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A C TA Obstetricia et Gynecologica


Educational strategies in performing cesarean section

Department of Obstetrics and Gynecology, Juliane Marie Centre for Women, Children and Reproduction, Rigshospitalet,
University Hospital of Copenhagen, Copenhagen, and 2Department of Obstetrics and Gynecology, University Hospital of
Copenhagen, Hillerød Hospital, Hillerød, Denmark

Key words Abstract

Cesarean section, surgical training, trainee,
learning curve, assessment, Objective Cesarean section is a common operation and one of the first surgeries performed
Structured Assessment of Technical Skills independently by trainees/residents in obstetrics and gynecology. Determination
of trainees’ technical skills level is dependent upon subjective faculty assessment.
Correspondence Based on three studies on learning curves in cesarean section, it is recommended
Kristine Madsen, Department of Obstetrics
that trainees perform between 10–15 and 40 supervised cesarean sections before
and Gynecology, Rigshospitalet, Blegdamsvej
operating independently. Surgical technical skills of trainees/residents may be
9, Copenhagen Ø, Denmark. E-mail:
kmadsen1979@gmail.com assessed by Objective Structured Assessment of Technical Skills (OSATS), which
provides a foundation for constructive feedback during surgical training. The
Conflict of interest Danish, Swedish and British Obstetric and Gynecological Societies’ guidelines on
The authors report no conflicts of interest. cesarean section were reviewed regarding cesarean section surgical technique.
Placental removal by traction on the umbilical cord is recommended uniformly;
Please cite this article as: Madsen K, however, the Danish guidelines recommend one-layer uterine incision closure,
Grønbeck L, Larsen CR, Østergaard J,
whereas the Swedish and British guidelines recommend two-layer closure.
Bergholt T, Langhoff-Roos J, Sørensen JL.
Maternal complications at cesarean section increase when the primary surgeon is
Educational strategies in performing cesarean
section. Acta Obstet Gynecol Scand a trainee/resident rather than an experienced surgeon. Basic surgical proficien-
2013; 92:256–263. cies regarding instruments, sutures and surgical technique as well as basic anat-
omy, should be verified before entering a training program for cesarean section.
Received: 28 May 2012 Such a training program for technical and non-technical skills in cesarean sec-
Accepted: 7 November 2012 tion should include theoretical instruction, video tutorials, practical experience
and direct supervision. Development of a specific OSATS for cesarean section is
DOI: 10.1111/aogs.12055
recommended. Training must be individually structured accommodating the
differences in trainees’ competencies. Before clinical training in the operating
room begins, all trainees must attain standardized cognitive and technical skills.
CS, Cesarean section; NOTTS, Non Technical Skills for
Surgeons; OSATS, Objective Structured Assessment of Technical Skills.

In surgical education it is important to reduce com-

plications to a minimum. A training tradition of “see
one, do one, teach one” is now considered insufficient
Cesarean section (CS) is a common open abdominal sur- to ensure patient safety, and consequently new training
gical procedure. In Denmark 21% of the children born in
2011 were delivered by CS (1). Cesarean section is one of
the first operations performed independently by trainees
in obstetrics and gynecology. Even though CS differs Key Message
from other open surgical procedures, various similarities Structured and validated education and assessment
also exist. Hence CS may be used for teaching basic prac- methods should be used at cesarean section and basic
tical anatomy and surgical proficiency regarding instru- surgical skills training should be verified.
ments, sutures and surgical techniques.

ª 2012 The Authors

256 Acta Obstetricia et Gynecologica Scandinavica ª 2012 Nordic Federation of Societies of Obstetrics and Gynecology 92 (2013) 256–263
K. Madsen et al. Educational strategies in cesarean section

