1Department of Obstetrics and Gynecology, Maharishi Markandeshwar Institute of Medical Sciences and Research, Mullana-133207 Ambala, Haryana, INDIA
2Department of Otorhinolaryngology, Maharishi Markandeshwar Institute of Medical Sciences and Research, Mullana-133207 Ambala, Haryana, INDIA
3Department of Obstetrics and Gynecology, Maharishi Markandeshwar Institute of Medical Sciences and Research, Mullana-133207 Ambala, Haryana, INDIA
Background: Simulation teaching means recreating clinical scenario for training / evaluation. Aim: To expose postgraduates to simulation / didactic lecture for postpartum hemorrhage (PPH) management; to assess which method was more effective. Methods: Present prospective study was conducted in Obstetrics Gynecology department of rural tertiary center of Northern India. Twenty postgraduates were randomly divided into two groups for simulation teaching / didactic lecture on PPH management. Analytic Data included pre and post lecture multiple choice questionnaire (MCQ), post-lecture Direct Observation of Procedural Skills (DOPS) assessment. Finally, feedback survey of students was conducted to assess perceptions about two modalities of teaching. Results: Both groups showed no difference in pre-lecture MCQ results. Comparison of DOPS performance showed significant difference (p=0.0026) between two groups with mean marks 5.10 ± 1.10 in Group 1, 3.40 ± 0.84 in Group 2. Significant improvement was observed in post-lecture compared to pre-lecture marks in both groups (mean difference- Group 1: 7.60 ± 1.26, Group 2: 4.20 ±1.01), with greater improvement among simulation group. Students rated simulation better with regard to interest (70%), enjoyment (75%), topic (70%), understanding (80%), posing questions (75%). Conclusions: Simulation teaching was more effective in imparting skills for PPH management compared to didactic lecture.
PPH is one of the major causes of maternal mortality all over world with reported global incidence of 2–11% (1-3). It is frequent complication of delivery in India with reported incidence of 2% - 4% after vaginal birth and 6% after cesarean section, uterine atony is the most common cause (50%) (4). Furthermore, the latest Indian figures report that PPH is responsible for 19.9% (5) of all maternal mortality, accounting for 78,00035 to 117,00011 maternal deaths, annually (6). Hence, management of this dreadful condition in its golden hour can reduce overall incidence as well as burden of maternal deaths resulting from PPH. This can happen only with better training of postgraduate students of department of Obstetrics and Gynecology in managing this condition. One such teaching modality for training of critical care amongst postgraduate students is simulation based teaching. It is an interactive and innovative educational tool that can help in building confidence, improve clinical knowledge through practice, errors can be allowed to occur, can even be scheduled, and can provide realistic experiences managing common and rare situations where exposure is limited to real life cases, and also it enhances team work. Also simulation provides safe learning environment where Obstetrics and Gynecology residents can be taught, practiced, and evaluated on technical skills without putting patient at risk in a real situation (7). After sufficient practice on mannequin, students can then be assessed on live patients in their work place using DOPS structured checklist, which further help in increasing their confidence and skills in dealing with life threatening conditions in real life scenario. DOPS is a Work Place Based Assessment (WPBA) tool in which subjects are observed in an environment quite similar to actual activities, with real patient and procedure (8), and help in focusing on important points of considered skill required to be evaluated. This method makes it easier to provide feedback to trainee as well as trainer. Therefore, it not only provides motivation and learning encouragement for students, but also gives direction to their learning efforts (9).
Hence, present study was conducted with the aim to train postgraduate students with newer modalities of teaching learning followed by assessment on live patients in work place, so as to know whether these modalities resulted in better understanding of subject and increase their overall skills and confidence level in managing such obstetric emergencies.
Aim: To compare simulation based teaching with didactic lecture approach in management of postpartum hemorrhage amongst postgraduate students of department of Obstetrics and Gynecology.
To compare knowledge and skills gained in management of PPH by the students using two modalities of teaching,
To assess performance of students in management of PPH using DOPS,
To assess the perceptions about two modalities of teaching and to know which modality helped in better understanding of subject amongst students of Obstetrics and Gynecology department of rural tertiary care center of Northern India.
Study Design: Prospective educational research study
Setting: The present prospective study was conducted in the department of Obstetrics and Gynecology of a rural tertiary care center of Northern India after proper Institutional ethical approval and informed written consent from the patients over a period of six months.
Sample size: All twenty postgraduate students of department of Obstetrics and Gynecology were enrolled in the study.
