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\begin{document}

\title{Breech assisted vaginal delivery and the role of simulation-based
training according to the PROMPT in a low-income setting: a
retrospective cohort study}



\author[1]{George Yared}%
\author[1]{Inaam Hatoum}%
\author[1]{Amina Krounbi}%
\author[1]{Charlotte Elhajjar}%
\author[1]{Janoub Khazaal}%
\affil[1]{Rafik Hariri University Hospital}%


\vspace{-1em}



  
  \date{May 27, 2024}


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\selectlanguage{english}
\begin{abstract}
Objective: to assess the effect of a simulation -based training program
(PROMPT) on the mode of delivery of breech presentation and to evaluate
the neonatal outcomes. Design: a retrospective cohort study Setting:
Rafic Hariri University Hospital (RHUH), a tertiary center in Beirut,
Lebanon Population: A total of 92 pregnant women delivering a singleton
with a breech presentation between June 2018 and December 2019 Methods:
We used data from the local perinatal registry at the RHUH. Clinical
outcomes were analyzed according to whether the obstetrician attended
the ``Train The Trainer'' course of the PROMPT or not. Main outcome
measures: Clinical measures include: the prevalence of cesarean
deliveries in the groups R6 and R7 according to the Robson's
classification and neonatal outcomes (Apgar score at 1 and 5 minutes and
admission to the neonatal intensive care unit (NICU) Results: The
prevalence to deliver a breech presentation by assisted vaginal delivery
is increased in group R6 of Robson's classification and not in group R7
after the simulation and the retention of skills is time-related. No
adverse neonatal outcomes were noted in both groups. Conclusion: The
simulation-based course improved the management of assisted vaginal
delivery in breech presentation mainly in group R6 of Robson
classification, without increasing neonatal complications and the
retention of skills decreases over time. Keywords: simulation, breech
delivery, Robson classification, PROMPT%
\end{abstract}%



\sloppy


\textbf{Introduction}

In obstetrics, a change in professional practice style and patient
characteristics may affect the main obstetrical skills including breech
assisted vaginal delivery due to lack of training of obstetricians. This
has an impact on Cesarean delivery rate which has increased worldwide
reaching a rate as high as 40.5\% in Latin America, 25\% in
Europe,19.2\% in Asia, and 7.3\% in Africa with a difference between
low- and high-income countries \textsuperscript{1}

Moreover, The Term Breech Trial in 2000 showed better neonatal outcomes
in terms of morbidity and mortality in planned CD versus planned
assisted vaginal delivery in breech presentation without any changes in
maternal outcomes. This led to a steady decline in the rate of breech
assisted vaginal delivery and to fewer opportunities for training and
mastering vaginal breech deliveries for future generations of
clinicians\textsuperscript{2}.

The mode of delivery is registered through the Robson classification of
cesarean sections (the ten-group classification system) endorsed by
World Health Organization (WHO) since 2015 as the best tool for cesarean
classification. Among the ten groups, group 6 refers to nulliparous
women who delivered a singleton fetus with breech presentation, and
group 7 refers to multiparous women who delivered a singleton fetus in
breech presentation regardless of the previous mode of
delivery\textsuperscript{3}.

Given these facts, the role of simulation is getting more important to
build specific skills in obstetrics and specifically in breech assisted
vaginal deliveries as it previously showed benefit in maintaining
obstetrical skills.

Worldwide many simulation programs were attempted and evaluated.

A systematic review in 2018 has shown that simulation-based training has
led to better clinical performance and quality of patient care
especially in obstetrical emergencies \textsuperscript{4}.

Another systematic review in 2019 showed that operative vaginal delivery
simulation sessions are associated with improvement in the knowledge,
competencies, and skills of healthcare professionals and better patient
outcomes \textsuperscript{5}.

A simulation training for vaginal breech delivery for resident doctors
is associated with better performance and skills and more comfort that
last for 10-26 weeks and this improvement declines over
time\textsuperscript{6,7}.

In the United Kingdom (UK), the Practical Obstetric Multi-Professional
Training (PROMPT) is an evidence based multi-professional obstetric
emergencies training package adopted as a local obstetric emergency
training program in Bristol and showed significant improvements in
obstetrical and neonatal outcomes compared in the 4 years before and 4
years after its introduction (neonatal hypoxic brain injuries, reduction
in injuries after shoulder dystocia and in emergency cesarean section).

According to Draycott in 2015, training for obstetric emergencies may
not be always generalized and effective \textsuperscript{8}. It depends
on the nature of clinical and non-clinical outcomes measured, the
setting where the simulation is conducted (simulation center/
on-site..). Bergh et al. suggested that local training of teams at their
unit using their own tools and supplies made them more familiar to their
setting and led to the most effective training. This implies the
integration of local clinical, medical, environmental and human
factors\textsuperscript{9}.

