Practical Guide to Simulation in Delivery Room Emergencies

Foreword
Acknowledgments
Contents
Contributors
Part I: Fundamentals of Simulation
1: Simulation in Obstetric: From the History to the Modern Applications
1.1 Introduction
1.2 History of Obstetrical Simulation
1.3 The Twentieth Century Became a “Dark Age” for Simulation
1.4 The Role of Obstetrical Simulation Today
1.5 Future Perspectives
1.6 Conclusions
References
2: The Role of Simulation in Obstetric Schools in the UK
2.1 Introduction
2.2 The History of Obstetric Simulation Training
2.3 Simulation in UK Obstetrics and Gynaecology Training Programme
2.4 Simulation Training in Practice
2.5 Low-Fidelity Simulation
2.6 High-Fidelity Simulation
2.7 The Application of Simulation Training
2.8 Beyond the Technical Skills
2.9 Conclusion
References
3: Ontologies, Machine Learning and Deep Learning in Obstetrics
3.1 Integrated Care Pathways
3.1.1 Introduction
3.1.2 Artificial Intelligence and SaMD
3.1.2.1 Software as a Medical Device
3.1.2.2 Software as a Medical Device: Digital Therapies
3.1.2.3 Artificial Intelligence and Software as a Medical Devices
FDA Artificial Intelligence/Machine Learning Action Plan
The State of Artificial Intelligence-Based FDA-Approved Medical Devices and Algorithms: An Online Database
3.1.3 Pathology Innovation Collaborative Community (PICC)
3.1.4 Standard and Healthcare
3.1.4.1 The Clinical Element Model (CEM)
3.1.4.2 Electronic Medical Records (EMR)
3.1.4.3 Electronic Health Records (EHR)
3.1.4.4 openEHR
3.1.4.5 Health Level Seven (HL7)
3.1.4.6 Unified Medical Language System (UMLS)
3.1.4.7 CEN/ISO EN13606
3.1.5 Artificial Intelligence is the Way Forward in Obstetrics
3.2 Ontologies
3.2.1 Lists, Thesauri, and Taxonomies
3.2.2 How Ontologies Work
3.2.3 Particularities of Ontologies in the Medical Domain
3.2.4 Ontologies in Healthcare, Medical Data Collection Systems, and Their Use with Ontology-Based Symbolic AI Methods
3.2.5 Ontology Software Language, Ontology Editor, and Ontology Reasoner
3.2.6 New Frontiers for Ontology Reasoning from Symbolic AI to Non-symbolic AI
3.3 Machine Learning
3.3.1 Supervised Machine Learning Algorithms
3.3.1.1 Classification
Confusion Matrix
Accuracy
Precision
Recall or Sensitivity
Specificity
Class Imbalance Problem
Ensemble Techniques
3.3.1.2 Regression
3.3.1.3 Supervised Learning
Linear Regression and Logistic Regression (and Variants!)
Decision Tree and Random Forest Classifier
Naïve Bayes Classifier
Support Vector Machines (SVM)
K-Nearest Neighbors (KNN)
3.3.2 Unsupervised Machine Learning Algorithms
3.3.2.1 Clustering
Measuring the Clustering Performance
Silhouette Analysis
Analysis of Silhouette Score
Calculating Silhouette Score
3.3.2.2 Association
3.3.2.3 Unsupervised Learning
K-Means Algorithm
Mean Shift Algorithm
3.3.3 Reinforcement Machine Learning Algorithms
3.3.3.1 Building Blocks: Environment and Agent
3.3.3.2 Agent
3.3.3.3 Agent Terminology
3.3.3.4 Environment
3.3.3.5 Properties of Environment
3.3.3.6 Constructing an Environment with Python
3.4 Deep Learning
3.4.1 Introduction to Deep Learning
3.4.2 Image Classification and Object Detection
3.4.3 Image Segmentation
3.4.4 Pose Estimation
3.4.5 Image Registration
3.4.6 Natural Language Processing
3.4.7 Geometric Deep Learning: Ongoing and Next Steps
3.5 Other Examples of AI in Obstetrics
3.5.1 Cardiotocography
3.5.2 Preterm Labor and Birth
3.5.3 Gestational Diabetes Mellitus
3.6 Conclusion
References
Part II: Simulation and Management of Pathologic Pregnancy
4: Assisted Reproductive Technologies: Complications, Skill, Triage, and Simulation
4.1 Introduction
4.2 Surgical Techniques Simulations
4.2.1 Salpingography (SS) and Transcervical Recanalization (TCR) Triage
4.2.2 Hysteroscopy Simulation
4.2.2.1 Systematic Reviews in Hysteroscopy Simulation
4.2.2.2 Hysteroscopy Curriculum
4.2.2.3 Hysteroscopy Training for Gynecologic Residents
4.2.2.4 Surgical Hysteroscopy Training for Fibroid Resection
4.2.2.5 HysteroTrainer
4.2.2.6 Development of a Model of Hydrometra Simulation
4.2.2.7 Hierarchical Task Decomposition for Hysteroscopy
4.3 Oocyte Retrieval
4.3.1 Oocyte Pick-Up Simulator
4.3.2 Assessment Methods to Improve Safety During Oocyte Retrieval
4.3.2.1 Transvaginal Ultrasound Guided Oocyte Retrieval plus Doppler
4.3.2.2 SIPS Technique
4.4 Embryo-Transfer Simulation
4.5 Ovarian Hyperstimulation (OHSS) Triage and Complications Avoidance
4.5.1 Evaluating High-Risk Patients
4.5.2 Ovarian Hyperstimulation and Pregnancy Outcomes
4.6 Ectopic Pregnancy Triage
4.6.1 Ectopic Pregnancy Risk and Triage and Complications Avoidance
4.6.2 Clinical Risk Scoring System
4.6.3 Triage Protocols for Ectopic Pregnancy
4.6.3.1 Serum hCG at 48 H
4.6.3.2 Two-Step Triage Protocol
4.6.3.3 M4 Decision Support System
4.6.3.4 M6 Decision Support System
4.6.4 Ectopic Pregnancy and Biological Factors
4.6.4.1 Ectopic Pregnancy and Ovarian Reserve
4.6.4.2 Ectopic Pregnancy and Frozen Embryo Transfers (FET)
4.6.4.3 Ectopic Pregnancy and BMI
4.6.4.4 Ectopic Pregnancy and Endometrial Thickness
4.6.4.5 Ectopic Pregnancy and Endometrial-Embryonal Synchronization
4.6.5 Ectopic Pregnancy Triage After a Previous Operation
4.6.5.1 Prediction Rule for Ectopic Pregnancy After Laparoscopic Salpingostomy
4.6.5.2 Cesarean Scar Pregnancies