Study Protocol and Outcome measures:
All twenty postgraduate students of Obstetrics and Gynecology department were made to solve a pre-lecture MCQ of 20 marks on management of PPH, to know their baseline knowledge. They were then randomly divided into 2 groups by lottery system to remove bias. Group 1 received simulation based teaching using demonstration of all steps of management of PPH with hands-on practice of steps on mannequins for 6 encounters and Group 2 was taught by traditional method of didactic lecture using chalk and board. After teaching both the groups by either modality, students in two groups were asked to perform on live woman; the steps of managing PPH. Assessment of all students was then done using single encounter of DOPS structured checklist of 10 marks, to know level of competency attained by students in each group. Finally, post-lecture MCQ of 20 marks was taken to assess the level of knowledge and skills attained by each teaching learning modality and to compare the two modalities of teaching. In second phase, cross-over of students was done so that students in both groups receive teaching by both the modalities. At the end of the study a feedback survey was conducted to know the perceptions of students about the two modalities of teaching and to know which teaching learning method was better and why.
The quantitative data in the form of marks obtained in pre-lecture, post-lecture and DOPS checklist was analyzed using two-sample Mann–Whitney test while analysis of feedback form results (Qualitative data) was done by five point Likert scale rating.
All twenty students attempted a 20 marks baseline pre-lecture MCQ and the marks obtained in
two groups showed no significant difference (Table 1: Comparison of Pre-lecture Marks on PPH in Group 1 and Group 2). Then, the two groups were taught by the two methods of teaching, respectively. During their first DOPS checklist encounter on live patients; comparison of performance after simulation based teaching and performance after didactic lecture revealed statistically significant difference (p=0.0026) with mean marks achieved in Group 1 was 5.10 ± 1.10 and Group 2 was 3.40 ± 0.84, respectively (Table 2: Comparison of Student Performance on DOPS Encounter on PPH Management in Two Groups, Graph1: Comparison of Mean values of Student Performance on DOPS Encounter of PPH Management in Two Groups). Comparison of post-lecture MCQ marks showed that both groups demonstrated significant improvement in comparison to pre-lecture MCQ (Table 3: Comparison of Pre-lecture and Post-lecture MCQ Marks in two Groups), with more improvement observed among simulation group (Mean (+/−SD)= 18.60 ± 1.90) (Graph 2: Comparison of Mean values of Post-lecture MCQ Marks on PPH Management and Standard Deviation in Two Groups, Graph 3:Comparison of Mean values of Pre-lecture and Post-lecture MCQ Marks on PPH Management in the Two Groups). It was observed that simulation based teaching resulted in better understanding of subject and performance on live patients as assessed by DOPS in comparison to didactic lectures. Finally, a qualitative analysis of feedback survey form results revealed that students ranked simulation-based teaching method higher with regard to interest 70% (14/20), enjoyment 75% (15/20), topic chosen 70% (14/20), understanding of subject taught 80% (16/20) and ease of posing questions 75% (15/20) (Table 4: Feedback survey Results).
Table 1: Comparison of Pre-lecture Marks on PPH in Group 1 and Group 2
Method of Teaching
Pre-lecture MCQ Marks
Simulation based Teaching (Group 1)
11.00 ± 3.16
Didactic lecture (Group 2)
11.00 ± 3.16
Table 2: Comparison of Student Performance on DOPS Encounter on PPH Management in Two Groups
Method of Teaching
(Mean ± SD)
(Mean ± SD)
3.40 ± 0.84
Table 3: Comparison of Pre-lecture and Post-lecture MCQ Marks in two Groups
Medical education is one of the dynamic fields that is undergoing major changes throughout the world and hence requires newer educational techniques and assessment modalities to cater for these ever changing demands. Also there exists an inherent difficulty in imparting knowledge on emergency medicine and critical care that are difficult to grasp, especially for medical students as it is often not possible to demonstrate live critical scenarios in hospital setting. Hence, a completely safe version mimicking such complex scenarios can be made using Simulation based teaching. Many studies have shown that use of simulation based teaching in training medical students and junior doctors is helpful in not only strengthening their knowledge but also in evaluating their overall performance in performing a particular task (10-12).
