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Year : 2010  |  Volume : 23  |  Issue : 3  |  Page : 405

Simulation for Teaching Normal Delivery and Shoulder Dystocia to Midwives in Training

1 Simulation Centre, Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Porto, Portugal
2 Simulation Centre, Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Porto; INEB - Institute of Biomedical Engineering, Porto, Portugal
3 INEB - Institute of Biomedical Engineering, Porto, Portugal

Date of Submission26-Sep-2009
Date of Acceptance06-Oct-2010
Date of Web Publication30-Nov-2010

Correspondence Address:
A Reynolds
Faculdade de Medicina da Universidade do Porto, Departamento de Ginecologia e Obstetrícia. Al. Prof. Hernâni Monteiro, 4200-319 Porto
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Source of Support: None, Conflict of Interest: None

PMID: 21290360


Introduction and objective: The cognitive impact of using simulation sessions in midwifery training has not been the subject of previous research. The aim of this study was to compare the effect on students' knowledge of a simulation session versus an image-based lecture, for teaching routine management of normal delivery and resolution of shoulder dystocia to midwives in training.
Methods: Sixty students were enrolled three weeks after a "labour and delivery" class, and randomly assigned to two groups. Ten were subsequently excluded as they were not able to attend the whole session and/or did not complete the tests. In the simulation group (n=26), students were divided into pairs and attended a 30-minute hands-on session in the simulation centre. In the lecture group (n=24), students participated in a 30-minute image-based interactive lecture. A ten-question multiple-choice test was taken before (pre-test) and after (post-test) both sessions, to evaluate students' knowledge of labour and delivery and shoulder dystocia. Learner satisfaction was evaluated by adding a six question Likert scale questionnaire to the post-test. Independent t-test, paired samples t-test, and Mann-Whitney test were used for statistical analysis, setting significance at p<0.05.
Results: The simulation group showed a significantly higher mean post-test score (6.38 vs. 5.16; p=0.003) and a significantly greater inter-test score progression (p<0.0001). Overall learner satisfaction was also higher in this group (p=0.0001).
Conclusions: A significantly higher short-term reinforcement of knowledge and greater learner satisfaction was obtained using simulation sessions compared to image-based lectures when teaching routine management of normal delivery and resolution of shoulder dystocia to midwives in training.

Keywords: Labour and delivery, midwifery training, patient simulators, shoulder dystocia

How to cite this article:
Reynolds A, Ayres-de-Campos D, Pereira-Cavaleiro A, Ferreira-Bastos L. Simulation for Teaching Normal Delivery and Shoulder Dystocia to Midwives in Training. Educ Health 2010;23:405

How to cite this URL:
Reynolds A, Ayres-de-Campos D, Pereira-Cavaleiro A, Ferreira-Bastos L. Simulation for Teaching Normal Delivery and Shoulder Dystocia to Midwives in Training. Educ Health [serial online] 2010 [cited 2022 Jan 27];23:405. Available from:


The past 20 years have witnessed a tremendous growth in innovative options for nursing education and this area has developed a tradition of rapidly incorporating new educational technology1. However, many authorities feel that systematic research is necessary to determine the best practices currently available for learning and to compare the efficacy of new technology with existing approaches2,3. Furthermore, objective measures of performance are needed to validate these new educational tools4 and to assess their effect on clinical practice5.

The advantages of teaching through simulation have been emphasized by leading nursing institutions in Europe and the USA, not only to overcome emerging problems such as an increased demand for nurses, but also to diminish the gap between theory and practice1,6. Simulation-based learning is believed to accommodate diverse learning styles as well as different teaching methods7,8, and it could also allow for a better integration of theoretical concepts9. Acquisition, retention and recall of knowledge are the most important aspects for this learning process, and it is possible that hands-on training with simulators may promote and strengthen the construction of solid networks of memory10.

Management of normal delivery is a key part of midwifery training and practice, and shoulder dystocia is the emergency situation that midwives are most likely to be directly involved in. Adequate management of these two situations requires a solid cognitive basis as well as adequate technical, communication and teamwork skills, which should all be present before training begins with real patients. Simulation sessions are becoming increasingly widespread in midwifery training without any demonstration of their efficacy or comparison with existing approaches.

