Skip to main content Accessibility help
Hostname: page-component-568f69f84b-jtg5s Total loading time: 0.434 Render date: 2021-09-22T18:29:49.607Z Has data issue: true Feature Flags: { "shouldUseShareProductTool": true, "shouldUseHypothesis": true, "isUnsiloEnabled": true, "metricsAbstractViews": false, "figures": true, "newCiteModal": false, "newCitedByModal": true, "newEcommerce": true, "newUsageEvents": true }


Published online by Cambridge University Press:  21 December 2010

Department of Women's Health, Southmead Hospital, Bristol BS10 5NB.
Research into Safety and Quality (RiSQ) Group, School of Clinical Sciences, University of Bristol, Bristol.
Research into Safety and Quality (RiSQ) Group, School of Clinical Sciences, University of Bristol, Bristol.
Research into Safety and Quality (RiSQ) Group, School of Clinical Sciences, University of Bristol, Bristol.
Tim Draycott, Research into Safety and Quality (RiSQ) Group, School of Clinical Sciences, University of Bristol, Bristol, BS10 5NB. Email address:


The World Health Organisation (WHO) has estimated that 1500 women die every day from preventable complications of pregnancy and childbirth. While barriers to accessing healthcare are undoubtedly multi-factorial, studies have repeatedly shown that providing skilled healthcare workers can result in untold benefits for women and babies in developing countries. The phenomenon of preventable maternal and fetal morbidity and mortality is not limited to the developing world. The Confidential Enquiries into Maternal Deaths (CEMD) and Stillbirths and Infant Deaths (CESDI) in the UK have repeatedly identified substandard care as a major contributor to maternal and neonatal mortality. In 2008 The King's Fund published Safe Births: Everybody's business, an independent enquiry into the safety of maternity services in England. This recommended that simulation-based training to assess clinical, communication and team skills should be available to all maternity staff, and that training should form a core activity. Many hospitals in the UK have been running in-house courses for staff for over a decade with measurable improvements in neonatal outcomes. The value of these training schemes is recognised and rewarded through reduced insurance premiums for participating hospital trusts as part of clinical negligence schemes. Gaining competence in managing obstetric emergencies presents particular challenges for trainees. Most emergencies are, thankfully, uncommon but some constitute life-threatening events where management naturally falls to the most experienced available clinician. The skills required are often particular to emergencies and therefore novel to trainees. Utilising emergencies as training opportunities is further complicated by the presence of a conscious patient.

Research Article
Copyright © Cambridge University Press 2010

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)


1 Fauveau, V, Stewart, K, Khan, SA, Chakraborty, J. Effect on mortality of community-based maternity-care programme in rural Bangladesh. Lancet 1991; 338: 1183–186.CrossRefGoogle ScholarPubMed
2 Brennan, M. Training traditional birth attendants reduces maternal mortality and morbidity. Trop J Obstet Gynaecol 1988; 1: 4447.Google ScholarPubMed
3 Lewis, G. (ed). The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer – 2003–2005. The Seventh Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. London: CEMACH; 2007; 16.Google Scholar
4 Hope, P, Breslin, S, Lamont, L, Lucas, A, Martin, D, Moore, I et al. Fatal shoulder dystocia: a review of 56 cases reported to the Confidential Enquiry into Stillbirths and Deaths in Infancy. Br J Obstet Gynaecol 1998; 105: 1256–261.CrossRefGoogle ScholarPubMed