4.6.6 Potentially Life Threatening Emergencies (PLE)
4.6.6.1 Self-Assessment Questionnaire
4.6.6.2 Combination of All Tools
4.6.7 How to Lower the Risk of Ectopic Pregnancy in IVF
4.7 Fertility Preservation
4.8 Ovarian Complication
4.8.1 Ovarian Torsion
4.8.2 Gynecological Ultrasound in the Context of Ovarian Torsion
4.8.3 Ovarian Abscess Ultrasound Diagnosis
4.8.4 Ultrasound Triage at the COVID-19 Era
4.9 Thrombosis
4.9.1 Acuity Scale: VELTAS
4.9.2 Pulmonary Embolism Triage
4.10 Preeclapsia
4.10.1 Community-Level (CLIP) Intervention
4.10.2 First Trimester Risk Assessment for Early-Onset Preeclampsia
4.10.3 Glycosylated Fibronectin Point of Care
4.10.4 Placental Growth Factor-PLGF
4.10.5 Prediction Models for Preeclampsia
4.10.5.1 Petra
4.10.5.2 PREP Models
4.10.5.3 Models Based on the PIERS Study
References
5: Acute Abdomen of Non-obstetric Origin in Pregnancy
5.1 Introduction
5.2 Anatomical and Functional Modifications During Pregnancy
5.3 Ionizing Radiation and Fetus
5.4 Acute Appendicitis
5.5 Gallbladder Disease
5.6 Pancreatitis
5.7 Intestinal Obstruction
References
6: Eclampsia: Skill, Triage, and Simulation
6.1 Part I: Background on Preeclampsia and Eclampsia
6.1.1 Introduction
6.1.2 Background
6.1.3 Diagnostic Parameters
6.1.4 Medical Management
6.1.4.1 General Principles
6.1.4.2 Eclampsia Prevention and Treatment
6.1.4.3 Magnesium Toxicity
6.1.4.4 Management of Severe Hypertension
6.1.4.5 Timing and Route of Delivery
6.2 Part II: Construction of a Preeclampsia–Eclampsia Simulation
6.2.1 General Goals and Learning Objectives for the Simulation
6.2.2 Simulation Construction and Design
6.2.3 Conducting the Simulation
6.2.4 Simulation Examples Cases
6.2.5 Feedback/Evaluation
6.2.5.1 Simulation Debriefing
6.2.5.2 General Debriefing Tips
6.2.5.3 Sample Debriefing Styles
6.2.5.4 Competencies
6.2.5.5 Example Checklists for Preeclampsia–Eclampsia Simulation
6.2.5.6 Example Global Assessment
6.2.6 Evaluation of Simulation Experience: Course Evaluation
6.2.7 Conclusion
Appendix: Simulation Scenario Design
Scenario Overview
Learning Objectives of Simulation Scenario
Patient Description
Target Trainees (Learners)
Anticipated Duration
Scenario Set-Up
Room Configuration (Set-Up)
Equipment Needed
Mannequins/Task Trainers/Standardized Patients Needed
Patient Medical Chart Information
Scenario Logistics
Expected Scenario Flow (Flowchart)
Expected Interventions of the Participants
Expected Endpoint of the Scenario
Distracters Within Scenario
Optional Challenges for Higher Level Learners
Videotaping Guidelines
Roles of Participants/Trainees
Roles of Standardized Patients (If Applicable)
References
7: Renal Failure in Pregnancy
7.1 Introduction
7.2 AKI in Pregnancy
7.3 CKD in Pregnancy
7.4 Kidney Transplant in Pregnancy
7.5 Delivery with Renal Failure
7.6 Conclusion
References
8: Simulation in Obstetric Patients with Cardiovascular Disorders
8.1 Introduction
8.2 Pre-pregnancy Counseling and Prevention of Cardiovascular Incidents
8.3 Timing of Delivery, Labor Induction, and Delivery Method
8.4 Postpartum Care
8.5 Cardiac Emergencies in Labor Ward
8.5.1 Severe Hypertension
8.5.2 Pulmonary Edema
8.5.3 Arrhythmia
8.5.4 Aortic Dissection
8.5.5 Acute Coronary Syndrome
8.6 Summary
References
9: Cardiac Arrest in Pregnancy: Simulation and Skills
9.1 Introduction
9.2 Physiological Changes During Pregnancy
9.2.1 Aortocaval Compression
9.2.2 Cardiovascular Changes
9.2.3 Respiratory Changes
9.2.4 Upper Respiratory Airway Changes
9.2.5 Risk of Aspiration
9.3 Etiology of Cardiac Arrest in Pregnancy
9.3.1 Hemorrhage
9.3.2 Thromboembolism
9.3.3 Cardiac Disease
9.3.4 Anesthesia-Related Death
9.3.5 Other Causes
9.4 Cardiopulmonary Resuscitation
9.4.1 Left Lateral Position
9.4.2 Airway and Breathing
9.4.3 Circulation
9.4.4 Defibrillation
9.5 Treat the Cause
9.5.1 Hemorrhage
9.5.2 Cardiac Arrest
9.5.2.1 Treatment of Shockable Rhythms
9.5.2.2 Non-shockable Rhythms
9.6 Post-resuscitation Care
9.7 Emergency Delivery
9.8 Conclusion
References
10: Aortic Dissection in Pregnancy
10.1 Introduction
10.2 The Risk Factor of the Aortic Dissection
10.2.1 Genetic Condition
10.2.2 Increased Aortic Wall Stress (Table 10.1)
10.2.3 Stimulant Agent (Cocaine)
10.2.4 Trauma, Torsional, and Deceleration Injury
10.2.5 Inflammatory Vasculitis
10.3 Clinical Symptoms
10.4 Management of Women Before Pregnancy
10.5 Management of Women with Aortic Dissection in Pregnancy
10.6 Surgical and Outcome Data
10.6.1 Type A Aortic Dissection
10.6.2 Type B Aortic Dissection
References
Part III: Simulation and Management of Pathological Fetus
11: Twin-Twin Transfusion Syndrome: Complications and Management
11.1 Introduction
11.2 Pathogenesis
11.3 Clinical Features
11.3.1 Intrapartum TTTS
11.4 Diagnosis
11.4.1 Prediction of TTTS (First-Trimester Ultrasound Scanning)
11.4.2 Second Trimester Diagnosis of TTTS
11.4.2.1 Assessment of Bladder Size
11.4.2.2 Doppler Studies
11.4.2.3 Comprehensive Fetal-Placental Anatomical and Fetal Biometric Survey
11.4.3 Echocardiogram
11.4.4 Differential Diagnosis
11.5 Quintero Staging System of TTTS
11.6 Maternal Clinic
11.7 Treatment of TTTS
11.7.1 Management of Quintero Stage I
11.7.1.1 Management of Women with Quintero Stage I TTTS with No Maternal Symptoms and No Cervical Shortening