In Australia the implementation of the PROMPT for the management of
postpartum hemorrhage led to improvements in clinical skills and
non-technical skills concerning confidence, leadership, communication
and teamwork with no significant impact on all clinical
parameters\textsuperscript{10,11}.

To our knowledge the maternity department at the Rafic Hariri University
Hospital is the only department in the middle east to follow the Train
the Trainers'' program and to adopt it as a training program for all
maternity staff and one of the first maternity to adopt the Robson
classification.

Given the plethora of evidence supporting the benefit of simulation in
obstetrics and after the implementation of the PROMPT to our maternity
staff, the aim of our study is to evaluate its effect on the attitude of
the obstetricians to perform assisted vaginal delivery for breech
presentation measured by the changes observed in the Robson
classification (groups R6 and R7) and on the neonatal outcomes measured
by the Apgar score and admission to the neonatal intensive care unit.

\textbf{Methods}

This is a retrospective cohort study conducted at the Rafic Hariri
University Hospital (a tertiary hospital in Beirut) where we divided the
obstetricians into two groups: the first group received the PROMPT
(Practical Obstetric Multi-Professional Training) and the other group
who did not receive this training.

Then we compared the mode of delivery of breech presentation according
to whether the obstetrician received the training or not. This
comparison is based on the classification of the Robson 10-group
classification adopted by the World Health Organization (WHO). The
training sessions took place between June 2018 and June 2019 and
included simulation sessions according to the PROMPT for the attending
physicians then simulation sessions by these PROMPT-certified attending
physicians for the residents in our department. The neonatal outcomes
including the Apgar score and the admission to the neonatal intensive
care unit (NICU) were noted as well.

Our study was approved by the Institutional Review Board (IRB) at our
center.

\textbf{Results}

During the period from June 2018 to December 2019, we had 92 cases of
breech deliveries at our department after the exclusion of medical
indications for cesarean delivery in case of breech delivery. These
include:preeclampsia, placenta previa, placenta abruption, fetal
distress and the scheduled cesarean in the absence of labor.

No induction of labor was performed.

In group R6 the prevalence of assisted vaginal delivery (VD) is
significantly higher (7/17=41.1\%) in the group of simulation and no
assisted vaginal delivery (0/20) was attempted in the group of
obstetricians who did not attend the simulation (Table 1).

The difference is significant (p\textless{}0.05), and the simulation has
an effect in the category R6 where the obstetrician who attended the
simulation session would try more frequently than the obstetrician who
did not attend the simulation session to deliver the patient by assisted
vaginal delivery. A senior physician (attending physician or senior
resident) was present in these cases.

On the other hand, in group R7 the prevalence of assisted VD is
comparable between both groups (6/29=20.7\% in the group of simulation
and 7/26=27\% in the group of obstetricians who did not attend the
simulation (p\textgreater{}0.05).

The rate of Cesarean delivery was significantly reduced in the groups R6
and R7 between July and December 2019, immediately after the end of
simulation sessions and then it increases between January and June 2020,
reaching comparable rates as before the training sessions (Figure 1).

Neonatal outcomes

The admission to the neonatal intensive care unit (NICU)

The reasons for admission to the NICU is mainly due to prematurity in
vaginal delivery and cesarean groups.

The prevalence of admission to the NICU in the assisted vaginal delivery
group was 20\% (4/20) and the reason for admission was mainly
prematurity because all the newborn admitted were delivered between 28
weeks and 33 weeks of gestation. All the term babies delivered vaginally
did not need admission to the NICU.

The prevalence of admission to the NICU in the cesarean group was 14\%
(10/72) 3 of these were delivered at full term (39 weeks,38 weeks and
38weeks+2d) The reasons for admission to the NICU were intrauterine
growth restriction (IUGR) in one case and respiratory distress in the 2
others and the other 7 cases were admitted to the NICU for prematurity.
One of these was delivered at 29 weeks+2d, intubated then died.

Apgar score

8 of the 9 cases of term pregnancies who delivered vaginally had an
Apgar score of 9/10 at 1 and 5 minutes of birth. The 9th case died at
birth because of IUGR and multiple malformations. The evaluation of the
Apgar score in the preterm group could be biased by the effect of
prematurity.

A low Apgar score associated with admission to the NICU (due to IUGR and
fetal distress) was found in term cesarean deliveries in 2 cases out of
57 (3.5\%).

