into OB/GYN residency training could standardize and improve physician education and competency.