methods must be introduced (2). Many gynecological representation of the rate of learning and it demonstrates
procedures are increasingly performed by laparoscopy, the time taken or the number of procedures that trainees
resulting in a reduced amount of open abdominal pro- perform to attain a certain skills level. A training program
cedures. This calls for greater attention when applying that shortens and improves the learning curves of train-
CS in the training of general surgical skills and open ees/residents could possibly reduce costs and improve
surgical procedures. It is important to provide struc- patient safety in terms of fewer errors and complications
tured teaching, assessment and feedback for trainees in (5,6).
performing CS. Fok et al. (3) retrospectively investigated the learning
This review investigates the current literature on surgical curves in CS for 10 trainees. Each trainee initially assisted
training in CS and provides an update on existing knowl- at a mean of 29 CS (range 21–49) and performed 24
edge of training, assessment and feedback of technical and (range 14–42) supervised sections. The following 50 CS
non-technical surgical skills. Elements to be included in a (emergency and elective), which they did independently,
future training program for CS are identified. were examined. The total operative time was significantly
reduced from 52.2 to 39.6 min between the first five CS
and the last five CS performed. A significant difference in
Material and methods
the learning curves for incision-to-delivery time was
We searched the PubMed database using the following established between the first five operations compared
search string; “Cesarean section and learning curve”, with the rest. A more rapid learning curve was demon-
“assessment and surgical training and open surgery”, “OS- strated when performing elective vs. emergency CS, how-
ATS” (i.e. Objective Structured Assessment of Technical ever, high-risk sections were not included. It was
Skills), “video assessment and surgical training”, “non tech- estimated that each trainee must perform approximately
nical skills for surgeons”, “motion analysis and ICSAD” (i. 40 CS under varying levels of supervision before master-
e. Imperial College Surgical Assessment Device), “cesarean ing the procedure independently. This was based on data
section and surgical technique and Cochrane review”, “risk on incision-to-delivery time interval and total operative
factors for maternal complications in cesarean section”, time in minutes, as well as subjective assessment by the
and “assessment in surgical training in obstetrics”. supervising surgeon (3).
The following MeSH terms were used in the search M€ uller and Zimmerman (4) investigated learning
strategy; “Cesarean Section”, (“Cesarean Section/educa- curves related to CS performed by 15 trainees. The train-
tion” OR “Cesarean Section/methods” OR “Cesarean Sec- ees were excluded from performing emergency and high-
tion/trends”), (“Educational Measurement/methods” OR risk sections, including for placenta previa and repeat CS.
“Educational Measurement/trends”), (“Surgical Proce- The change from the steep to the flat part of the learning
dures, Operative/education” OR “Surgical Procedures, curves was determined visually and defined as the end of
Operative/methods” OR “Surgical Procedures, Operative/ the initial learning phase. No objective assessment of
trends”), “Clinical Competence”, (“Obstetric Surgical surgical skills was made, and the visual estimation was an
Procedures/adverse effects” OR “Obstetric Surgical Proce- imprecise measurement of surgical skills and could poten-
dures/education” OR “Obstetric Surgical Procedures/ tially affect the outcome measures. For both the total
methods” OR “Obstetric Surgical Procedures/standards” operation time and the incision-delivery time, the steep
OR “Obstetric Surgical Procedures/trends”). part of the curve ended after 20 CS. Hence, they
The “related citations” in PubMed and reference lists of estimated that an average of 20 supervised average-risk
the retrieved articles were reviewed. The articles were CS would provide a level of competence compatible with
screened by title and abstract and, if relevant, the full text sufficient patient safety (4).
was reviewed. Any uncertainty relating to study eligibility Soergel et al. (5) analyzed elective and emergency CS
was discussed in the group until consensus was reached. We performed by 22 novice trainees (with no experience) and
had no restrictions on publication year or study design, and 23 experienced surgeons (>300 CS). The incision-to-suture
included articles in Scandinavian languages, English and time and incision-to-delivery time were significantly higher
German. The literature search was updated in April 2012. in operations performed by trainees compared with
experienced surgeons. Trainees would rarely perform the
CS with any expected fetal complications or distress,
Results thereby potentially increasing the speed of the learning
curves. The point in the learning curves where the steep
Cesarean section training – learning curves
part proceeds to the flatter part determined the completion
We identified three studies about CS training, all focusing of the basic learning process. The learning curves reached a
on learning curves (3–5). A learning curve is a graphical flatter part after 10 to 15 CS regarding both total operation

ª 2012 The Authors

Acta Obstetricia et Gynecologica Scandinavica ª 2012 Nordic Federation of Societies of Obstetrics and Gynecology 92 (2013) 256–263 257
Educational strategies in cesarean section K. Madsen et al.