The present study compared simulation based teaching with didactic lecture and observed that simulation based teaching is a better modality of teaching learning especially for obstetric emergency situation than didactic lectures. Also the students in simulation group performed far better than didactic lecture group on their first encounter of DOPS structured checklist on live patients in labor room (p=0.0026). Similar results were reported by many studies in obstetrics that reveal simulation based teaching as a better modality to teach residents how to manage obstetric emergencies and how to recognize and avoid pitfalls in managing difficult deliveries (13-15). Similarly, Schroedl et al. examined simulation based education to teach topics related to medical ICU and observed higher scores in skills assessment among simulation training as compared to didactic lecture group (16). Another study demonstrated significantly higher performance in simulation group among residents and nurses taught about obstetrical emergencies compared to didactic teaching (17) and a similar study in Anesthesia also demonstrated an improved task performance among students taught by simulation based teaching as compared to those learning observed practice (18). A study observed use of simulation based teaching in medical emergencies amongst the final year of medical students and found superior performance as compared to didactic lecture (19). Some other similar studies on the other hand reported no significant statistical difference between simulation and didactic groups in knowledge or confidence attained and performance at any phase of study, rather they suggested that it is the combination of the two modalities (didactic and simulation based teaching) that resulted in significant improvement in knowledge (p < .002) and confidence (p < .001) (20)
In the present study no difference was observed between the two groups in pre-lecture scores, but a significant difference was observed in post-lecture scores with significantly higher scores in simulation based teaching group. Similar results were reported by a study conducted in Radiology department which compared simulation based teaching with didactic lecture and reported no differences between the two groups in pre-lecture test scores, but significantly higher scores for model/simulation group on both the post-lecture multiple choice (p = 0.038) and post-lecture model (p = 0.041) examinations. They also observed significantly higher scores in the model/simulation group regarding overall interest in peri-operative ultrasound (p= 0.047) as well understanding of the physiologic concepts (p=0.021) on feedback survey (21). Another similar study comparing simulation based teaching with didactic lecture reported a significant difference in improvement from baseline and post teaching MCQ in simulation group compared to lecture (p = 0.0387). In the same study, students rated simulation-based teaching better with regard to interest (p = 0.0068), enjoyment (p = 0.0044), subject taught (p = 0.0313), understanding (p = 0.0476) and accessibility to posing questions (p = 0.001) (22), similar to our study in which also students rated simulation based teaching more interesting, interactive, enjoyable as compared to didactic lectures. Other studies also report that students enjoyed simulation based education more than the didactic lectures (23, 24).
Hence, simulation based teaching results in better understanding of subject as well as help in
overall improvement of skills of students in comparison to didactic lectures, especially for teaching obstetric emergency maneuvers.
As these newer modalities of teaching and assessment are underutilized in obstetrics and gynecology critical care, hence their future implementation in the curriculum for teaching of postgraduate students can result in overall improvement of their knowledge, skills and confidence. Also DOPS as a teaching and assessment tool can be utilized in obstetrics for teaching postgraduate students on live patients in working environment which can further help in development of skills as well as increase in confidence of students in managing such emergencies in real life scenario.
As both simulations based teaching and DOPS are time and resource consuming, their long-term advantages and disadvantages with regard to retaining knowledge and applying it on patient care need to be further evaluated by larger studies in future. The main limitation of present study was that it was conducted for a shorter duration with lesser number of students, hence in future more studies with larger number of students and for longer duration can be done for better understanding of such teaching-learning and assessment methods for development of newer generation doctors.
I want to acknowledge the efforts of staff of department of Obstetrics and Gynecology of MMIMSR for their constant support and guidance.
Source of Support: There is no source of support.
Conflict of Interest: There are no conflicts of interest.
Research committee approval: Study was done after proper Institutional Ethical approval.
