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Simulation of childbirth improves clinical management capacity and self-confidence in medical students
  1. Paolo Mannella1,
  2. Rachele Antonelli1,
  3. María Magdalena Montt-Guevara1,
  4. Marta Caretto1,
  5. Giulia Palla1,
  6. Andrea Giannini1,
  7. Federica Pancetti1,
  8. Armando Cuttano2,
  9. Tommaso Simoncini1
  1. 1 Division of Obstetrics and Gynecology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
  2. 2 Division of Neonatology, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
  1. Correspondence to Professor Paolo Mannella, Division of Obstetrics and Gynecology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa 56126, Italy; paolo.mannella{at}


Background The learning process of physiological mechanisms of childbirth and its management are important elements in the education of medical students. In this study, we verify how the use of a high-fidelity simulator of childbirth improves competence of students in this regard.

Methods A total of 132 medical students were recruited for the study in order to attend a physiological childbirth in a no-hospital environment after being assigned to two groups. The control group received only a normal cycle of lectures, while the simulation (SIM) group followed a specific training session on the simulator. Subsequently, both groups were assessed for their technical and non-technical skills in a simulated childbirth. Also, a self-assessment test regarding their self-confidence was administrated before and after simulation, and repeated after 8 weeks.

Results The SIM group showed better performance in all the domains with a better comprehension of the mechanisms of childbirth, managing and assistance of labour and delivery. In addition, compared to the control group, they presented a better self-related awareness and self-assurance regarding the possibility of facing a birth by themselves.

Conclusion The present study demonstrated that the use of a high-fidelity simulator for medical students allows a significant improvement in the acquisition of theoretical and technical expertise to assist a physiological birth.

  • simulation
  • childbirth
  • technical skills
  • no-technical skills

Statistics from


The use of high-fidelity simulation in obstetrics has been long accepted in education1–3 and has been proposed worldwide as new method of teaching and learning.4 Currently, in different Schools of Medicine, as at the University of Pisa,5 6 simulation is offered together with the traditional front-side lessons. This aspect is particularly important and appropriate in obstetrics in which the practice of a physiological birth is usually also reserved to residents or midwives under training. Even if a clerkship rotation is obligatory in delivery rooms, medical students have little chance to personally attend a labour and childbirth.

With the development of high-fidelity simulation, it is possible for medical students to safely recreate various scenarios of labour and delivery and gain experience without involving patient directly. In this way, students can improve information and knowledge obtained on the benches of the universities and have the opportunity to correct any technical and theoretical errors without harming any patient. As it occurs in other medical fields, through simulation students can improve their individual skills and revalue their errors during the debriefing session. These issues have led to the promotion of simulation in delivery room as an effective tool for the preparation of single operators or multiprofessional teams7 trained to face even the most stressful conditions with a good dose of calm which derives from the possibility of being able to repeat several times the same procedure in non-emergent and non-insecure conditions.8

One of the most interesting aspects of simulation is the ability to decide and manage a labour in non-hospital environments. Many future physicians will be involved in the emergency room or in ambulance at a patient’s home and their diagnostic capacity regarding labour and the decision-making process will be much more improved and far beyond the purely technical aspects.

For these reasons, the scope of this study was to evaluate the effects of a specific training on the simulator in medical students on their decision-making capacity and on the management of labour and physiological childbirth outside the hospital environment. In addition, technical and non-technical skills regarding the assistance of physiological labour and childbirth were secondarily analysed.

Material and methods

This was a randomised study performed with the collaboration of 132 undergraduate medical students of the University of Pisa, Pisa, Italy who voluntarily participated from June to July 2016, without knowing the objectives and experimental design of the study. This technical issue was required as previously published studies9 10 have demonstrated that the performance of participants can be influenced by the knowledge of the proceedings in progress. The entire study lasted about 8 weeks (figure 1). As a mandatory requisite, it was requested that students had attended the course of gynaecology and obstetrics and not yet passed the final exam. For a better homogenisation of the entire sample, all students received an intensive course of 2 hours with a frontal lecture on specific topics that involved both technical and non-technical aspects of the care of a physiological birth. This lesson addressed the various stages of childbirth and allowed the standardisation of knowledge of study participants. In this way, all participants, regardless of level of individual preparation, had been informed on theoretical and practical requirements, thus enabling them to face the scenario on the mannequin.

Figure 1

Experimental design of the study.