time and incision-to-delivery time. Supervision and contin- future role of videos in CS training remains to be inves-
uing evaluation by experienced surgeons were recom- tigated.
mended because the learning process is individual. This
was illustrated by variations in the data for incision-to-
Assessment in surgical training
delivery time for the trainees (5).
Surgical skills are a combination of cognitive factors,
including knowledge and decision making, technical
Training of surgical skills
skills, communication and leadership skills (8). It is
Trainees’ or residents’ surgical skills levels are often deter- important to distinguish learning from assessment of
mined on the basis of subjective assessment at the end of technical skills; learning refers to acquiring new skills,
a trainee/resident post. Trainees’ performance outside the whereas assessment is the evaluation of these skills.
operating theatre and personality traits may affect the Assessment methods should be objective, standardized,
assessment (7). Elapsed time in training, log books, num- feasible, valid, reliable, practical and cost-efficient (6).
ber of performed procedures and procedural time are Definitions regarding assessment are listed in Table 1.
used to determine the skills level of trainees. These Methods for objective assessment of trainees’ technical
parameters are indirect measures of surgical technical skills provide a foundation for constructive feedback
skills, and do not assess the quality of the performance when new surgical procedures are taught (10). Global
(2,6,8,9). rating scales like OSATS, procedure-specific checklists
Trainees/residents may not acquire all the necessary and video assessment are thoroughly validated
skills in a clinical setting. The concept of a “pre-trained methods.
novice” was introduced where trainees learned basic tech- The original OSATS was introduced by Martin et al.
nical skills and completed the early learning curves in a (16) and included the following assessment criteria:
simulated environment. This should potentially result in respect for tissue, time and motion, instrument han-
improved patient safety and learning efficacy in a sub- dling, knowledge of instruments, use of assistants, flow
sequent analogous clinical situation (10). of operation and knowledge of specific procedure. Sev-
Surgical skills acquired by distributed practice trans- eral studies have since used an OSATS scale entailing a
ferred better from simulated environments to a live ani- global-rating part for general surgical skills and a check-
mal model, compared with skills acquired by massed list part for procedure-specific skills. OSATS was devel-
practice (11). The quality and amount of expert feedback oped for use in simulated settings, and was tested in
received during the learning process has been described simulated open procedures and on live anesthetized ani-
as essential for the acquisition of technical skills. Feedback mals (16–18). It is an objective examination in surgical
at the completion of a task (summary feedback) was training, which measures surgical competence and dem-
superior to feedback given while the task occurred (con- onstrates excellent construct validity (7). Several other
current feedback) regarding technical skills retention studies demonstrated similar results (17–19). The Royal
(suturing and instrument knot-tying) among medical stu-
dents (12). Specific training of supervising surgeons
should be provided to obtain more structured feedback
for trainees. Table 1. Definitions regarding assessment (8,19).
During an operation the supervising surgeon must Construct validity The extent to which a test measures what it is
maintain overall control of the procedure, while still supposed to measure, and the extent a test
allowing the trainee hands-on experience to obtain proce- discriminates between various performance
dure proficiency. Surgical training should be based on levels
progressive independence where the supervision of train- Content validity The extent to which the subject being measured,
is actually measured by the assessment method
ees is withdrawn as their skills increase (13).
Concurrent validity The extent to which the result of the
Instruction video clips were displayed to trainees dur- assessment method correlates with a standard
ing the surgical procedure in INVEST (INtraoperative or other test which measures the same trait
Video-Enhanced Surgical Training). This allowed trainees Predictive validity The ability of the assessment method to predict
to subsequently perform the procedural task instead of future performance
the supervisor taking over. The method demonstrated Reliability The extent to which the test is consistent in its
significant difference in skill acquisition on the OSATS outcome
Inter-rater reliability refers to the agreement
rating scale (14). In a laboratory-based course on intuba-
between two or more observers testing the
tion procedures, the addition of a short video instruction same subject
substantially improved performance (15). A possible

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258 Acta Obstetricia et Gynecologica Scandinavica ª 2012 Nordic Federation of Societies of Obstetrics and Gynecology 92 (2013) 256–263
K. Madsen et al. Educational strategies in cesarean section