11.7.1.2 Management of Women with Quintero Stage I TTTS with Disturbing Symptoms or Short Cervical Length
11.7.2 Management of Quintero Stage II–IV
11.7.3 Management of Quintero Stage V
11.8 Approaches to Management of TTTS
11.8.1 Fetoscopic Laser Ablation of Anastomotic Vessels
11.8.1.1 Contraindications
11.8.1.2 Preparation Before Procedure
11.8.1.3 Procedure
The Equatorial Dichorionization (Solomon) Technique
11.8.1.4 Complications and Management
11.8.1.5 Follow-Up Recommendations After Fetoscopic Laser Ablation
11.8.1.6 Delivery Time After Fetoscopic Laser Ablation
11.8.1.7 Outcome for Fetoscopic Laser Ablation
11.8.2 Amnioreduction
11.8.2.1 Procedure
11.8.2.2 Complications and Management
11.8.2.3 Follow-Up Recommendations After Fetoscopic Amnioreduction
11.8.2.4 Delivery Time After Fetoscopic Amnioreduction
11.8.2.5 Outcome for Amnioreduction
11.8.3 Amnioreduction Versus Laser Coagulation
11.8.4 Septostomy
11.8.5 Selective Fetal Reduction
References
12: Intrauterine Fetal Death: Management and Complications
12.1 Definition
12.2 Brief History of Fetal Death
12.3 Incidence
12.4 Risk Factors
12.4.1 Race
12.4.2 Maternal Age and Parity
12.4.3 Multiple Gestations and Assisted Reproductive Technologies (ARTs)
12.4.4 Previous Adverse Pregnancy Outcomes and Previous Stillbirth
12.4.5 Previous Cesarean Delivery
12.4.6 Obesity and Gestational Weight Gain
12.4.7 Male Fetal Sex
12.4.8 Postterm Pregnancy
12.4.9 Smoking
12.5 Causes
12.5.1 Maternal Causes
12.5.1.1 Hypertensive Disorders and Diabetes Mellitus
12.5.1.2 Thyroid Disease
12.5.1.3 Systemic Lupus Erythematosus (SLE)
12.5.1.4 Renal Disease
12.5.1.5 Intrahepatic Cholestasis of Pregnancy (ICP)
12.5.1.6 Inherited and Acquired Thrombophilias
12.5.2 Pathologies Related to the Fetus
12.5.2.1 Alloimmunization
12.5.2.2 Fetal Alloimmune Thrombocytopenia
12.5.2.3 Genetic Abnormalities
12.5.2.4 Fetomaternal Hemorrhage
12.5.2.5 Fetal Growth Restriction (FGR)
12.5.3 Placental and Umblical Cord Abnormalities
12.5.3.1 Placental Abruption
12.5.3.2 Placenta Previa (Fig. 12.11), Vasa Previa and Neoplasms of the Placenta Can Be Other Causes of Stillbirth [56]
12.5.3.3 Umbilical Cord Abnormalities
12.5.4 Infections
12.6 Clinic Evaluation
12.6.1 Placental Evaluation
12.6.2 Fetal Evaluation and Autopsy
12.6.3 Genetic Evaluation
12.6.4 Maternal Evaluation
12.7 Management at the Delivery Room
12.8 Complications and Managements
12.8.1 Infections
12.8.2 Postpartum Hemorrhage
12.8.3 Genital Tract Lacerations
12.8.4 Uterine Rupture and Perforation
12.8.5 Retained Placenta
12.8.6 Disseminated İntravascular Coagulopathy (DIC)
12.9 COVID-19 and Stillbirth
References
13: Abortion an Obstetric and Anesthesiologic Emergency: Skills and Simulation
13.1 Abortion
13.2 Risk Factors
13.3 Etiology
13.4 Clinical Manifestations
13.5 Diagnostic Evaluation
13.5.1 Laboratory Evaluation
13.6 Differential Diagnosis
13.7 Types of Spontaneous Abortion
13.8 Early Second Trimester Pregnancy Loss
13.8.1 Etiology
13.9 First Trimester Abortion Treatment
13.9.1 Surgical Treatment
13.9.2 Medication Evacuation
13.9.3 Comparison and Selection of Treatment
13.10 Second Trimester Abortion Treatment
13.10.1 Dilatation and Evacuation (D&E)
13.10.2 Medical Abortion
13.10.3 Abdominal Surgery
13.11 Pain Management
13.12 Antibiotic Prophylaxis
13.13 Special Conditions
13.14 Complications and Management
13.15 Abortion in Era Covid
References
Part IV: Simulation of Normal and Abnormal Labour
14: Labor Simulations: “Hard Drill Makes an Easy Battle”
14.1 Background
14.2 Normal Labor
14.2.1 Cervical Dilation
14.2.2 Uterine Contractions
14.2.3 Fetal Head Position
14.2.4 Fetal Head Station
14.2.5 Normal Vaginal Delivery
14.3 Breech Delivery
14.4 Operative Vaginal Deliveries
14.5 Shoulder Dystocia
14.6 Postpartum Hemorrhage (PPH)
14.7 Conclusion
References
15: Intrapartum Ultrasonographic Simulation in Dystocic Labor
15.1 Introduction
15.2 Background
15.3 Simulation Training in Obstetrics and Intrapartum Ultrasound
15.4 Assessment of Fetal Head Position
15.5 Assessment of Fetal Head Attitude
15.6 Assessment of Fetal Head Station: Head Perineal Distance (HPD)
15.7 Assessment of Fetal Head Descent: Angle of Progression (AoP)
15.8 Intrapartum Ultrasound Simulator: IUSim™
15.9 Intrapartum Ultrasound Simulator: ProgSim™
15.10 Transabdominal Ultrasound Simulation Models
15.11 Conclusion
References
16: Simulation and Learning Curve of the Traditional and Sonographic Pelvimetry
16.1 Introduction
16.2 Learning Curves
16.3 Learning Curve Applications for Pelvic Obstetrical Evaluation
16.3.1 Learning Curves Comparison Between Transabdominal Sonography and Digital Vaginal Examination
16.3.2 Simulation and Learning Curve for Leopold Maneuvers Assessment
16.3.3 Learning Curves and Ultrasonographic Estimation of Fetal Weight
16.4 Simulation in Pelvimetry
16.4.1 Pelvis Simulators/Phantoms/Mannequins
16.4.2 Imaging Pelvimetry Techniques
16.4.3 Biomechanics Computer Modeling Simulation
16.4.4 Sonopelvimetry Simulation
16.4.5 Individual Prognosis Through Virtual Simulation
16.5 Conclusions
References
17: Simulation of Urgent Obstructed Delivery: Scenario and Triage
17.1 Introduction
17.2 Incidence of Obstructed Delivery
17.3 Risk Factors for Obstructed Labor
17.3.1 Prolonged Second Stage of Labor
17.3.2 Fetal Malpresentation and Asynclitism
17.3.3 Cephalopelvic Disproportion
