Training Midwives on Rotation of the Persistent Posterior Fetus in the Second Stage of Labor Utilizing Simulation

Manual/digital rotation of the persistent occiput posterior (POP) fetus has established as a valid intervention that decreases operative vaginal deliveries (OVD) and cesarean deliveries due to fetal malposition. Few certified nurse-midwives (CNMs) receive formal training in this skill, though this is within their scope of practice, and many report a lack of confidence in performing this skill. To date, no formal studies have investigated educating providers specifically about manual/digital rotation, though many studies affirm the effectiveness of simulation in training obstetric providers. The overarching goal of this project is to increase confidence and attempted manual/digital rotation of the persistent occiput posterior (POP) fetus among certified nurse-midwives (CNMs) during the second stage of labor by implementing a hands-on simulation training.MethodsThis quality improvement initiative developed and implemented an in-person training and clinical simulation on manual/digital rotation of the POP fetus for CNM faculty practice members at the University of Utah. Pre-survey data was collected before the training, and post-survey data was collected two months after the intervention to assess a change in self-reported confidence and attempted manual/digital rotations in the intrapartum setting utilizing a 5-point Likert scale ranging from "strongly agree" to "strongly disagree." Also, the pre-survey included an assessment of previous exposure to training on this topic to provide some baseline data. While the pre and post-surveys are not formally validated instruments, they were reviewed by the project chair, the content expert, and another CNM with significant experience researching with survey data. ResultsEight CNMs participated in the in-person training (N=8), with a 100% pre and post-survey response rate. The pre-intervention survey indicated that 87.5% (n=7) of participants had received previous didactic education on the topic, and 25% (n=2) reported previous hands-on training. Using the Wilcoxon signed-ranks test, provider confidence in attempted digital/manual rotation was found to be higher after training than before (Z=-2.070, p<.038). However, no significant change was seen when comparing manual rotation attempts before the training/simulation and in the two months following the intervention (Z=-.707, p<.48).ConclusionsThe results from this project support the current body of knowledge that the use of simulation for obstetrical providers has wide-ranging positive outcomes. This hands-on training appears to be a valuable intervention to improve provider confidence in performing the intrapartum clinical skill of digital/manual rotation of the POP fetus. Improved provider confidence is clinically significant because if it results in increased attempts at rotation and those rotations are successful; this may have an end-effect of decreasing the overall cesarean rate. However, an increase in self-reported attempts at digital/manual rotation of the POP fetus was not seen following this intervention, which, given the short time frame, was not entirely unanticipated. This study is limited by small ample size, the short follow-up time, as well as potential respondent bias in the design of the pre and post surveys with the Likert scale, including an option of ‘3' that indicated neither agree nor disagree. Replication and expansion of this quality improvement project are needed to determine if the rise in obstetric provider confidence is replicable, and if that confidence results in more attempts at manual rotation over a more extended follow-up time.