College of Obstetricians and Gynaecologists has created stress compromising surgical performance among novice
a modified OSATS for CS, but its validity has not been surgeons (26). Non-technical skills like leadership and
investigated (20). decision making were impaired during simulated crises,
Checklists are a dichotomy list, typically yes/no, and can such as hemorrhage or cardiac arrest (27).
be procedure-specific or general. They are used for objec- In CS non-technical skills are very important. The pro-
tively rating a performance during direct observation, and cedure is often performed under acute circumstances,
usually require observation of the entire surgical procedure. attended by more than one specialist and involving two
However, checklists can be imprecise, and if all compo- patients (the parturient and fetus). In addition, nervous-
nents of a procedure are weighed equally on the checklist, ness and anticipation prevail among patients and rela-
trainees may omit important steps and still obtain a high tives. These factors may all add to stress in the operating
score. Global rating scales demonstrated superior reliability room, thereby increasing the need for good non-technical
and validity compared with checklists (6,21). skills of surgeons in order to control the situation.
Video assessment is a reliable and valid method of
assessing basic tissue handling skills in open procedures
Surgical technique and complications in cesarean
and has, for instance, been described in open inguinal
hernia repairs. The method offers anonymity and raters
can be located remotely from the procedure, thereby The Danish, Swedish and British obstetric and gynecolog-
increasing assessment objectivity (21). Video assessment ical societies’ guidelines on CS were reviewed, to deter-
can distinguish between individuals with widely different mine if consensus existed regarding CS surgical technique
experience, whereas subtle variations may not show (19). (Table 2). Several similarities between the guidelines were
Video assessment can be rather time-consuming, how- present, and placental removal by traction on umbilical
ever. New research demonstrated that junior staff are as cord was uniformly agreed on. However, one-layer clo-
able to perform assessment and feedback as qualified sure of the uterine incision was recommended by the
senior staff (22). This may increase the usefulness of the Danish guidelines whereas the Swedish and British Socie-
method. Video assessment can be used in conjunction ties recommended two-layer closure (28–31).
with global rating scales or checklists. The techniques used at CS are more surgically trau-
matic compared with other abdominal procedures such
as hysterectomy and oophorectomy, and the difficulty of
Non-technical skills in surgery
CS varies. Several publications recommend the surgical
Non-technical qualities are important for surgical out- technique in CS to be based on a transverse lower
come, patient safety and operating room dynamics, but abdominal wall opening using a Joel-Cohen type of
formal teaching is often inadequate and neglected. Non- method (29,32,33).
technical skills can be taught by simulation in realistic In a recent study, the risk of major obstetric hemor-
surroundings, and the entire multi-professional surgical rhage was increased at CS carried out by junior trainees
staff may be included, resulting in improved communica- (with under three years of specialist training) compared
tion and teamwork (6,23,24). with senior obstetricians (19.6% vs. 13.1%) (34). Another
Several behavioral rating systems for evaluating sur- study confirmed that CS performed by a trainee rather
geons’ non-technical skills exist: The Non Technical Skills than a senior surgeon was associated with a significantly
for Surgeons (NOTTS), Non-Technical Skills Scale (NO- higher risk of postoperative maternal complications (35).
TECHS) and Observational Teamwork Assessment for
Surgery (OTAS). The NOTTS system entails five catego-
ries of skills: situation awareness, decision making, task Discussion
management, communication, and teamwork and leader-
Creating a training program for cesarean section
ship. The taxonomy includes a behavioral marker system
with examples of good and poor behavior within each A surgical training program for performing CS must
skills category (6,10,24,25). include teaching of technical and non-technical skills. The
Both technical and non-technical skills may be training must be individually structured according to
impaired by stress in the operating room. Increased stress trainees’ competencies. Before trainees/residents begin
was identified among primary operators and junior sur- clinical training and perform actual operations, they must
geons compared with assistants and senior surgeons. demonstrate cognitive skills regarding sutures and instru-
Distractions, time pressure, bleeding and increased com- ments as well as knowledge of the steps in performing
plexity of a procedure added to the stress. Clear evidence CS. During clinical training the trainees must acquire
was lacking, but there was a tendency towards excessive technical skills and learn to perform CS in accordance

ª 2012 The Authors

Acta Obstetricia et Gynecologica Scandinavica ª 2012 Nordic Federation of Societies of Obstetrics and Gynecology 92 (2013) 256–263 259
Table 2. The most common maternal cesarean section complications and recommendations to reduce complication rates.

Information source

Royal College of Obstetricians and

Danish Society of Obstetrics and Swedish Society of Obstetrics and Gynaecologists guidelines (United
Complications Gynecology guidelines (29,38) Gynecology guidelines (30,39) Kingdom) (31,40) Cochrane review, Hofmeyr et al. (33)

Abdominal wound Antibiotic prophylaxis (ampicillin Antibiotic prophylaxis in emergency Antibiotic prophylaxis (ampicillin or Antibiotic prophylaxis (ampicillin or first-generation
Educational strategies in cesarean section

infection or first-generation cephalosporin) CS. Only with special indications in first-generation cephalosporin) cephalosporin)
Either before surgery or after elective CS Chlorhexidine for skin preparation
clamping of umbilical cord No hair removal or depilatory creams or clipping
instead of shaving

Endometritis Removal of placenta by traction Removal of placenta by traction on Removal of placenta by traction on Removal of placenta by traction on umbilical cord
on umbilical cord umbilical cord umbilical cord Antibiotic prophylaxis
Antibiotic prophylaxis Antibiotic prophylaxis in acute CS Antibiotic prophylaxis

Urinary infection Antibiotic prophylaxis Antibiotic prophylaxis in acute CS Antibiotic prophylaxis Antibiotic prophylaxis

Uterine rupture in One-layer closure Two-layer closure of uterine incision Two-layer closure of uterine incision One-layer closure either interrupted or continuous
subsequent pregnancy with continuous suture locking suture

