The Sponge Perineum An Innovative Method of Teaching Fourth

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					542      September 2006                                                                                    Family Medicine

Innovations in Family Medicine Education

                                          Joshua Freeman, MD, Feature Editor
                                           Alison Dobbie, MD, Feature Editor

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            The “Sponge Perineum:” An Innovative Method
             of Teaching Fourth-degree Obstetric Perineal
            Laceration Repair to Family Medicine Residents
              Rhonda A. Sparks, MD; Andrea D. Beesley, PhD; Andrew D. Jones, MD

Background: Fourth-degree perineal lacerations are an uncommon, unpredictable injury that family
physicians may face. Methods: After a needs assessment and feasibility review, we developed goals,
objectives, instructional tools, and a feedback survey for a curriculum using a novel model to simulate
perineal laceration repair. Results: Fifty-six learners evaluated the session, expressing increased
confidence with perineal laceration repair, the usefulness of the model, and their desire to see it
included in the Advanced Life Support in Obstetrics course. Conclusions: The “sponge perineum”
is an inexpensive, effective tool to teach perineal laceration repair. Further study is needed with
actual patient experiences.

(Fam Med 2006;38(8):542-4.)

Severe perineal lacerations are an              ery, macrosomia—their occurrence         for a simulation to teach severe
uncommon complication in obstet-                is still an unpredictable, unplanned,    perineal laceration repair.
ric practice—estimates of the inci-             intrapartum event. Opportunities            We conducted a review of the
dence of third- or fourth-degree lac-           for residents to repair these injuries   published and presented literature
eration range from 5.85%–29.7%.1,2              under authentic circumstances will       for models of perineal laceration
Although risk factors for severe                inevitably be few. Further, though       repair. One model uses a beef
injuries are known—nulliparity,                 these injuries and their repair are      tongue to simulate the tissue found
shoulder dystocia, operative deliv-             included in residency curricula,         during the repair.4 This has a real-
                                                most learners lack hands-on repair       istic texture but is time-consuming
                                                experience, even with simulations.       to prepare, expensive, and learn-
                                                Even in obstetrics and gynecology        ers may have religious or moral
From the Department of Family Medicine,         (OB-GYN) residency programs,             objections to meat products. Two
University of Oklahoma (Dr Sparks); Mid-con-    59% of residents receive no struc-       published models allow for repair
tinent Research for Evaluation and Learning,    tured training in perineal repair.3      of second-degree lacerations but
Denver (Dr Beesley); and Exempla Saint Joseph
Hospital Family Medicine Residency Program,     Given the limitations of residency       not more-severe injuries.5,6 The
Denver (Dr Jones).                              experience, this is an ideal scenario    Advanced Life Support in Ob-
Innovations in Family Medicine Education                                                                  Vol. 38, No. 8       543

stetrics (ALSO) course includes a            Digital Resources Library (www.               view Board approval to study this
presentation on this subject but no Through some experi-             curriculum with resident learners
simulation.7 This paper describes            mentation, we found that a model              through the University of Okla-
our inexpensive, simple model to             constructed in this way provided an           homa Health Sciences Center in
teach perineal laceration repair and         opportunity to “repair” the sponge            Oklahoma City. All our teaching
feedback from its use at the Univer-         using the same sequence of steps              materials can be accessed at www.
sity of Oklahoma Family Medicine             needed to repair an actual perineal 
Residency Program (OUFMRP).                  laceration.                                      Our curriculum began with
Our goal was that graduates be                  We conducted an informal needs             a teaching session explaining
comfortable performing fourth-               assessment for the session to deter-          perineal laceration repair and the
degree perineal laceration repair            mine its fit within current teaching           sponge model. This was followed
in clinical practice.                        efforts. We planned our curriculum            by hands-on practice with the
                                             to both be used during the ALSO               sponge model, including a test
Methods                                      course and as a module to teach               during which learners’ skills were
   OUFMRP is a 12-12-12 univer-              residents on our family medicine              verified with the checklist. After
sity-based residency program that            obstetrics service. We designed and           completing the session, learners
trains residents to provide broad-           pilot tested a curriculum to teach            completed our survey. These results
spectrum care, including obstetrics.         perineal laceration repair with the           were tabulated, and averages and
Because many of our residents go             model. We generated goals and                 standard deviations for each ques-
on to practice obstetrics in rural           objectives and developed a skill              tion were calculated.
areas, we had a strong local need            checklist for the procedure and a
for effective training in perineal           post-session survey to gather learn-                Results
laceration repair. The subjects              er feedback about their confidence                      The sponge perineum model has
of this study were residents at              with perineal repair, the sponge                    been in use for 3 years at OUFMRP,
OUFMRP and participants in the               model and its place in ALSO, and                    integrated with our ALSO course
ALSO course at OUFMRP.                       other aspects of our teaching ses-                  workshops and our inpatient OB
   This project began with a novel           sion. We obtained Institutional Re-                 service. It is also frequently used
idea for a perineal model. The
“sponge perineum”
is constructed us-
ing a two-layer car-                                                          Figure 1
washing sponge and
is shown in Figure                                                  Picture of Sponge Model
1. The sponge is
oval shaped, 8 cm                                                      Vaginal wall
tall, 15 cm wide,
                                          Hymenal ring
and 20 cm long.
The sponge has two
lengthwise layers,
a coarsely textured                              Rectal sphincter
white layer 2 cm
thick and a larger                                                                   Rectal sphincter
smooth blue layer.
To const r uct the
model, the sponge is
cut to represent the                           Perineum
perineal anatomy of
a fourth-degree lac-
eration. For details
on the appearance
construction of the                                                                          Rectal
model, see the full                                                                          mucosa
instructor’s guide
and teaching mate-
                      For more detailed description and pictures, see complete materials at
rials located at the
Family Medicine
544      September 2006                                                                                                 Family Medicine