Subsequently, students were divided into two groups: (a) control (con) and (b) simulation (SIM) (figure 1) with a simple randomisation (alphabetical order of surname). This type of randomisation was chosen in consideration of the homogeneity of recruited participants (medical students which had attended the course of gynaecology and obstetrics).

The con group performed the birth simulation directly on the simulator (prompt flex, birthing simulator, limbs and things and Laerdal, Gatesville, Texas, USA). Instead, the SIM group received a specific lesson on the simulator with the possibility of direct interaction with the teacher, focusing on the most appropriate practical approach to women in the process of childbirth, from the initial clinical evaluation until care of childbirth in each of its phases. Subsequently, SIM participants played simulation of childbirth on the simulator as con.

The performance of the two groups was evaluated by an external observer on the basis of a technical skill evaluation scale (TS scale) (box 1) and a non-technical skill evaluation scale (NTS scale) (box 2). For any TS scale or NTS scale executed by the participant, the external observer scored 1 for correct and 0 for incorrect action. Some actions could be repeated. Participants could achieve a total score ranging from 0 to 14 (maximum) for the TS scale and from 0 to 10 (maximum) for the NTS scale. In addition each participant, at time 0 (that is, after the frontal lecture) and at time 1 (after simulation with mannequin), filled out an anonymous self-assessment test of 11 questions on possible scenarios where each candidate expressed his level of confidence from 1 to 5, considering 5 as the maximum score (box 3).

Box 1

Technical skill evaluation scale (TS scale)

  • Leopold manoeuvres.

  • Vaginal exploration and evaluation of dilatation, effacement and position of the cervix.

  • Evaluation of the presentation of the baby.

  • Evaluation of the station of the baby.

  • Driving of pushing.

  • Protection of the perineum during the delivery of the head.

  • Delivery of the head.

  • Position of the hands.

  • Delivery of the anterior shoulder.

  • Protection of the perineum during the delivery of the posterior shoulder.

  • Delivery of the posterior shoulder.

Box 2

Non-technical skill evaluation scale (NTS scale)

  • Evaluation of the obstetrical history of the woman.

  • Evaluation of the amniotic fluid.

  • Evaluation of the rhythm of contractions.

  • Diagnosis of initial labour.

  • Diagnosis of imminent delivery.

  • Evaluation of the timing of delivery.

  • Evaluation of delivery on-site.

Box 3

11-question self-assessment test

  1. Pregnant called because she is at the end of pregnancy and reports painful contractions. How afraid are you with this situation from 1 to 5?

  2. Pregnant refers to leak water because she is at the end of pregnancy and reports painful contractions. How afraid are you with this situation from 1 to 5?

  3. You are in front of a woman from whose vagina emerges the baby’s head. How afraid are you with this situation from 1 to 5?

  4. How much are you confident to perform a vaginal exploration in a pregnant in labour, from 1 to 5?

  5. How much are you confident to distinguish breech from head presentation by a vaginal exploration, from 1 to 5?

  6. How much are you confident to evaluate the cervix dilatation, from 1 to 5?

  7. How much are you confident to evaluate the cervix length, from 1 to 5?

  8. How much are you confident to recognise middle pelvis, from 1 to 5?

  9. How much are you confident to drive woman pushing on the basis of your diagnosis, from 1 to 5?

  10. How much are you confident to decide you have to deliver the baby on-site or to move to the closest hospital, from 1 to 5?

  11. How much are you confident to manage the delivery of the baby by yourself, from 1 to 5?


The scenario of simulation was rebuilt mimicking a typical circumstance that can occur to a crew of first aid in the house of the patient. The operative centre informed doctor to go to the house of a 30-year-old woman, at first pregnancy, a term that referred the rupture of the amniotic sac and pain. The house was about 1.5 hours from the nearest hospital. The candidate, as a head team physician, according to the clinical condition of the patient, had to decide if the pregnant could be transported to the hospital or to be assisted on site. The scenario was therefore divided into two phases: in the first phase, the patient had painful contractions and loss of amniotic liquid but she was still in prodromal or initial phase of labour. In this phase, the external observer had to consider only the TS scale and NTS scale in order to guide the candidate to a correct diagnosis and therefore to decide transporting the pregnant to the hospital. After this stage, even if the candidate had acted correctly or incorrectly, it was reported that 6 hours had passed and the pregnant reported worsening of pain and an increase of the frequency of contractions. The candidate, in this second phase, had to prove through the TS scale and NTS scale to have reassessed the patient, realising that an imminent childbirth was ongoing and consequently delivery of the baby occurs on site.