Uterine rupture after Recommendation: Interpregnancy Recommendation: Interpregnancy

one-layer closure interval over 24 months interval over 18–24 months

Seroma, wound Suturing of subcutaneous layer if Suturing of subcutaneous layer Closure of subcutaneous tissue
disruption, hematoma over 2 cm if over 2 cm

Thromboembolic In elective CS; early ambulation Thromboprophylaxis with In elective CS; early ambulation, and No evidence for thromboprophylaxis
prophylaxis In acute CS; only with additional low-molecular-weight heparin with two or more additional risk
risk factors: subcutaneous heparin depending on maternal factors: subcutaneous heparin
three days postpartum risk factors minimum seven days postpartum
For acute CS; subcutaneous heparin
for minimum seven days

Abbreviation: CS, cesarean section.

K. Madsen et al.

Acta Obstetricia et Gynecologica Scandinavica ª 2012 Nordic Federation of Societies of Obstetrics and Gynecology 92 (2013) 256–263
ª 2012 The Authors
K. Madsen et al. Educational strategies in cesarean section

Table 3. Framework for a training program for teaching trainees/residents in performing cesarean section.

Training strategies Content Assessment method

Cognitive component Self study Practical anatomy and physiology Cognitive testing before surgery
Books and guidelines Suture material and technique
E-learning Instruments and instrument handling
Visual material incl. video Pre-operative factors with relevance
or slideshows for surgery
Formalized teaching Steps in the surgical procedure
In small groups Post-operative complications
In lectures

Technical component Formalized teaching and Suture and instrument technique Objective Structured Assessment of
practice One-hand and two-hand knot tying Technical Skills (OSATS) (16) rating
In small groups Tissue identification and respect scale and procedure specific checklist
At bench stations Actual cesarean sections Video assessment of surgical procedure
Performing cesarean sections (parts of/entire operation)
In operating room with supervisor

Non-technical component Self study Non-technical skills of surgeons The Non Technical Skills for Surgeons
Literature, articles (NOTTS) (25)
Formalized teaching OSATS procedure specific checklist
In small groups 360° feedback
In simulated environment
with surgical staff

with current recommendations. They will need to receive process whereby expert opinion from remote locations
feedback throughout training for improving their perfor- can be collected and analyzed until group consensus is
mance. Cesarean section may be used for learning basic achieved, and it would be a good approach to obtain
practical anatomy even though some structures and tissue consensus on an OSATS for CS (36). The CS OSATS
may differ during pregnancy. Trainees/residents must should be investigated to determine if it demonstrates
demonstrate predefined standardized technical and non- content and construct validity, so it can discriminate
technical skills before they are allowed to operate without between novices, intermediary trainees and experts.
a supervising senior surgeon. After the completion of The assessment methods described in this article were
training, it may be interesting to examine how well the tested in simulated settings, in live animal models or in
trainees retain their surgical skills. The surgical training open surgical procedures (such as inguinal hernia repairs)
program should include theoretical instructions, video (7,16,21). It was never established if these assessment
tutorials, practical experience and direct supervision. The methods directly apply to CS, thus warranting future
value and importance of each of these elements alone or studies to investigate this area.
in combination with each other should be investigated in Patient safety should not be compromised when teach-
future research. The proposed training program is out- ing trainees. The outcome of the procedure should be the
lined in Table 3. same, whether it was performed by a supervised trainee/
resident or the supervising surgeon. This emphasizes the
need for appropriate supervisor intervention in surgical
Future perspectives for developing a cesarean
training (8,37).
section training program
Our group was encouraged to design the framework for a CS
training program, as previously only three studies were pub-
lished on surgical training regarding CS. The final training We are grateful to the librarians at the Royal Library of
program should be developed in collaboration with national Copenhagen, and the Medical Research Library at Rigs-
and, if possible, international guideline groups, as well as hospitalet, Copenhagen University Hospital, Copenhagen,
with specialists from obstetric and gynecological units. Denmark for assistance with the search strategy.
Structured and validated education and assessment
should be used at CS and also basic surgical skills train-
ing. An OSATS should be specifically designed for assess-
ment during CS. The Delphi method is an anonymous No funding was obtained.

ª 2012 The Authors

Acta Obstetricia et Gynecologica Scandinavica ª 2012 Nordic Federation of Societies of Obstetrics and Gynecology 92 (2013) 256–263 261
Educational strategies in cesarean section K. Madsen et al.

16. Martin JA, Regehr G, Reznick R, MacRae H, Murnaghan J,

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ª 2012 The Authors

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