5 King's, Fund. Safe Births: Everybody's Business. An independent enquiry into the safety of maternity services in England. London: King's Fund; 2008; 93.Google Scholar
6 Draycott, TJ, Crofts, JF, Ash, JP, Wilson, LV, Yard, E, Sibanda, T et al. Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol 2008; 112: 1420.CrossRefGoogle ScholarPubMed
7 Draycott, T, Sibanda, T, Owen, L, Akande, V, Winter, C, Reading, S et al. Does training in obstetric emergencies improve neonatal outcome? BJOG 2006; 113: 177–82.CrossRefGoogle ScholarPubMed
8 Siassakos, D, Hasafa, Z, Sibanda, T, Fox, R, Donald, F, Winter, C et al. Retrospective cohort study of diagnosis-delivery interval with umbilical cord prolapse: the effect of team training. BJOG 2009; 116: 10891096.CrossRefGoogle ScholarPubMed
9 NHS Litigation Authority. Clinical Negligence Scheme for Trusts: Maternity Standards. 2009.Google Scholar
10 Ellis, D, Crofts, JF, Hunt, LP, Read, M, Fox, R, James, M. Hospital, Simulation Center, and Teamwork Training for Eclampsia Management: A Randomized Controlled Trial. Obstet Gynecol 2008; 111: 723–31.CrossRefGoogle Scholar
11 Siassakos, D, Timmons, C, Hogg, F, Epee, M, Marshall, L, Draycott, T. Evaluation of a strategy to improve undergraduate experience in obstetrics and gynaecology. Med Educ 2009; 43: 669–73.CrossRefGoogle ScholarPubMed
12 Kirkpatrick, D. The Four Levels: An overview in evaluating training programs: The Four Levels. 3rd edition. San Francisco, California. Berrett-Koehler, 2006, 29.Google Scholar
13 Maslovitz, S, Barkai, G, Lessing, JB, Ziv, A, Many, A. Recurrent obstetric management mistakes identified by simulation. Obstet Gynecol 2007; 109: 12951300.CrossRefGoogle ScholarPubMed
14 Siassakos, D, Draycott, T, Crofts, J, Hunt, L, Winter, C, Fox, R. More to teamwork than knowledge, skills and attitude. BJOG 2010; In Press (DOI: 10.1111/j.1471–0528.2010.02654.x.).CrossRefGoogle ScholarPubMed
15 Crofts, JF, Bartlett, C, Ellis, D, Hunt, LP, Fox, R, Draycott, TJ. Training for Shoulder Dystocia: A Trial of Simulation Using Low-Fidelity and High-Fidelity Mannequins. Obstet Gynecol 2006; 108: 1477–485.CrossRefGoogle Scholar
16 Black, RS, Brocklehurst, P. A systematic review of training in acute obstetric emergencies. BJOG 2003; 110: 837–41.CrossRefGoogle ScholarPubMed
17 Johannsson, H, Ayida, G, Sadler, C. Faking it? Simulation in the training of obstetricians and gynaecologists. Curr Opin Obstet Gynecol 2005; 17: 557–61.CrossRefGoogle Scholar
18 Taylor, HA, Kiser, WR. Reported comfort with obstetrical emergencies before and after participation in the advanced life support in obstetrics course. Fam Med 1998; 30: 103107.Google ScholarPubMed
19 Flora, RF, Rich, M, Siegfried, J, Fanning, J. The ALSO Course for Use in Patient Safety and as a Competency-Based Orientation for Interns. Obstet Gynecol 2006; 107 (4 Suppl): 77S78S.CrossRefGoogle Scholar
20 Jha, V KS, Duffy, S. Simulated Delivery Suite (SoDeS) Management Course: An Innovative Method for Future Training in Obstetrics. IETI 2003; 40: 379–85.Google Scholar
21 Siassakos, D, Crofts, JF, Winter, C, Weiner, CP, Draycott, TJ. The active components of effective training in obstetric emergencies. BJOG 2009; 116: 10281032.CrossRefGoogle ScholarPubMed
22 Gardner, R, Raemer, DB. Simulation in obstetrics and gynecology. Obstet Gynecol Clin North Am 2008; 35: 97127.CrossRefGoogle Scholar
23 Gelbart, N. The king's midwife: a history and mystery of Madame du Coudray. Berkeley and London: University of California Press; 1998.Google Scholar
24 Beaubien, JM, Baker, DP. The use of simulation for training teamwork skills in health care: how low can you go? Qual Saf Health Care 2004; 13: I51–I56.CrossRefGoogle Scholar