17.3.4 Bandl’s Ring
17.4 Maternal and Neonatal Outcomes of Obstructed Labor
17.4.1 Outcomes of Prolonged Second Stage of Labor
17.4.2 Outcomes of Obstructed Labor
17.5 Management of Obstructed Labor
17.5.1 Fluid Resuscitation
17.5.2 Expectant Management Beyond 3 h of Second Stage of Labor
17.5.3 Use of Ultrasound
17.5.4 Manual Rotation
17.5.5 Operative Vaginal Delivery
17.5.6 Symphysiotomy
17.5.7 Cesarean Delivery
17.5.8 Cesarean Delivery Positioning
17.5.9 Cesarean Delivery Incision
17.5.10 Cesarean Delivery Medical Adjuncts
17.5.11 Bandl’s Ring at the Time of Cesarean Delivery
17.6 Cesarean Delivery Techniques
17.6.1 Alternate Hand Technique
17.6.2 Pull Vs Push Techniques
17.6.3 Shoulder First Technique
17.6.4 Abdominovaginal Delivery Technique
17.7 Medical Devices
17.7.1 Obstetric Spoon
17.7.2 C-Snorkel
17.7.3 Pillow
17.7.4 Uterine Rupture
17.7.5 Fetal Death
17.8 Obstetrical Trainer for Second-Stage Cesarean Delivery
17.9 Conclusion
References
18: Twin Vaginal Delivery
18.1 Introduction
18.2 Simulation-Based Training of Twin Vaginal Delivery
18.2.1 Technical Skills Teaching and Training
18.2.2 Non-technical Skills Teaching and Training
18.2.3 Simulation Setting; Off-Site Vs. In-Situ
18.3 Simulation-Based Training During the Coronavirus Disease 2019 (COVID-19) Pandemic
References
19: Emergency Delivery in Patients with Obesity
19.1 Introduction and Epidemiology
19.2 Prenatal Assessment
19.3 Emergency Delivery
19.3.1 Risk Factors for Emergency Delivery
19.3.2 Anesthesia Prospective
19.3.2.1 Epidural Analgesia
19.3.2.2 Epidural Anesthesia for C-Section
19.3.2.3 Combined Spinal-Epidural Versus Spinal Anesthesia for C-Section
19.3.2.4 General Anesthesia for C-Section
19.3.3 Emergency C-Section Delivery
19.3.4 Implications of COVID-19 on Emergency Delivery
19.4 Postpartum Period
19.4.1 Weight Gain Retention
19.4.2 Breastfeeding and Chestfeeding
19.4.3 Postpartum Depression
19.5 Summary
References
Part V: Simulation and Management of Pathologic Delivery
20: Breech Delivery and Updates in Simulation for Breech Vaginal Delivery
20.1 Introduction
20.2 Breech Presentation
20.3 Breech Delivery
20.3.1 Breech Vaginal Delivery
20.3.1.1 Cardinal Movements of Labor
Engagement and Descent
Lateral Flexion
Internal Rotation
Expulsion
External Rotation
Shoulder Engagement and Descent
Shoulder Internal Rotation
Head Flexion and Delivery
20.3.1.2 Vaginal Breech Delivery Technique
20.3.1.3 Resolution of Common Complications in Breech Delivery
Cervical Head Entrapment
Nuchal Arm
Delivery of the Aftercoming Head
20.3.2 Candidates for Vaginal Breech Delivery
20.3.2.1 Labor Induction or Augmentation
20.3.2.2 Potential Maternal and Neonatal Complications of Breech Vaginal Delivery
20.3.2.3 Counseling
20.3.2.4 External Cephalic Version
20.3.3 Breech Delivery of the Second Twin
20.3.4 Preterm Breech Delivery
20.3.4.1 Delivery Route at 22w0d-27w6d
20.3.4.2 Delivery Route at 26–36 Weeks
20.3.4.3 Summary
20.3.5 Revisiting the Term Breech Trial
20.3.5.1 Summary of Findings
20.3.5.2 Impact and Potential Flaws
20.3.5.3 Studies Performed in Response to the Term Breech Trial
20.3.6 Current Training
20.3.6.1 Simulation in Obstetrics
20.3.6.2 Simulation for Breech Delivery and Supporting Data
20.3.6.3 Ideal Simulation Training
References
21: Umbilical Cord Prolapse: Simulation, Skills and Triage
21.1 Introduction
21.2 Definition
21.3 Incidence
21.4 Risk Factors
21.5 Pathophysiology
21.6 Diagnosis
21.7 Management
21.8 Perinatal Morbidity and Mortality
21.9 Predictors of Outcome
21.10 Cord Prolapse in Pandemic COVID Era
References
22: Unexpected Placental Invasion: Scenario, Management, and Simulation
22.1 Introduction
22.2 Diagnosis
22.3 Unexpected PAS
22.4 Clinical Scenario
22.4.1 Scenario 1
22.4.2 Scenario 2
22.5 Conclusion
References
23: Abnormal Invasive Placentation Simulation of Emergency Scenario: Low- and Full-Resource Setting
23.1 Introduction
23.2 Low-Resource Settings
23.2.1 Cases
23.3 Full-Resource Team
23.4 Full-Resource Setting
23.4.1 Surgical Staging
23.5 Conclusions
References
24: Uterine Rupture: A Rare Event But Terrible to Know How to Face
24.1 Introduction
24.2 Incidence
24.3 Biology of Uterine Rupture
24.4 Uterine Rupture After Myomectomy
24.5 Uterine Rupture During Pregnancy
24.6 Uterine Rupture During Labor and Delivery
24.7 Uterine Rupture During Surgery
24.8 Uterine Rupture Management
24.9 Uterine Rupture Emergency: New Considerations in COVID-19 Era
24.10 Uterine Rupture: Case Series
24.11 Prelabor Uterine Rupture and Previous Placenta Previa Diagnosis
References
Part VI: Operative Delivery Simulation
25: Urgent Cesarean Section with Misgav Ladach (Stark’) Method: Simple Cesarean Delivery and Learning Curve
25.1 Toward an Optimal Cesarean Section
25.2 The Evidence-Based Cesarean Section
25.3 Controversial Issues
25.4 Educational Issues
25.5 Conclusion
References
26: Simulation of Urgent Cesarean Delivery: Scenario and Triage
26.1 Introduction
26.1.1 Triage
26.1.1.1 The Impact of a Globally Accepted Classification System
26.1.1.2 The Optimal Timing for Delivery
26.1.2 Simulation of Ceaserean Section: Training for Emergency CS
26.1.3 Scenarios and Cases
26.2 Conclusion
References
27: Forceps Application: Training, Simulation, and Learning Curve
27.1 Introduction
27.2 Forceps Delivery in Modern Obstetric Practice