Research involving simulation-based learning in healthcare has increased over the last decade but remains scarce in midwifery training. Further, a recent systematic review noted that the vast majority of studies focus on the acquisition and training of procedural skills, while knowledge and non-technical skills are seldom evaluated11. A small number of papers have addressed the impact of simulation on cognitive skills in other healthcare areas but conclusions are difficult to generalise, as different teaching methodologies are applied and a lack of uniformity is found in assessment tools12-16. One study compared a self-study session versus a simulation session to teach management of labour and delivery to medical students (n=107)16, and another compared a traditional lecture versus a simulation session to teach hypertension pharmacotherapy to pharmacy students (n=95)13. Both reported significantly higher post-test scores in the simulation group. Another study compared a self-directed learning package with the same solution plus two scenario-based image workshops and with the same solution plus two simulator sessions on graduate nurses’ knowledge and skills (n=74), also reporting simulation to be the more effective educational tool15. A further study compared a traditional lecture followed by a self-directed simulation experience with a simulator session to teach a pediatric clinical situation to nurse practitioners (n=16), finding no differences in the assessment of knowledge12.

The aim of this study was to evaluate the cognitive impact on midwifery students of attending a simulation session versus an image-based lecture for management of normal delivery and resolution of shoulder dystocia.

Material and methods

All 60 students attending the first year of midwifery training at a state-owned university in Portugal over two consecutive academic years, 2005/2006 and 2006/2007, were approached, provided informed consent and asked to participate in the study. In Portugal the midwifery post-graduate course takes a minimum of two years to complete and includes classroom instruction, problem-based learning and 1204 hours of ward training. All students had a previous nursing degree and at least two years of professional experience, only two were male, and none reported previous labour ward experience or prior contact with obstetrical simulation.

Three weeks after a two-hour class on “labour & delivery” theory, students were randomly assigned to two groups using computer-generated random numbers. In the simulation group (n=29), students were divided into pairs and attended a 30-minute simulator-based session using the S560 NoelleTM simulator (Gaumard® Scientific, Miami, USA). This is a full-body mannequin incorporating a computer-controlled mechanical apparatus for fetal descent. In the lecture group (n=31) students participated in a 30-minute image-based interactive lecture.

The main objectives of the simulation and lecture sessions were to reinforce students’ understanding of the labour process, to review the management of uneventful cephalic vaginal deliveries, and to cover the resolution of shoulder dystocia. In the simulator session, students began by performing a vaginal examination. Then they were asked to assist a cephalic vaginal delivery and, finally, the session ended with a shoulder dystocia resolution scenario. The lecture session consisted of a 24-image slideshow presentation illustrating the same concepts that were delivered during the simulation-based session. In both sessions, time was given for questions. As both sessions were occurring at the same time, two different instructors with similar teaching experiences were involved in both academic years.

The impact of these sessions on students’ knowledge was assessed using multiple choice questionnaire (MCQ) tests, administered just before (pre-test) and immediately after the sessions (post-test). A pool of 20 questions was previously prepared and randomly distributed to the two tests so that each consisted of ten questions with five possible answers of which only one was correct. The tests evaluated students’ comprehension of the concepts surrounding labour and delivery, (e.g. definition of head engagement) and facts surrounding shoulder dystocia, (e.g. criteria for establishing the diagnosis of shoulder dystocia). It did not evaluate aspects that were only related to hands-on experience. The content of the simulation and image lectures was developed by a health educator (DAC) who did not participate in the sessions, and who also prepared the test questions.

Students’ perception of the learning experience and feelings towards the prospect of facing real situations were evaluated by a five-point Likert scale questionnaire administered with the post-test.

The students assigned to the lecture group attended a compensatory simulation session one week after the image-based lecture. After this session, they were asked to rate an additional question using the five-point Likert scale: “I considered the simulation session to be a more useful learning tool”.

The research was approved by the institution’s Ethics Committee.

Statistical analysis

The Statistical Package for Social Sciences (SPSS version 13.0) and Matlab® v7.0 programmes were used to perform the following statistical tests: paired samples t-test, independent t-test, and Mann-Whitney test. Significance was set at p<0.05. As the Kolmogorov-Smirnoff test revealed a normal distribution of learners’ grades, parametric tests were applied. Paired t-test was used to analyze the pre-post change in test grades in each group, and the independent t-test was used to compare grades and their change between groups. A hypothesis test using the Mann-Whitney test was used to compare learners’ perceptions and feelings in both groups.