\textbf{Discussion}

Main findings

To our knowledge, this is the first study that compared the rate of
assisted vaginal delivery in breech presentation according to Robson's
classification before and after the simulation-based training course. In
assisted vaginal delivery for breech presentation, the simulation
sessions for obstetricians seem to give more confidence to the
obstetrician to try assisted vaginal delivery in the category R6, with
no significant effect in the category R7. The introduction of a
simulation-based course improved the management of vaginal breech
deliveries and led to the presence of a more senior physician during the
assisted vaginal delivery of breech presentation (attending physician
and senior resident). The effect of simulation is time-related and this
is explained by the increase of the rate of cesarean deliveries in the
groups R6 and R7 to reach the same rates as before the simulation, so
repeated simulation sessions are needed to maintain the same level of
performance.

In our study no significant changes were noted in neonatal outcomes in
terms of admission to the NICU and the Apgar score in the vaginal
delivery and cesarean groups. The main reason for unfavorable neonatal
outcomes was prematurity. We could conclude that breech assisted vaginal
delivery, after simulation sessions, in some well selected cases could
lead to maternal and neonatal favorable outcomes.

Strength and limitations

The strength of this study is that it evaluated, for the first time, the
effect of simulation in the trend to deliver breech presentation
vaginally and the changes emerged according to the Robson's
classification in a low-income setting in Lebanon. Our results highlight
the importance of simulation to decrease the cesarean rate in the group
R6 in particular. Due to the small number of patients included in the
study (92 patients) done at a public hospital, it is unclear whether we
can extend the results of our study to general population and to private
hospitals that contributes to a considerable proportion of institutional
deliveries.

Interpretations

Our conclusion that a simulation-based training led to better outcomes
and more confidence in the management of breech assisted vaginal
delivery aligns with previous findings by Hardy et
al.\textsuperscript{12}.

The retention of skills is time related. Stone et al. showed a decrease
in retained skills in breech deliveries 10-26 weeks after the training,
but the level of comfort was not affected by the
time\textsuperscript{6}.

Predictive criteria for a higher risk unsuccessful breech vaginal
delivery include according to the Royal College to Obstetricians and
Gynaecologists in 2017: hyperextended neck on ultrasound, high estimated
fetal weight (\textgreater{}3,8kg), low estimated fetal weight
(\textless{}10\textsuperscript{th} percentile), footling presentation
and antenatal fetal compromise. The presence of skilled experienced
obstetrician leads to a safe breech vaginal
delivery\textsuperscript{13}.

This is where the role of simulation could be beneficial.

According to the new guidelines of the Coll\selectlanguage{ngerman}ège National des Gynécologues
et Obstétriciens Français (CNGOF) in 2020 the risk of neonatal
complications is low in vaginal delivery or elective cesarean in term
breech pregnancies \textsuperscript{14}.

The implementation of an evidence -based training programme (PROMPT) in
obstetric emergencies adapted to the local settings with collaborative
collective efforts is generative of safety and high performance in local
maternities leading to better maternal and neonatal outcomes.

Obstetric simulation is a cornerstone in cases of high-acuity,
low-frequency obstetric events.

Conclusion:

The prevalence of breech assisted vaginal delivery increased after
implementation of a simulation-based training especially in the group R6
of the Robson classification, without increasing neonatal adverse
effects.

Contribution to authorship

Inaam Hatoum and Amina Krounbi collected and analysed the data

Inaam Hatoum, Charlotte El Hajjar and Janoub Khazaal wrote the
manuscript.

George Yared revised the manuscript before the submission.

Disclosure of interests

The authors disclose no conflict of interest.

Ethics approval

Our study was approved by the Institutional Review Board (IRB) at Rafic
Hariri University Hospital.

Funding

The authors received no financial support for the research, authorship,
and/or publication of this article.

Figure and table legends

Table 1: Prevalence of vaginal delivery in breech presentation according
to Robson' classification and the status of simulation

Figure 1: Prevalence of cesarean delivery in R6 and R7 between 2016 and
June 2020

\textbf{References}

1: Betran AP, Ye J, Moller AB, Zhang J, Gulmezoglu AM, Torloni MR. The
increasing trend in cesarean section rates: global, regional, and
national estimates: 1990--2014. PLoS ONE. 2016;11(2)

2: Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR.
Planned cesarean section versus planned vaginal birth for breech
presentation at term: a randomized multicenter trial. Term Breech Trial
Collaborative Group. Lancet. 2000 Oct 21;356(9239):1375-83.

3: Betran AP, Vindevoghel N, Souza JP, Gu¨lmezoglu AM, Torloni MR (2014)
A Systematic Review of the Robson Classification for Caesarean Section:
What Works, Doesn't Work and How to Improve It. PLoS ONE 9(6): e97769.
doi:10.1371/journal.pone.0097769

4: Amatullah, A. F. (2018, January). Using interprofessional
simulation-based training to improve the management of obstetric
emergencies: A systematic review. Clinical Simulation in Nursing,
14,45-53

5: Katherine H Bligard, Kim L Lipsey, Omar M Young Simulation Training
for Operative Vaginal Delivery Among Obstetrics and Gynecology
Residents: A Systematic Review. Obstet Gynecol,2019 Oct;134 Suppl
1:16S-21S.