The same scenario was repeated after 8 weeks and all the participants were re-evaluated.

Statistical analysis

Statistical analysis was performed using GraphPad Prism 6 (GraphPad Software). All data are presented as mean±SEM. Normality of the data was determined using the Kolmogorov-Smirnov test. The non-parametric two-tailed Mann-Whitney test was used to compare numeric variables that did not show a normal distribution. Categorical variables were compared using the Χ2 test. In addition to analyse the mean of more than two groups simultaneously, one-way analysis of variance was performed followed by Tukey multiple comparison post hoc tests. A P value of <0.05 was considered as statistically significant.


After the lectures and randomisation of the population, participants received a self-test assessment (SA0) (box 3) showing a very similar degree of confidence regarding childbirth. Since all participants were at the same level of their theoretical preparation, no significant difference was found regarding their perception of childbirth (figure 2A).

Figure 2

(A) Pretraining self-assessment test. (B) Post-training self-assessment test. Participants filled out a pretest to show their degree of confidence regarding childbirth before starting simulation. ***P<0.005 versus con. CON, control; SIM, simulation.

After that, the SIM group received an intensive training course of 2 hours with the use of the mannequin. The training was focused on specific topics that involve both technical and non-technical aspects of the care of physiological birth. In the meantime, the con group had 2 hours of round table with an expert ob-gyn operator where participants could ask any type of technical and non-technical questions. Therefore, a new self-assessment test was applied to both of the groups (SA1). Training with simulation significantly increased the level of confidence regarding delivery in the SIM group (figure 2B).

Subsequently, the two groups performed a delivery of a baby with a simulation of a scenario where both technical (figure 3A) and non-technical skills (figure 3B) were assessed. In both of these domains, the SIM groups significantly displayed superior performance. Even in the general management of the scenario, from the diagnostic phase to the phase of childbirth care, the SIM group had significantly improved performances (figure 4), demonstrating a better capacity for clinical management and decision-making.

Figure 3

Technical (A) and non-technical skill evaluations (B). An external observer evaluated technical skills of the two groups (con and SIM) after simulation. ***P<0.005 versus con. Con, control; NTS scale, non-technical skill evaluation scale; SIM, simulation; TS scale, technical skill evaluation scale.

Figure 4

Total score on making decision and delivery: an external observer evaluated the final impact of simulation on birth considering TS scale and NTS scale together. ***P<0.005 versus con. Con, control; NTS scale, non-technical skill evaluation scale SIM, simulation; TS scale, technical skill evaluation scale.

After the simulation test, a new self-assessment test was administered (SA2) that showed a statistically significant improvement in the degree of participants’ confidence, demonstrating that the use of the simulator improved self-confidence both in the control population, which has not received a specific training, and in the same SIM group (figure 5), where the repeating of the simulation improves the perception of their own abilities (figure 6A), even if in non-statistically significant way.

Figure 5

Self-assessment test after scenario. Participants filled out a test after scenario training to show their degree of confidence regarding childbirth after performing simulation. *P<0.05 versus con. Con, control; SIM, simulation.

Figure 6

(A) Self-assessment test after scenario, (B) technical and (C) non-technical skill evaluation, (D) total score on making decision and delivery: participants repeated the tests after 8 weeks. *P<0.05 versus con. Con, control; NTS scale, non-technical skill evaluation scale SIM, simulation; TS scale technical skill evaluation scale.

However, after 8 weeks, both con and SIM groups statistically improved scores on TS scale and NTS scale, and also overall management of the scenario (figure 6B–D); and there were still significant differences between the SIM group (who had performed the training session on the simulator) and the con group despite having used the simulator during the test on the self-test assessment (SA3).


The present study aimed at demonstrating the impact of simulation, as an educational tool, to be used in association with traditional lectures for the training of medical students in the field of obstetrics and specifically in childbirth. The most interesting feature about the study was that the routine use of the training session on simulator improved not only the acquisition of technical and non-technical skills, but also the capacity in clinical management and decision-making processes associated with better awareness of their own abilities and self-confidence.