25 Draycott, T, Fox, R, Montague, I. Royal College of Obstetricians and Gynaecologists. Shoulder Dystocia. Clinical Guideline No.42. London: RCOG Press; 2005.Google Scholar
26 National Health Service Litigation Authority: Summary of substandard care in cases of brachial plexus injury. NHSLA Journal 2003; 2: suppl: ixxi.Google Scholar
27 Allen, RH, Bankoski, BR, Butzin, CA, Nagey, DA. Comparing clinician-applied loads for routine, difficult, and shoulder dystocia deliveries. Am J Obstet Gynecol 1994; 171: 1621–627.CrossRefGoogle ScholarPubMed
28 Sorensen, JL, Lokkegaard, E, Johansen, M, Ringsted, C, Kreiner, S, McAleer, S. The implementation and evaluation of a mandatory multi-professional obstetric skills training program. Acta Obstet Gynecol Scand 2009; 88: 1107–117.CrossRefGoogle Scholar
29 Crofts, JF, Ellis, D, Draycott, TJ, Winter, C, Hunt, LP, Akande, VA. Change in knowledge of midwives and obstetricians following obstetric emergency training: a randomised controlled trial of local hospital, simulation centre and teamwork training. BJOG 2007; 114: 15341541.CrossRefGoogle ScholarPubMed
30 Daniels, K, Arafeh, J, Clark, A, Waller, S, Druzin, M, Chueh, J. Prospective randomized trial of simulation versus didactic teaching for obstetrical emergencies. Simul Health 2010; 5: 4045.CrossRefGoogle ScholarPubMed
31 Crofts, JF, Bartlett, C, Ellis, D, Hunt, LP, Fox, R, Draycott, TJ. Management of shoulder dystocia: skill retention 6 and 12 months after training. Obstet Gynecol 2007; 110: 10691074.CrossRefGoogle ScholarPubMed
32 Deering, S, Poggi, S, Macedonia, C, Gherman, R, Satin, AJ. Improving resident competency in the management of shoulder dystocia with simulation training. Obstet Gynecol 2004; 103: 1224–228.CrossRefGoogle ScholarPubMed
33 Crofts, JF, Attilakos, G, Read, M, Sibanda, T, Draycott, TJ. Shoulder dystocia training using a new birth training mannequin. BJOG 2005; 112: 997–99.CrossRefGoogle ScholarPubMed
34 MacKenzie, IZ, Shah, M, Lean, K, Dutton, S, Newdick, H, Tucker, DE. Management of shoulder dystocia: trends in incidence and maternal and neonatal morbidity. Obstet Gynecol 2007; 110: 10591068.CrossRefGoogle ScholarPubMed
35 Crofts, J. Obstetric Simulation: What Works, Where. In: 1st European Conference on Simulation in Women's Health; 2010; London: RCOG.Google Scholar
36 Deganus, SA. SYMPTEK homemade foam models for client education and emergency obstetric care skills training in low-resource settings. J Obstet Gynaecol Can 2009; 31: 930–35.CrossRefGoogle ScholarPubMed
37 Kim, EJ, Theprungsirikul, P, McDonald, MK, Gurewitsch, ED, Allen, RH. A biofidelic birthing simulator. Models for research and training in complicated human births. IEEE Eng Med Biol Mag 2005; 24: 3439.CrossRefGoogle ScholarPubMed
38 Ronsmans, C, Graham, WJ. Maternal mortality: who, when, where, and why. Lancet 2006; 368: 11891200.CrossRefGoogle Scholar
39 AbouZahr, C. Global burden of maternal death and disability. British Med Bull 2003; 67: 111.CrossRefGoogle Scholar
40 Waterstone, M, Bewley, S, Wolfe, C. Incidence and predictors of severe obstetric morbidity: case-control study. Br Med J 2001; 322: 10891093.CrossRefGoogle Scholar
41 Buckland, SS, Homer, CS. Estimating blood loss after birth: using simulated clinical examples. Women Birth 2007; 20: 8588.CrossRefGoogle Scholar
42 Karavolos, S, Al-Habib, A, Madgwick, K, Fakokunde, A, Okolo, S, Yoong, W. Correspondence. BJOG 2006; 114: 117–8.CrossRefGoogle Scholar
43 Bose, P, Regan, F, Paterson-Brown, S. Improving the accuracy of estimated blood loss at obstetric haemorrhage using clinical reconstructions. BJOG 2006; 113: 919–24.CrossRefGoogle ScholarPubMed
44 Daniels, K, Parness, AJ. Development and use of mechanical devices for simulation of seizure and hemorrhage in obstetrical team training. Simul Health 2008; 3: 4246.CrossRefGoogle Scholar