6: Stone H, Crane J, Johnston K, Craig Retention of Vaginal Breech
Delivery Skills Taught in Simulation. J Obstet Gynaecol Can. 2018
Feb;40(2):205-210.

7: Deering S, Brown J, Hodor J, Satin A Simulation~training and resident
performance of singleton vaginal~breech~delivery. J.Obstet Gynecol. 2006
Jan;107(1):86-9.

8: Draycott T. Not all training for obstetric emergencies is equal, or
effective\textbf{.}T.\emph{BJOG}. 2017; 124: 651.

9: Bergh AM, Baloyi S, Pattinson RC. What is the impact of
multi-professional emergency obstetric and neonatal care training? Best
Pract Res Clin Obstet Gynaecol. 2015 Nov;29(8):1028-43. doi:
10.1016/j.bpobgyn.2015.03.017. Epub 2015 Apr 8. PMID: 25937554

10: Kumar A, Sturrock S, Wallace EM, Nestel D, Lucey D, Stoyles S,
Morgan J, Neil P, Schlipalius M, Dekoninck P. Evaluation of learning
from Practical Obstetric Multi-Professional Training and its impact on
patient outcomes in Australia using Kirkpatrick's framework: a mixed
methods study. BMJ Open. 2018 Feb 17;8(2):e017451. doi:
10.1136/bmjopen-2017-017451. PMID: 29455162; PMCID: PMC5855459

11: Shoushtarian M, Barnett M, McMahon F, Ferris J. Impact of
introducing practical obstetric multi-professional training (PROMPT)
into maternity units in Victoria, Australia. BJOG. 2014
Dec;121(13):1710-8. doi: 10.1111/1471-0528.12767. Epub 2014 Apr 21.
PMID: 24751206.

12: Hardy L, Garratt JL, Crossley B, Copson S, Nathan E, Calvert K,
Epee-Bekima M. A retrospective cohort study of the impact of In Time
obstetric simulation training on management of vaginal breech
deliveries. Aust N Z J Obstet Gynaecol. 2020 Oct;60(5):704-708.

13: Management of Breech Presentation: Green-top Guideline No. 20b.
BJOG. 2017 Jun;124(7):e151-e177. doi: 10.1111/1471-0528.14465. Epub 2017
Mar 16. Erratum in: BJOG. 2017 Sep;124(10 ):e279. PMID: 28299904.

14: Sananès N. Breech Presentation: CNGOF Guidelines for Clinical
Practice~-~Benefits and Risks for the Neonate and Child of Planned
Vaginal Delivery versus Elective Cesarean Section{]}. Gynecol Obstet
Fertil Senol. 2020 Jan;48(1):95-108. French. doi:
10.1016/j.gofs.2019.10.023. Epub 2019 Oct 31. PMID: 31678508.

Table 1: Prevalence of vaginal delivery in breech presentation according
to Robson' classification and the status of simulation\selectlanguage{english}
\begin{longtable}[]{@{}llllllll@{}}
\toprule
Doctors who attend the simulation & Doctors who attend the simulation &
Doctors who attend the simulation & Doctors who attend the simulation &
Doctors who didn't attend the simulation & Doctors who didn't attend the
simulation & Doctors who didn't attend the simulation & Doctors who
didn't attend the simulation\tabularnewline
Robson 6 & Robson 6 & Robson 7 & Robson 7 & Robson 6 & Robson 6 & Robson
7 & Robson 7\tabularnewline
Cesarean & Vaginal delivery & Cesarean & Vaginal delivery & Cesarean &
Vaginal delivery & Cesarean & Vaginal delivery\tabularnewline
10 & 7 & 23 & 6 & 20 & 0 & 19 & 7\tabularnewline
Prevalence of assisted vaginal delivery in each group (\%) & Prevalence
of assisted vaginal delivery in each group (\%) & Prevalence of assisted
vaginal delivery in each group (\%) & Prevalence of assisted vaginal
delivery in each group (\%) & Prevalence of assisted vaginal delivery in
each group (\%) & Prevalence of assisted vaginal delivery in each group
(\%) & Prevalence of assisted vaginal delivery in each group (\%) &
Prevalence of assisted vaginal delivery in each group
(\%)\tabularnewline
7/17=41.1\% & 7/17=41.1\% & 6/29=20.7\% & 6/29=20.7\% & 0/20=0\% &
0/20=0\% & 7/26=27\% & 7/26=27\%\tabularnewline
\bottomrule
\end{longtable}

\textbf{Hosted file}

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\selectlanguage{english}
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