From the planning point of view, the execution of an emergency cesarean section is complex and with this procedure, the ability of the team to work together is maximally stressed.
Good crew resource management is pivotal to obtaining the goals cause also the best surgeons, without a close-knit team, fail in these circumstances.
In our study, with simulation, we evaluated the abilities of each operator to rapidly activate the procedure to perform an emergency cesarean section for a massive abruption placenta.
The goal of our study was to measure the activity of the team working without considering the own technical skills of each operator.
The use of a sequential protocol, which provides the performance of only 5 actions for each operator, statistically significantly improves the global performance of the entire team but also the perception of the work of each participant.
In fact, after the training, operators have the perception of better communication, of working more harmoniously with the remaining members of the team, avoiding overlapping, calls, and stress, and, in general, they feel much more useful in their actions to achieve the result.
Finally, but certainly, one of the most important results, the time interval between the decision of the emergency cesarean section and its execution is significantly reduced.
We purposely chose placental abruption because neonatal outcomes are directly related to the procedure completion time. Indeed, we were focused on teamworking and not on specific technical skills. Diagnosis of a massive abruption placenta is easy and the decision to perform an emergency cesarean section was not questionable by operators. Technical skills component is certainly important but, in this study, we focused on the rapid setup of an operating room and the preparation of the patient for surgery. For this reason, the overall time of the cesarean section procedure (from the incision to the closure of the skin) was not calculated, but only the time to set up the operating field and arrive at the incision (decision to delivery interval).
The time to perform an emergency cesarean section and to have low adverse outcomes is much debated. The best maternal-fetal outcomes depend on the so-called "30-minute rule"(Leung and Lao, 2013). This is the time that must pass between the appearance of the sign (massive bleeding rather etc) and the birth of the fetus and includes all the aspects of the cesarean section such as the immediate preparation of the room, the arrival of the operators, up to the extraction of the fetus. The 30-minute interval has been supported by a consensus of experts, not directly supported by clinical trials or experimental evidence. According to the Guidelines for Perinatal Care published jointly by the American Academy of Pediatrics and ACOG, “hospitals should have the capability of beginning a cesarean delivery within 30 minutes of the decision to operate (American Academy of Pediatrics et al., 2007). Many studies have followed the optimal timing, often with conflicting results (Schauberger and Chauhan, 2009)(Dupuis, 2006)(Bloom et al., 2006). Surprisingly, in fact, a first evaluation would seem that the time factor is not so important or even pejorative (Bloom et al., 2006). In reality, as the same authors concluded, “even if shorter intervals were associated with low cord pH and higher neonatal risk, however shorter intervals likely occurred with higher risk cases”(Bousleiman et al., 2022).
It is not the focus of this study to discuss the appropriate timing of the intervention, and the type of surgical procedure rather than the more or less stringent indications for the execution of the urgent cesarean section. What appears obvious, however, is that the less time it takes to set up the operating room and prepare the patient, the more time the operator has to proceed with the extraction of the fetus, especially in the most complicated cases.
And that is the purpose of this protocol: guarantee rapid times for setting up the operating room up to the time of the incision beyond the specific indication.
The concept of emergency in obstetrics is also much discussed and "relative". Therefore, the choice of emergency cesarean section for massive placental abruption is not casual. Placental abruption associated with massive maternal hemorrhage represents one of the main indications for an emergency cesarean section which can hardly be discussed both when performing the procedure and even less at a scientific level.
We demonstrated that a well-coded sequence of actions performed by the staff (gynecologist, anesthesiologist, first midwife, second midwife, healthcare assistant) determines a better synchronization of operators without overlapping tasks that can, unintentionally, occur to support the team but which have an opposite and confounding effect on the final result. Based on this study, each operator is trained to perform only and exclusively 5 actions. These actions have been codified and synchronized as an orchestra conductor synchronizes and directs the input of various instruments during a concert.
The adequate preparation of the personnel, educated on the execution of only 5 actions for each role, allows a clear reduction in the time to incision.
However, this study presents some points of weakness. First of all, it is a complete lack of clinical data on reporting the effects of this simulation program on the care activity. This criticism is very difficult to resolve beyond the perception of the operators themselves and this issue has been largely debated in the literature. Fortunately, performing an emergency cesarean section is not very frequent and the validation of this protocol with clinical data would perhaps take years. At the same time, the interest of the study is to evaluate the effectiveness of a procedure for setting up an operating room, not for the execution of cesarean section, an element that is decidedly operator dependent and that we treated in different programs. Hi-fidelity simulation has been demonstrated to meliorate competencies (Issenberg et al., 2005), define professional competence(Epstein and Hundert, 2002), improve patient outcomes (Cook et al., 2011), and develop and enhance teamwork (Baker et al., 2006)(Shapiro et al., 2004). Epecially in obstetrics, simulation is increasingly used for training of adverse and low-frequent events, such as shoulder dystocia (Mannella et al., 2016) or vacuum application (Mannella et al., 2021) or for didactic purposes (Mannella et al., 2018).
Another debated element is the degree of realism of these high-fidelity simulations which can interfere with the final result (i.e. the execution time). In our case, this objection is only partially true. To enhance the realistic effect, all the simulations were performed without the staff being previously warned of the simulation and during daily work. Most operators only became aware that it was a simulation while it was running or even at the end of it. In our institute, simulations are usually performed on the job. Therefore, although the participants could hypothesize that it could be a simulation, they were unaware of what kind of urgency it was until they arrived on site.
Based on our research, we can conclude that the implementation of simple and immediate operational protocols such as our "five actions for five people" brings considerable benefits both in terms of improving the quality of assistance and in the perception of staff who work as a team. Even if it is difficult to demonstrate an effect in the clinical practice given the small number of cases, it is still desirable that procedures of this type are widely introduced and confirmed with ad hoc simulation studies.