27.3 Training and Simulation in Forceps Delivery
27.3.1 Technical Skills Training for Forceps Deliveries
27.3.2 Simulation Training in Forceps Deliveries
27.3.2.1 Simulation Scenarios
Debriefing of Performance in the Scenario
27.4 Forceps Delivery Learning Curve
References
28: Vacuum Extractor: Skills, Education, Simulation, and Learning
28.1 Introduction
28.2 The History of Vacuum Extraction
28.3 Indications and Prerequisites for Vacuum Delivery
28.4 Birth Injury
28.5 Skills, Education, and Learning
28.6 Simulation Training
28.7 Conclusion
References
Part VII: Postpartum Haemorrhage Simulation
29: Abruptio Placentae: Simulation and Scenario
29.1 Pathophysiology
29.2 Etiology
29.3 Risk Factors
29.4 Clinical Features
29.5 Imaging
29.6 Pathological Aspects
29.7 Adverse Effects
29.7.1 Maternal Consequences
29.7.2 Fetal/Neonatal Consequences
29.8 Chronic Abruption
29.9 Recurrence
29.10 How to Make a Proper Diagnosis
29.11 Management
29.12 Different Scenarios
29.12.1 Conservative and Operative Management
29.12.2 Uterine Apoplexy or Couvelaire Uterus
29.12.3 Postpartum Care
29.13 Importance of Simulation
References
30: Skills Training and Multi-Professional Simulation Training on Postpartum Haemorrhage
30.1 Introduction
30.2 Why Simulation Training?
30.3 Skills Training and Simulation Training in Teams
30.4 Technical Skills Training
30.5 Bimanual Compression
30.6 Learning Goals for Multi-professional Simulation Training
30.7 How to Carry Out Multi-Professional Simulation Training on PPH?
References
31: Combined Management of Postpartum Obstetric Bleeding Using Zhukovsky Balloon Tamponade
31.1 Double-Balloon Zhukovsky Catheter for the Management of Postpartum Bleeding After Vaginal Deliveries
31.2 Double-Balloon Zhukovsky Catheter for the Management of Postpartum Bleeding after Caesarean Deliveries
31.3 Double-Balloon Zhukovsky Catheter in Women with Placenta Praevia
References
32: PPH: Triage, Scenario, and Simulation
32.1 Introduction
32.2 PPH Prevalence
32.3 PPH Management Protocol
32.4 PPH Simulation Program
32.5 Conclusions
References
33: Postpartum Hemorrhage: Conservative Treatments
33.1 Introduction
33.2 Pharmacological Management
33.2.1 Uterotonic Agents
33.2.1.1 Oxytocin
33.2.1.2 Carbetocin
33.2.1.3 Methylergonovine
33.2.1.4 Prostaglandins
Sulprostone
Carboprost
Misoprostol
33.3 Tranexamic Acid
33.4 Uterine Tamponade Procedures
33.5 Selective Arterial Embolization
33.6 Surgical Management
33.6.1 Uterine Compression Sutures
33.7 Vascular Ligation
References
34: The Role of Noninvasive Uterine Mechanical Compression in the Golden Hour of Postpartum Hemorrhage
34.1 Introduction
34.2 The Uterus and the Placenta. Memento “sine anatomia non sciemus” (Vesalius)
34.3 The Uterine Contraction
34.3.1 Uterine Atony Is the Absence of Tone and Posture
34.3.2 Noninvasive Uterine Mechanical Compression
34.3.3 Uterine Compression and the Balloon
34.4 Conclusions
References
Part VIII: Management of Puerperium and Simulation
35: Complicated Cesarean Hysterectomy
35.1 Introduction
35.2 Preoperative Risk Assessment
35.3 Placenta Accreta Spectrum (PAS)
35.4 History of Uterine Surgery
35.5 Uterine Atony
35.6 Retained Placenta
35.7 Patient Counseling
35.8 Hypogastric Artery and Intra-Aortic Balloon Catheter Insertion
35.9 Incision and Delivery
35.10 Surgical Procedure
35.11 Complications
References
36: Postpartum Uterine Inversion: Skill, Simulation and Learning Curve
36.1 Introduction
36.2 Incidence and Mortality
36.3 Definition
36.4 Aetiology
36.5 Diagnosis
36.6 Treatment of Uterine Inversion
36.7 Manual Replacement (Conservative Approach)
36.8 Surgical Treatment
36.9 Recent Techniques
36.10 Reinversion
36.11 Management of the Placenta
References
37: Emergency and Urgency in Puerperium: Scenario and Complications
37.1 Introduction
37.2 Venous Thromboembolism
37.2.1 Risk Factors and Prevention
37.2.2 Symptoms and Clinical Features
37.2.3 Diagnosis
37.2.4 Massive Pulmonary Embolism
37.2.5 Treatment
37.2.5.1 Medical Treatment
37.2.5.2 Surgical Treatment
37.3 Sepsis in Puerperium
37.3.1 Definition and Risk Factors
37.3.2 Symptoms, Clinical Features and Diagnosis
37.3.3 Management
37.4 Secondary Postpartum Haemorrhage
37.4.1 Risk Factors and Prevention
37.4.2 Etiology and Risk Factors
37.4.3 Diagnostic Approach to Secondary PPH
37.4.4 Treatment
References
Part IX: Obstetric Anesthesia Emergencies
38: Fundamentals of Emergencies in Obstetrics: Training and Simulation
38.1 Simulation-Based Obstetric Anesthesia Training in Emergency Cesarean Section
38.1.1 Simulation
38.1.2 Complication During General and Regional Anesthesia
38.1.2.1 Difficult/Failed Intubation
38.1.3 Preoperative Preparation [7]
38.1.4 Extubation Strategy
38.1.5 Hypotension
38.1.6 Total Spinal Anesthesia
38.1.7 Local Anesthetic Systemic Toxicity
38.1.8 Accidental Dural Puncture
38.1.9 Postdural Puncture Headache
38.2 Simulation-Based Obstetric Anesthesia Training in Embolism
38.2.1 Simulation
38.3 Simulation-Based Obstetric Anesthesia Training in Maternal Collapse/Arrest
38.4 Simulation-Based Obstetric Anesthesia Training in Severe Maternal Hemorrhage
38.4.1 Simulation
38.5 Simulation-Based Obstetric Anesthesia Training in Severe Preeclampsia-Eclampsia
38.5.1 Simulation
38.6 Simulation-Based Obstetric Anesthesia Training in Placental Retention