In the literature, various studies have demonstrated the role of simulation as an educational tool for residents in obstetrics5 and also in medical students.1 11 Recent reports indicate that simulation improves the quality of care8 and patient–physician communication.12

From these studies already published, it seems that also in undergraduate medical students, technical and non-technical skills are greatly improved by the routine use of low-fidelity or high-fidelity simulators.

For this reason, Birch and colleagues supported the use of simulation-based training over traditional lecture-only methodology because they offer several advantages and improvements in clinical management and interdisciplinary communication.9 13

The original aspect of our work is to focus our attention on the perception of medical students regarding their own abilities and thus their confidence. This aspect has not extensively been reported in the literature, especially applied to simulation and is still an important element that creates greater discomfort even in experienced, non-specialist operators. Although Scholz and colleagues14 evaluated students’ feelings of the understanding of both the physiology of parturition and that of obstetric procedures, there are no studies focusing on the evaluation of participants’ degree of self-confidence on facing a delivery, by themselves. For this reason, we created a self-assessment test, which was applied at different stages of the study. In this test, we assessed the most frequent comments and fears reported by first-aid operators when dealing with an external hospital delivery.

The special attention to self-perception of participants is not random. Many of the first-aiders report that one of the most limiting factors in this type of rescue is their personal experience. It is paradoxical that very experienced practitioners who deal with daily life-threatening disease have difficulties solving a physiological childbirth but, at the same time, only the repetition of the experience makes them much more confident. Starting from this assumption, with this self-assessment test we tried to evaluate how the simple execution of simulation could improve the individual perception of their own skills. Validated tests in this regard are not available in the literature; hence, we created a test on the basis of the most frequent experiences and feelings reported by first aiders during this type of emergency.

Beyond the technical and non-technical skills that have been analysed, we also evaluated how self-confidence changed throughout the use of a birth simulator. This allowed, though artificially, experiencing repeatedly childbirth, in a safely manner.

This constitutes the second original element of the study. Participants attended a spontaneous birth, in a scenario with an outpatient setting, which was completely rebuilt and made decision more complicated for non-expert operators.

The addition of the scenario is an essential element for simulation and study for various reasons. As an out-of-hospital environment had been rebuilt, that is, a normal home, the operator is better assisted in playing the role of first rescuer. Beyond the issues of technical and non-technical skills, with the out-of-hospital scenario, we considered another important aspect: the decision-making process of the student whether to attend home delivery, relying solely on own skills or to go to the nearest hospital with the risk of having to deal with delivery in the ambulance. This element shrinks in the eyes of the authors as the true strength of our study. Since the study is directed to undergraduate medical students (not obstetric specialists or midwives), the purpose of the simulation was to verify and improve their abilities as future general practitioners to decide whether to deal with the birth and then carry it out.

In order to evaluate the technical and non-technical skills of the participants, we created a TS scale and an NTS scale. It is necessary to specify that these scales are not recognised or validated by any study but we had to use them because, to the best of our knowledge, there are no pre-established sequences of technical and non-technical actions that can be adopted for our type of scenario (general practitioner in a non-hospital environment). Experienced operators in association with first-aiders prepared these sequences, especially for the non-tech section. Choosing a non-validated scale, although seeming a weakness of the study, has often been needed to make it more likely to evaluate participants within the scenario. This, however, led us to use different TS scale and NTS scales from those reported in the literature10; basically because they are not adaptable to our scenario.

Indeed, the difficulty of having a delivery was increased in clinical management and decision-making, such as transporting the patient to the hospital or assisting at birth alone.

First-aiders often complain about the difficulty not only of assisting childbirth, but also of understanding whether, in that particular case, the most appropriate action is to go to the nearest hospital or to face childbirth. This decision, even in the sphere of physiology, is taken with difficulty due to fear of possible legal repercussions. This element has been deliberately stressed for participants in a stressful decision that may also somehow compromise the performance in other domains.

On the basis of our data we warmly support the routine use of simulation as an educational tool not only to explain or perform ‘medical issues’ but overall to achieve an adequate preparation of undergraduate students regarding important decisions that need to be taken in labour and delivery.



  • Contributors PM: designed data collection tools, monitored data collection for the whole study, analysed the data, drafted and revised the paper. He is the PI of the study and is guarantor. MMMG: wrote the statistical analysis plan, cleaned and analysed the data. RA, MC, GP and AG: executed simulations and collected data. AC and FP: monitored data collection, analysed the data and revised the paper. TS: coordinated the entire project and he is guarantor.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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