This OSCE station was designed to:

Test the student’s knowledge of normal labor and delivery

Test their ability to identify a common labor abnormality

Determine their ability to order appropriate obstetric interventions to resolve the labor abnormality.

The student is provided the following information prior to this 15 minute encounter:

Marie Manikin is a 24 year old primigravida at 39 4/7 weeks gestational age. She arrived in L&D today at 0300 with SROM and contractions. On admission, her cervix was 3 cm/50%/-1.

She was rechecked at 0700 and found to be 5/C/0 station. She received an epidural at that time. It is now 1100 and she is asking for a redose of her epidural.

Go in and introduce yourself to Marie, review her intrapartum records, examine her, and write a progress note, documenting your findings and recommendations, if any.

No faculty will be present for this evaluation, and the manikin will not speak. But your interaction is being video recorded for later review.

The manikin is silent, but the vital signs monitor shows:  P=92, RR=20, BP=110/70, T=102.6

EFM tracing shows fetal tachycardia (170 BPM), moderate variability, no accelerations, no decelerations, and contractions every 7 minutes.

Hospital records are available for review that include the initial history and physical, and a followup exam note.

Expectations:

• Students will introduce themselves, wash their hands, and perform an examination of her abdomen and pelvis
• Students will quickly review the patient’s intrapartum records
• Students will specifically note
  • Maternal temperature of 102.6
  • EFM (which had been normal, Cat 1) now shows fetal tachycardia and contractions every 7-10 minutes (Cat 2)
  • Cervix is unchanged (5 cm dilated, completely effaced)
• Students will recognize an arrest of labor
• Students will recognize chorioamnionitis
• Students will recognize the need for pitocin
• Students will recognize the need for antibiotics
• Students will recognize the need for tylenol
• Students will recognize the need for close followup to insure progress toward delivery is being made.

Students will be able to write a competent labor progress note.

Student-3-Evaluate a patient in labor

Faculty-3-Evaluate a patient in labor

Marie Manikin Intrapartum Notes

Results

I thought this was going to be a terrific module, but I was wrong. After talking at length with the students during their debriefing, and evaluating their responses, I determined a number of problems:

1. Not enough time. 15 minutes was way too short for students trying to evaluate a silent manikin, read the chart, evaluate the EFM, Notice the vital signs, reach a diagnosis of arrest of labor plus chorioamnionitis, and write down a plan.
2. Too Complex. Having them deal with either chorio or fever with tachycardia, or arrest of labor would have been OK. But giving them three overlapping problems in a test situation was too much.
3. Too Advanced. This station would be a good test for R2 or R3’s, but not M3’s. Our students just didn’t have enough L&D experience with complicated patients to be able to quickly reach the right diagnosis, know the treatments, and write them down.
4. Having them scan the paper chart slowed them down, and provided no more information than they were already given. Having the chart added a sense of realism, but wasn’t necessary for testing purposes.
5. Test results hinged on their charting of a progress note, and they are not well trained in this. In our institution, the progress notes are primarily written by residents and sometimes M4s. The M3 students get little opportunity to document their findings, so their progress note writing skills were relatively undeveloped.
6. An unattended manikin was not the right approach with this case.  Because there were no faculty involved either in the room or remotely through video, the students had no one to help them out as they struggled through this overly ambitious case.

Conclusions

While this module might be OK for an R2 or R3, I wouldn’t use it unchanged for M3s.