References
39: Simulation of Difficult Airway Management in Obstetric Emergencies
39.1 Introduction
39.2 Definition
39.3 Airway Assessment
39.3.1 Preparation
39.3.2 Preoxygenation
39.3.3 Position
39.4 Anticipated Difficult Airway Management
39.4.1 Difficult Airway Management
39.4.1.1 Practical Tutorial for Using a D-blade for Difficult Airway Management
39.5 Learning the Multimodal Airway Management Concept with Virtual Reality
39.5.1 Topical Anesthesia and Nerve Blocks
39.5.2 Sedation During Awake Tracheal Intubation
39.6 Induction Agents and Muscle Relaxants for GA
39.6.1 Recommendations for Tracheal Intubation Using Other Devices
39.6.2 Failed Intubation and Tracheostomy
39.6.3 Extubation
39.7 Learning Points and Recommendations in Obese Parturients
39.7.1 Good Practice and Recommendations for Obese Parturients
39.8 Teaching, Skills and Training
39.9 Obstetric Anesthesia in the COVID-19 Era
39.10 Medico-Legal Issues in Complicated Airway Management
References
40: Sonographic Locating of the Lumbar Space in the Difficult Spine and Obese Parturient: Simulation and Skills
40.1 Introduction
40.2 Anatomy of the Lumbar Spine
40.3 Basic Concepts of Spinal Ultrasound
40.4 Scanning Planes
40.4.1 Parasagittal Transverse Process View
40.4.2 Parasagittal Articular Process View
40.4.3 Parasagittal Oblique (Interlaminar) View (PSO View)
40.4.4 Transverse Spinous Process View
40.4.5 Transverse Interspinous (Interlaminar) View. (T1)
40.5 Preprocedural US-Guided Epidural Block Technique
40.6 Real-Time US-Guided Epidural Block Technique
40.7 Water-Based Spine Phantom
40.8 Neuraxial Anaesthesia for Labour and Delivery
40.9 The Technique Combined Spinal-Epidural (CSE) Injection
40.10 Effects of Obesity in Pregnant Women on Local Anaesthetic Pharmacology
40.11 Reducing the Risk of Complications
40.12 Clinical Manifestations
40.12.1 Simulation Case Presentation
40.13 Conclusion
References
41: Amniotic Fluid Embolism and the Role of Thromboelastometry. And What About Simulation?
41.1 Amniotic Fluid Embolism
41.1.1 Definition
41.1.2 Incidence and Outcome
41.1.3 Pathophysiology
41.1.4 Risk Factors
41.1.5 Clinical Course
41.1.6 Diagnosis
41.1.7 Differential Diagnosis
41.1.8 Management
41.2 Viscoelastometric Testing: ROTEM and TEG
41.2.1 Thromboelastometry in Laboring Women
41.2.2 Parameters of ROTEM
41.2.3 Tests of ROTEM
41.2.4 Clinical Application
41.3 Simulation
41.3.1 Case
41.3.2 Call for Help Early
41.3.3 Anticipate and Plan
41.3.4 Designate Leadership
41.3.5 Establish Role Clarity
41.3.6 Know the Environment
41.3.7 Use All Available Information
41.3.8 Distribute the Workload
41.3.9 Allocate Attention Wisely
41.3.10 Mobilize Resources
41.3.11 Communicate Effectively
41.3.12 Use Cognitive Aids
41.4 Conclusion
Addendum
Lab Results
References
42: Septic Shock in Obstetric Emergency
42.1 Introduction
42.2 Definition of Sepsis
42.3 Incidence and Mortality
42.4 Risk Factors
42.5 Sepsis’s Start Sites
42.5.1 Genital Tract Infection
42.5.2 Urinary Tract Infection
42.5.3 Pneumonia
42.5.4 Influenza
42.6 Microorganisms
42.7 Diagnosis
42.8 Treatment
42.8.1 General Approaches
42.8.2 Antibiotic Therapy
42.8.3 Fluid Management
42.8.4 Vasopressors
42.9 Delivery
42.10 Human Immunoglobulin
References
43: Transfusional Optimization Using Viscoelastic Test Guided Therapy in Major Obstetric Hemorrhage: Simulation and Skills
43.1 Introduction
43.2 The Routine Laboratory Bundle
43.3 Looking for a Goal-Directed and Point-of-Care Transfusional Approach in MOH
43.4 Thromboelastography (TEG® 5000 and TEG® 6s Hemostasis Analyzers with TEG Manager® Software)
43.5 How TEG Works
43.6 Rapid TEG (r-TEG)
43.7 Functional Fibrinogen
43.8 Platelet Mapping Assays
43.9 Rotational Thromboelastometry (ROTEM®)
43.10 Parameters of TEG and ROTEM (Table 43.3)
43.10.1 Calculated Parameters
43.11 Thromboelastography and Rotational Thromboelastometry Role in Major Obstetric Hemorrhages
43.12 VHA Guided Protocols
43.13 Clinical Scenario
References
44: Thromboelastography (TEG): Point of Care Test of Hemostasis for Emergency Postpartum Hemorrhage
References
45: Improving of Hemodynamic and Hemostatic in the Golden Hour
45.1 The “Golden Hour” in Mothers
45.1.1 Hemorrhages
45.1.1.1 Diagnosis and Prevention of Postpartum Hemorrhages
45.1.1.2 Treatment of Postpartum Hemorrhages [9]
45.1.2 Cardiac Disease in Mothers During Peripartum and the “Golden Hour”
45.1.2.1 Acute Right Ventricular Failure
45.1.2.2 Acute Left Ventricular Failure
45.2 The “Golden Hour” in Newborns
45.2.1 Delayed Cord Clamping (DCC)
45.2.2 Prevention of Hypothermia
45.2.3 Support to Cardiovascular System
45.2.4 Monitoring and Record
References
Part X: Neonatal Emergencies
46: Neonatal Resuscitation
46.1 Introduction
46.2 Preparation
46.3 Initial Assessment
46.4 Neonatal Resuscitation
46.4.1 Initial Stabilization (Providing Warmth, Stimulation, Clearing the Airway)
46.4.2 Breathing (Positive Pressure Ventilation)
46.4.3 Chest Compressions
46.4.4 Medications and Volume Expansion
46.5 Heart Rate and Oxygenation Assessment in the Delivery Room
46.6 Practical Tutorial of Neonatal Resuscitation
46.7 Withholding or Discontinuing Resuscitation
46.8 Postresuscitation Care
46.9 Conclusion
References
47: Premature Neonatal Life Support
47.1 Introduction
