Climbing together towards safety: simulation in the delivery room of a hospital at the foot of the Alps

Just like a rope team tackling a climb, step by step, training in the delivery room is also built on synergy, trust, expertise, and shared training. In a mountain setting where case studies are limited, simulation is a safety net for dealing with obstetric and neonatal emergencies.

In the mountains, you take small steps…

In the heart of Carnia, in Tolmezzo, a small mountain hospital in Friuli Venezia Giulia, emergency management in the delivery room faces a double challenge: demographic decline and reduced clinical exposure due to the depopulation of mountain areas. In this context, promoting a culture of safety and implementing effective tools to improve operational readiness becomes a strategic necessity.In situ simulation of obstetric and neonatal scenarios has proven to be a fundamental tool for maintaining a high level of preparedness among the multidisciplinary team involved in childbirth. Starting in 2020, the team at Tolmezzo Hospital embarked on a structured simulated training program with the aim of addressing perinatal emergencies in a protected but as realistic an environment as possible.

Paul® and MamaAnne®: simulation for a safer life start

The first steps… towards building a shared project

Some mountain trails require a good guide, a master who has already mapped out the route to be taken and the obstacles to be overcome. Our guide was Dr. Loris D’Orlando (head of anesthesia and medical director of our facility) and, thanks to his encouragement and the donation of a task trainer (Mamanatalie^®, Laerdal), we took our first steps into the world of simulation in 2020.

The goal was ambitious: to involve gynecologists, midwives, anesthetists, neonatologists, nurses, and healthcare assistants in complex simulations that integrated all the professional roles present in the delivery room.

The group designated to design the simulation course includes at least two professionals from each area of maternal and child health; each tutor has been trained at the SIMNOVA Center, completing a course for simulation facilitators.

For each simulation, the team of participants consists of at least one gynecologist, one midwife, one pediatrician, one pediatric nurse, one anesthetist, one intensive care nurse/operating room nurse, and one healthcare assistant (OSS).

There were many doubts at the beginning… Are seven participants too many? Is the simulation too long if it starts with a C-section and ends with the newborn? We chose to recreate a scenario that reflected reality as closely as possible, moving away from the classic simulations with mannequins and two to four participants at a time, which we were used to.

Since 2020, we have been conducting simulations once a month: the four-hour sessions currently include one exercise divided into groups and two simulation scenarios with a simulated patient, which take place in the labor/delivery ward and neonatal unit (in situ), followed by structured debriefings. Over time, as we have grown in our ability to ‘manage’ the simulations, we have added technical issues to the soft skills objectives. In the neonatal field, we have been able to increase the level of difficulty of the scenarios thanks to the recent donation of a more sophisticated neonatal simulator (Newborn Anne®, Laerdal).

A constantly evolving format

Over time, the format has been redesigned to make the experience increasingly immersive and effective:

Theory

The theoretical introduction aims to share the priorities and critical issues that each team faces in managing these situations. However, we have gradually remodeled the format: from face-to-face theoretical lessons, we have moved to teaching materials (PDF texts, videos, recorded PowerPoint presentations) uploaded to a shared platform that each participant is invited to access before the simulated experience.

Soft skills

We immediately focused our attention on soft skills with the aim of increasing awareness of team dynamics, particularly improving communication. In particular, an active methodology was adopted that involves operators reflecting personally on the principles of Crisis Resource Management: operators take turns commenting on a point they consider fundamental with personal experiences. We have built on our experience in Novara on the use of LEGO bricks for debriefer training and applied it to encourage operators to reflect on non-technical skills, removing the clinical component and easing the tension caused by classic ‘performance anxiety’.

The scenarios

We chose to contextualize the simulation scenarios in a hypothetical holiday or night shift to assess the effectiveness of the procedures and protocols at the most critical moments, when resources are limited and it becomes even more important that each operator, with their specific skills, knows the priorities and difficulties of each member of the team intervening in the delivery room.

We used a hybrid simulation method combining a simulated patient with task trainers. We discovered that what we initially considered a lack of resources turned out to be an asset, because the simulated patient creates very realistic tension and highlights critical issues such as transport from the delivery room to the operating room and communication with the patient.

We simulated two situations: (a) urgent/emergency cesarean section (CS) and care for the newborn in the first minutes of life; (b) postpartum hemorrhage (PPH).

Over time, the complexity of the scenarios increased, in parallel with the team’s experience and the adoption of new simulators, such as the most recent Newborn Anne^®.

Final considerations: still climbing together, step by step

The outcome is positive: the simulations have improved operational effectiveness and strengthened cohesion among professionals. The critical issues that emerged, such as the lack of codified language or the heterogeneity of protocols, are now addressed in a protected and collaborative environment.

In a mountain setting where ‘networking’ is not a metaphor but a necessity, continuous simulation is the anchor point for ensuring safety and quality in the most critical moments of birth. Just like in a rope team, we move forward together, one step at a time.