                                                                                                class. At OUFMRP, we feel we
                                          Table 1                                               have developed an inexpensive,
                                                                                                effective tool to teach perineal lac-
                                Learner Survey Results                                          eration repair to family medicine
                                                                                                Acknowledgments: All financial support for this
 Familiarity with procedure before             2.95    (1=not at all, 5=a lot)                  project was from the University of Oklahoma
                                                                                                Department of Family Medicine.
 Confidence about procedure after the session   4.13    (1=not at all, 5 =a lot more confident)      This study was presented in a different
 Usefulness of model                           4.48    (1=not at all, 5=very)                   format at the Society of Teachers of Family
                                                                                                Medicine 2002 Annual Spring Conference in
 Should teaching model be included in ALSO     4.82    (1=definitely not, 5= definitely yes)      San Francisco.

ALSO—Advanced Life Support in Obstetrics                                                        Corresponding Author: Address correspondence
                                                                                                to Dr Jones, Exempla Saint Joseph Hospital
                                                                                                Family Medicine Residency Program, 2005
                                                                                                Franklin Street, Midtown II, Suite 350, Denver,
                                                                                                CO 80205. 303-318-2007. Fax: 303-318-2003.
to review perineal laceration repair.             ready tool to use in teaching. The
Fifty-six learners have completed                 model has been easy to use and                                 REFERENCES
our survey about the model. Over-                 provides practice in the repair of            1. Handa VL, Danielsen BH, Gilbert WM.
all learner response was strongly                 all perineal lacerations. Limita-                Obstetric anal sphincter lacerations. Obstet
positive, as reported in Table 1.                 tions are that some learners have                Gynecol 2001;98:225-30.
                                                                                                2. Oberwalder M, Connor J, Wexner SD.
Learners reported being somewhat                  difficulty visualizing the anatomi-               Meta-analysis to determine the incidence of
unfamiliar with the procedure be-                 cal structures as represented on                 obstetric anal sphincter damage. Br J Surg
fore the session (2.95 on a Likert                the sponge. It can be challenging                2003;90:1333-7.
                                                                                                3. McLennan MT, Melick CF, Clancy SL,
scale, with 1 being unfamiliar and                to use this model with a group of                Artal R. Episiotomy and perineal repair: an
5 being very familiar). Despite this,             learners with heterogeneous suture               evaluation of resident education experience.
they stated that they felt confident               and surgical skills. The study also              J Reprod Med 2002;47:1025-30.
                                                                                                4. Sauerwein M, Maier R. Teaching advanced
performing the procedure after the                does not assess perineal laceration              episiotomy repair with a beef tongue model.
session (4.13). Learners felt that the            repair skill among graduates of the              Presented at the Society of Teachers of Fam-
sponge model was useful (4.48) and                program, instead relying on learner              ily Medicine 2001 Annual Spring Confer-
                                                                                                   ence in Denver.
should be included in ALSO (4.82).                expressions of confidence in their             5. Cain JJ, Shirar E. A new method for teaching
An early group of learners was                    skills. The next steps for the sponge            the repair of perineal trauma of birth. Fam
asked to submit their checklist for               perineum are to develop an objec-                Med 1996;28:107-10.
                                                                                                6. Nielsen PE, Foglia LM, Mandel LS, Chow
review. All seven of these learners               tive structured clinical examination             GE. Objective structured assessment of
reported successfully completing                  (OSCE) to objectively measure                    technical skills for episiotomy repair. Am J
all steps of the repair noted on our              residents’ procedural competence.                Obstet Gynecol 2003;189:1256-60.
                                                                                                7. American Academy of Family Physicians.
task checklist.                                   To evaluate actual patient care, we              Perineal lacerations. In: American Academy
                                                  are considering a questionnaire                  of Family Physicians. 2000 Advanced Life
Discussion                                        comparing real patient experience                Support in Obstetrics slides. Leawood, Kan:
                                                                                                   AAFP, 2000.
  The use of the sponge perineum                  with the sponge model and assess-             8. Sparks RA, Beesley AD, Jones AD. The
has been a positive addition to                   ing the use of skills learned with the           sponge perineum: a model to teach perineal
our ALSO course and obstetrics                    model. Overall, learners expressed               laceration repair. Accessed
                                                                                                   June 5, 2006.
curriculum, providing residents                   increased confidence after practic-
with skill practice and the faculty               ing with the model and wanted it to
with an inexpensive, convenient,                  continue to be a part of our ALSO

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