47.2 Additional Resources and Personnel Needed for a Premature Delivery
47.3 Delayed Cord Clamping
47.4 Heat Loss Prevention
47.5 Oxygen Use
47.6 Respiratory Support of a Premature Infant in the Delivery Room
47.6.1 CPAP
47.6.2 Positive Pressure Ventilation
47.6.3 Endotracheal Intubation
47.6.4 Surfactant Administration
47.6.5 Practical Aspect in Preventing Heat Loss and Providing Respiratory Support in the Delivery Room; Illustrations and Video Guide
47.6.5.1 Heat Control
47.6.5.2 Continuous Positive Airway Pressure with a Mask
47.6.5.3 Positive Pressure Ventilation with a Mask
47.6.5.4 Endotracheal Intubation
47.6.5.5 Continuous Positive Airway Pressure with Nasal Prongs
47.6.5.6 Less Invasive Surfactant Administration
47.7 Neuroprotective Strategies to Reduce Brain Injury in Premature Infants
47.7.1 Antenatal Strategies
47.7.2 Postnatal Strategies
47.8 Resuscitation at Limits of Viability
47.9 Conclusion
References
48: Umbilical Venous Catheter Placement: A Step-by-Step Guide for Neonatologists
48.1 Introduction
48.2 Anatomical and Physiological Background
48.3 Insertion of Umbilical Venous Catheter
48.3.1 Before Insertion
48.3.2 The Procedure
48.4 Insertion of the Umbilical Venous Catheter in  Emergency Situations
48.5 Complications: Malposition and Migration
48.5.1 “Low-Lying” Umbilical Venous Catheters
48.5.2 “High-Lying” Umbilical Venous Catheters
48.6 Care of the Umbilical Venous Catheter
48.7 Simulating Umbilical Venous Catheter Placement in an Educational Setting
48.8 Conclusion
References
49: Simulation of Newborn Thermoregulation and Temperature Preservation After Birth
49.1 Mechanisms of Heat Loss
49.2 Prevention of Heat Loss in the Delivery Room
49.3 Prevention of Heat Loss in NICU
49.4 Conclusions
References
50: Role of Training in Neonatal Encephalopathy Prevention
50.1 Introduction
50.2 Neonatal Encephalopathy
50.3 Staging
50.4 Pathophysiology of NE
50.5 Epidemiology
50.6 Purpose of This Study
50.7 Cardiotocographic Diagnostic Criteria
50.7.1 Patterns of EFM Tracings
50.7.2 Therapeutic Actions Based on Type of Cardiotocographic Tracing
50.8 Sensitivity and Specificity in the Identification of Pathological CTG
50.9 Reliability of the Predictive Ability of Cardiotocography
50.10 Influence of Guidelines on the Reliability of Interpretation
50.11 Strategies to Improve Fetal Monitoring Outcomes
50.12 Can Technology Solve the Problem?
50.13 Development of the Intelligent Decision Support Software
50.14 CTG Training Role
50.15 Training for the Entire Staff
50.16 Existing Training in Cardiotocography
50.17 Neonatal Encephalopathy and COVID-19 Neonatal Infection
50.17.1 Pre- and Neonatal Infection
50.17.2 SARS-Cov-2 Congenital Infection and Hypoxic Ischemic Encephalopathy
50.17.3 Clinical Reports
50.17.4 Autoptic Brain Findings
50.17.5 Neurological Consideration
50.18 Conclusions
References
Part XI: Covid 19 Pandemy and Obstetric Simulation
51: Voluntary Termination of Pregnancy, Therapeutic, and Spontaneous Abortion: What Is Happening in Coronavirus Era? An Italian Experience
51.1 International and Italian background
51.2 Voluntary Abortion
51.3 Therapeutic Termination of Pregnancy
51.4 Spontaneous Abortion
51.5 A Lesson to Be Learned
References
52: SARS-CoV-2-Related Acute Respiratory Failure in Pregnant Women: What Role Can Simulation Play?
52.1 Introduction
52.2 SARS-CoV-2 Disease and Lung Injury in Pregnant Women: Incidence, Clinical Presentation, Severity, and Outcomes
52.3 Prevention and Limitation of Viral Transmission, Barrier Procedures
52.4 Pregnancy, SARS-CoV-2, and Simulation
References
53: Acute Abdomen in Pregnancy: Triage, Skills, and Simulator during COVID-19 Pandemic Situation
53.1 Introduction
53.2 Ectopic Pregnancy
53.3 Diagnosis
53.4 Differential Diagnosis
53.5 Management
53.6 Role of Laparoscopic Simulators
53.7 Management of Ectopic Pregnancy during COVID-19 Pandemic Situation
53.8 Conclusions
References
54: Postpartum Hemorrhage in COVID-19 Patients: Instruction for Use
54.1 Introduction
54.2 Epidemiology and Identification of COVID-19 Patients at High Risk for PPH
54.3 Preventing Postpartum Hemorrhage at Home
54.4 General Changes to Routine Labor and Delivery Work Flow
54.5 Management of Postpartum Hemorrhage in COVID-19 Patients
54.6 Our Experience
54.7 Our Institutional Pathways for COVID-19 and Non-COVID Patients
54.8 Assistance to Labor of COVID-19 Patients
54.9 Importance of Simulation
54.10 Conclusions
References
55: Urgent Cesarean Delivery in COVID-19 Patients: Simulation, Skill, and Triage
55.1 Introduction
55.2 Urgent Cesarean Section
55.3 The Misgav Ladach Method for Cesarean Section
55.4 Hospital Disaster Preparedness
55.5 Preparation and Transport to Operating Room
55.6 Personal Protecting Equipment
55.7 COVID-19 Infection in Pregnancy
55.8 Cesarean Section and COVID-19 Considerations
55.9 Our Experience
55.10 Conclusions
References
56: Cardiopulmonary Resuscitation of a Pregnant Woman During COVID-19 Pandemic
56.1 Introduction
56.2 Control of Provider Exposure
56.3 Recognize Cardiac Arrest
56.4 Chest Compression
56.5 Airway Management
56.6 Defibrillation
56.7 Causes of CA in COVID-19
56.8 Conclusion
References
Part XII: Complications, Medico-Legal Issues and Importance of Simulation
57: Can the Simulation of Delivery Prevent Perineal Trauma?