1. Anderson FW. Maternal mortality: an enduring epidemic. Clin Obstet Gynecol 2009; 52(2): 214-23. 2. Oyelese Y, Scorza WE, Mastrolia R, Smulian JC. Postpartum hemorrhage. Obstet Gynecol Clin North Am 2007; 34(3): 421-41. 3. Mercier FJ, Van de Velde M. Major obstetric hemorrhage. Anesthesiol Clin 2008; 26(1): 53-66. 4. Amy JJ. Severe Postpartum Hemorrhage: A Rational Approach. Nat Med J India 1998; 11: 86-8. 5. World Health Organization, authors. Maternal mortality in 2005: estimates developed by WHO, UNICEF, UNFPA and the World Bank. Geneva (Switzerland): WHO; 2007. [cited 2007]. Available from: URL; www.who.int/reproductivehealth. 6. Registrar, General, India and Centre for Global Health Research, Maternal Mortality in India, 1997–2003: Trends, Causes and Risk Factors, New Delhi: Registrar General, India, 2006. [cited 2006]. Available from: URL; www.cghr.org/.../RGI-CGHR-Maternal-Mortality-in-India-1997–2003. 7. Castanelli DJ. The rise of simulation in technical skills teaching and the implications for training novices in anaesthesia. Anaesth Intensive Care 2009; 37(6): 903-10. 8. Shahgheibi S, Pooladi A, Bahramrezaie M, Farhadifar F, Khatibi R. Evaluation of the effect of direct observation of procedural skill (DOPS) on clinical externship students learning level in obstetrics ward of Kurdistan university of medical sciences. J Med Educ 2009; 13: 29-33. 9. Jalili M. DOPS or direct observation of procedural skills. [cited 2010 Jul 11]. Available from: URL; http://jouybari.blogfa.com/post/4472. 10. Okuda Y, Bryson EO, DeMaria S Jr, Jacobson L, Quinones J, Shen B, et al. The utility of simulation in medical education: what is the evidence? Mt Sinai J Med 2009; 76(4): 330-43. 11. Van Sickle KR, Ritter EM, McClusky DA, Lederman A, Baghai M, Gallagher AG, et al. Attempted establishment of proficiency levels for laparoscopic performance on a national scale using simulation: the results from the 2004 SAGES Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR) learning center study. Surg Endosc 2007; 21(1): 5-10. 12. Seymour NE, Gallagher AG, Roman SA, O'Brien MK, Bansal VK, Andersen DK, et al. Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Ann Surg 2002; 236(4): 458-63. 13. Dayal AK, Fisher N, Magrane D, Goffman D, Bernstein PS, Katz NT. Simulation training improves medical students' learning experiences when performing real vaginal deliveries. Simul Health 2009; 4(3): 155-9. 14. Fahey JO, Mighty HE. Shoulder dystocia: using simulation to train providers and teams. J Perinat Neonatal Nurs 2008; 22(2): 114-22. 15. Maslovitz S, Barkai G, Lessing JB, Ziv A, Many A. Recurrent obstetric management mistakes identified by simulation. Obstet Gynecol 2007; 109(6): 1295-300. 16. Schroedl CJ, Corbridge TC, Cohen ER, Fakhran SS, Schimmel D, McGaghie WC, et al. Use of simulation-based education to improve resident learning and patient care in the medical intensive care unit: a randomized trial. J Crit Care 2012; 27(2): 219.e7-13. 17. Daniels K, Arafeh J, Clark A, Waller S, Druzin M, Chueh J. Prospective randomized trial of simulation versus didactic teaching for obstetrical emergencies. Simul Health 2010; 5(1): 40-5. 18. Hallikainen J, Väisänen O, Randell T, Tarkkila P, Rosenberg PH, Niemi-Murola L. Teaching anaesthesia induction to medical students: comparison between full-scale simulation and supervised teaching in the operating theatre. Eur J Anaesthesiol 2009; 26(2): 101-4. 19. Ruesseler M, Weinlich M, Müller MP, Byhahn C, Marzi I, Walcher F. Republished: Simulation training improves ability to manage medical emergencies. Postgrad Med J 2012; 88(1040): 312-6. 20. Picard M, Curry N, Collins H, Soma L, Hill J. Comparison of high-fidelity simulation versus didactic instruction as a reinforcement intervention in a comprehensive curriculum for radiology trainees in learning contrast reaction management: Does it matter how we refresh? Acad Radiol 2015; 22(10): 1268-76. 21. Ramsingh D, Alexander B, Le K, Williams W, Canales C, Cannesson M. Comparison of the didactic lecture with the simulation/model approach for the teaching of a novel perioperative ultrasound curriculum to anesthesiology residents. J Clin Anesth 2014; 26(6): 443-54. 22. Solymos O, O'Kelly P, Walshe CM. Pilot study comparing simulation-based and didactic lecture-based critical care teaching for final-year medical students. BMC Anesthesiol 2015; 15: 153. 23. Morgan PJ, Cleave-Hogg D, McIlroy J, Devitt JH. Simulation technology: a comparison of experiential and visual learning for undergraduate medical students. Anesthesiology 2002; 96(1): 10-6. 24. Paskins Z, Peile E. Final year medical students' views on simulation-based teaching: a comparison with the Best Evidence Medical Education Systematic Review. Med Teach 2010; 32(7): 569-77.