From the total of 60 enrolled students, ten were excluded after randomization because they were not able to attend the whole session and/or did not complete one of the tests. Three of these were from the simulation group and seven from the lecture group (Figure 1). Thus, results pertain to the remaining 50 students, 26 from the simulation arm (14 in the first year and 12 in the second year) and 24 from the lecture arm (12 in each year). An additional student from the simulation group, failed to complete the satisfaction questionnaire.

Figure 1:  Study flow chart.

Pre-test and post-test average scores are listed in Table 1, together with inter-group and intra-group statistical comparisons. Pre-test scores were similar in both groups, but post-test scores were significantly higher in the simulation group, as was the change in test scores.

Table 1:  Average test scores* evaluating students’ knowledge in the two study groups. Inter-group** and intra-group*** statistical analysis of differences (p). SD= standard deviation

Students’ satisfaction was globally positive in both groups, as more than 91% of students reported a Likert score of 4 or 5 in each of the first four questions related to students’ perception of the learning experience, and more than 70% of students reported a Likert score of 4 or 5 in each of the last two questions that evaluated their feelings towards the prospect of facing real situations (Table 2). However, satisfaction was significantly higher in the simulation arm, with an average Likert score of 4.28 versus 4.04 in the lecture group (p=0.0001). This occurred mainly because of a significantly higher satisfaction in questions 1 through 4, (average rating of 4.53 versus 4.25; p<0.0001); no difference between groups was found for questions 5 and 6 (average rating of 3.78 versus 3.63, p=0.5251). Moreover, students in the simulation group expressed a higher feeling of having learnt something new (question 2, p=0.02), and that their perception of labour and delivery mechanisms had improved (question 3, p=0.008).

Table 2:  Likert-scale* averages for students of the simulation and lecture groups of perceptions of their learning experiences and feelings towards the prospect of facing real situations


In this study, a simulator-based education session focusing on management of delivery and shoulder dystocia yielded significantly higher short-term knowledge scores and greater satisfaction among learners than an image-based interactive lecture session. It is possible that the efforts needed to apply skills or procedures with the simulator promote a deeper integration of the underlying concepts and strengthen the construction of the networks of memory necessary for retention and recall of knowledge10 .

Participants in this study had a similar professional background, and none had previous labour ward experience or prior contact with obstetric simulators. Randomisation also helped assure a similar distribution between the groups. Nevertheless, it cannot be ruled out that results were influenced by other unmeasured differences in group characteristics or by post-randomization exclusions.

Relatively short MCQ tests were used to assess student’s knowledge to help assure high student participation. They proved sufficiently discriminative to document differences between pre- and post-test scores, as well as between the two study groups. Other studies have used written examination tests13, MCQ tests16, instructor-developed knowledge assessment tools12 and patient evaluation using checklists15.

Image-based lectures were chosen for the control group because they can also be made to focus on practical aspects of learning and allow for a similar type of interactivity. Both image-based lectures and simulators differ from traditional classes in their capacity to gain attention of adult post-graduate students. Even though image-based lectures were at maximum attended by 12 students, it is possible that the observed differences in outcomes were, at least in part, due to the small-group teaching component of the simulation session.

Higher satisfaction in groups attending simulation sessions has been reported by others16-19, but the finding that the groups did not differ in their feelings towards facing real clinical situations in the future is new, to our knowledge. This could have been due to the study’s limited sample size, but it is also possible that a 30-minute hands-on session is insufficient to change students’ self-confidence in this area of practice.

Our findings support the introduction of delivery simulator sessions into the nursing midwifery curriculum, suggesting that they achieve a greater retention of knowledge and higher student satisfaction than image-based lectures. This finding is particularly relevant in this context, as management of normal delivery and shoulder dystocia are key competences for the training midwife and these effects, to our knowledge, have not been shown before.

Acquisition of delivery simulators represents an important investment for midwifery schools. The requirement for small groups necessitates greater overall instructor time, another cost of simulators in training. These aspects need to be considered carefully when introducing simulator-based sessions into learning curricula, as an increase in costs is likely.

Further research is needed to ascertain the impact of delivery simulator sessions on other key aspects of management of normal delivery and shoulder dystocia, such as their effect on technical skills and attitudes. Transferability of these competences to real-life situations also needs to be evaluated in the future.


The authors would like to thank the students who participated in this study, Dr. Monica Cruz Pires for her collaboration as lecturer, and Prof. João Bernardes for his assistance in reviewing the manuscript.


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