57.1 Introduction
57.2 Childbirth-Related Perineal Trauma
57.2.1 Types of Childbirth-Related Perineal Trauma
57.2.2 Prevalence of Perineal Trauma
57.2.3 Interventions and Risk of Perineal Trauma
57.2.3.1 Manual Perineal Protection (MPP)
57.2.3.2 Angle of episiotomy
57.2.3.3 The Use of Forceps in Operative Vaginal Delivery
57.3 Simulation and Perineal Trauma
57.3.1 Simulation in Healthcare
57.3.2 Perineal Simulators
57.3.3 Impact of Simulation Training on Perineal Trauma
57.4 Summary and Conclusion
References
58: Shoulder Dystocia and Simulation
58.1 Introduction
58.2 Simulation in Obstetrics
58.3 Communication and Teamwork
58.4 Simulation Training in Shoulder Dystocia
References
59: The Role of Episiotomy in Emergency Delivery
59.1 Introduction
59.2 Surgical Technique
59.3 Timing
59.4 Surgical Repair
59.4.1 Interrupted Cutaneous Suture Group
59.4.2 Continuous Suture Group
59.5 Indications
59.5.1 Non-reassuring Fetal Heart Rate
59.5.2 Operative Vaginal Delivery
59.5.3 Shoulder Dystocia
59.5.4 Macrosomia
59.5.5 Perineal Tears Prevention
59.6 Complications
59.7 Legal and Ethical Aspects
59.8 Conclusions
References
60: Obstetric Errors: Sepsis and Shoulder Dystocia as Examples of Heuristic Thinking in Obstetrics
60.1 Sepsis and Shoulder Dystocia
60.2 The Case of Shoulder Dystocia and How to Avoid Cognitive Errors
60.3 Conclusions
References
61: Importance of Simulation to Avoid Childbirth Trauma
61.1 Introduction
61.2 Modeling Birth Injuries in the Fetus
61.3 Birth Traumatic Injuries
61.3.1 Damages of the Tentorium Cerebelli and Falx
61.3.2 Subpial Hemorrhages
61.3.3 Hemorrhages in the Area of the Square Lobules of the Cerebellum
61.3.4 Signs of Brain Compression
61.3.5 Rupture of Bridging Veins
61.4 Classification of Birth Traumatic Injuries
61.5 Head Configuration (Molding) and Birth Traumatic Injury
61.6 Association of Pathological Configuration with Specific Brain Lesions
61.7 How Simulation Helps to Prevent the Birth of Traumatic Injuries?
61.8 Causes and Mechanisms of Birth Trauma During Childbirth, Obstetric Maneuvers, and Operations
61.8.1 Spontaneous Childbirth
61.8.1.1 Active (Intensive) Protection of the Perineum
61.8.1.2 Forcible Rotation of the Head in the Second Position (ROA)
61.8.2 Shoulder Dystocia
61.8.2.1 Extraction the Shoulders by Tightening the Fetus Head
61.8.2.2 Removing the Fetus by Grasping It and Pulling on the Chest Without Waiting for a Labor Pane
61.8.3 Breech Delivery
61.8.4 Cesarean Section
61.8.5 Vacuum Extraction Operation
61.8.6 Operation with Obstetric Forceps
61.8.7 Squeezing Out the Fetus. Kristeller Maneuver
61.9 Conclusion and Inferences
61.9.1 Inferences
References
Part XIII: Appendix
62: The Role of Images in Obstetric Teaching: Past, Present, and Future
62.1 Introduction
62.2 Ancient Greece
62.3 Roman Empire
62.4 Arabian Obstetrics
62.5 Medieval Obstetric History
62.6 Obstetrics in Renaissance
62.7 Obstetric of Seventeenth and Eighteenth Centuries
62.8 Obstetric of Nineteenth and Twentieth Century
62.9 Twentieth Century Obstetrics and the Development of Imaging
62.10 COVID-19 Pandemic
62.11 Obstetrics Images in Emergency Complications and Author’s Experience
62.12 Future Perspectives
References
63: Importance of Skill, Learning Curve, and Simulation in Endoscopy
References
64: Fibroids in Obstetric and Gynecology: Training and Skill in Myomectomy
64.1 Introduction
64.2 The Rationale for a Correct Myomectomy
64.3 The Pseudocapsule Biology
64.4 Myomectomy as Prostatectomy: Intriguing Parallelism Originating Intracapsular Technique
64.5 Laparoscopically/Robotically Assisted Intracapsular Myomectomy
64.6 Hysteroscopic Intracapsular Myomectomy
64.7 Vaginal Intracapsular Myomectomy
64.8 The Outcome of Intracapsular Myomectomy on Muscular Healing
64.9 How and How Much Myomas Might Affect Pregnancy and Childbirth
64.10 Causes of Symptomatic Fibroids During Pregnancy
64.11 Myoma-Related Obstetric Complications During Pregnancy
64.12 Myomectomy During Pregnancy
64.13 Myoma-Related Obstetric Complications Affecting Childbirth and Postpartum
64.14 Cesarean Myomectomy Rationale and Technique
References
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65: Rupture of the Uterus: A Dramatic Condition in a Genital Organ
References
66: Skills, Learning Curve and Simulation in an Italian University Clinic
66.1 Simulation
66.2 The “Martina Floridi” Obstetrical-Gynaecological Simulation Teaching Laboratory of the Degree Course in Midwifery at the University of Perugia
66.3 Simulation in Midwifery Degree Training
References
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