45 Cardew, S, Siassakos, D, Appleyard, T, Fudge, N, Draycott, T. Improving the accuracy of blood loss estimation at antepartum haemorrhage using a semi-quantitative, pictorial, visual assessment tool. Int J Gynecol Obstet 2009; 107 (Supplement 2): S415.CrossRefGoogle Scholar
46 Rizvi, F, Mackey, R, Barrett, T, McKenna, P, Geary, M. Successful reduction of massive postpartum haemorrhage by use of guidelines and staff education. BJOG 2004; 111: 495–98.CrossRefGoogle Scholar
47 Whittle, R, Quenby, S, Scholefield, H. Does training in obstetric emergencies improve outcomes for women with postpartum haemorrhage? Abstracts presented at the Blair Bell Research Society meeting. Derby, 28–29 June 2007, BJOG 2007; 115: 125.Google Scholar
48 Thompson, S, Neal, S, Clark, V. Clinical risk management in obstetrics: eclampsia drills. Br Med J (Clinical Research Ed) 2004; 328: 269–71.CrossRefGoogle Scholar
49 Crofts, JF, Bartlett, C, Ellis, D, Winter, C, Donald, F, Hunt, LP et al. Patient-actor perception of care: a comparison of obstetric emergency training using manikins and patient-actors. Qual Saf Health Care 2008; 17: 2024.CrossRefGoogle ScholarPubMed
50 Murphy, DJ, MacKenzie, IZ. The mortality and morbidity associated with umbilical cord prolapse. Br J Obstet Gynecol 1995; 102: 826–30.CrossRefGoogle ScholarPubMed
51 Johanson, RB, Menon, V, Burns, E, Kargramanya, E, Osipov, V, Israelyan, M et al. Managing Obstetric Emergencies and Trauma (MOET) structured skills training in Armenia, utilising models and reality based scenarios. BMC Medical Education 2002; 2: 5.CrossRefGoogle ScholarPubMed
52 Siassakos, D, Hasafa, Z, Sibanda, T, Crofts, J, Winter, C, Draycott, T. Cord prolapse simulation training to improve outcome. 9th Annual International Meeting on Simulation in Healthcare. Simul Health 2009; 4: 5960.Google Scholar
53 Hannah, ME, Hannah, WJ, Hewson, SA, Hodnett, ED, Saigal, S, Willan, AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet 2000; 356: 1375–383.CrossRefGoogle ScholarPubMed
54 Sharma, JB, Newman, MR, Boutchier, JE, Williams, A. National audit on the practice and training in breech deliveries in the United Kingdom. Int J Gynaecol Obstet. 1997; 59: 103108.CrossRefGoogle Scholar
55 Lavin, JP Jr., Eaton J, Hopkins M. Teaching vaginal breech delivery and external cephalic version. A survey of faculty attitudes. J Reprod Med 2000; 45: 808812.Google ScholarPubMed
56 Silvert, M. Doctors need more training in delivering breech babies. Br Med J 2000; 320: 1689.Google ScholarPubMed
57 Royal College of Obstetricians and Gynaecologists. The Management of Breech Presentation. Guideline No.20b. London: RCOG Press; 2006.Google Scholar
58 Deering, S, Brown, J, Hodor, J, Satin, AJ. Simulation training and resident performance of singleton vaginal breech delivery. Obstet Gynecol 2006; 107: 8689.CrossRefGoogle ScholarPubMed
59 Draycott, T, Winter, C, Crofts, J, Barnfield, S. Practical Obstetric Multi-Professional Training (PROMPT) Trainer's Manual, London: RCOG Press, 2008.Google Scholar
60 Patel, RR, Murphy, DJ. Forceps delivery in modern obstetric practice. Br Med J 2004; 328: 1302–305.CrossRefGoogle ScholarPubMed
61 UNICEF, WHO, UNFPA. Guidelines for monitoring the availability and use of obstetric services. New York: United Nations Children's Fund; 1997.Google ScholarPubMed
62 Cheong, YC, Abdullahi, H, Lashen, H, Fairlie, FM. Can formal education and training improve the outcome of instrumental delivery? Eur J Obstet Gynecol Reprod Biol 2004; 113: 139–44.CrossRefGoogle ScholarPubMed
63 Sau, A, Sau, M, Ahmed, H, Brown, R. Vacuum extraction: is there any need to improve the current training in the UK? Acta Obstet Gynecol Scand 2004; 83: 466–70.CrossRefGoogle ScholarPubMed
64 Leslie, KK, Dipasquale-Lehnerz, P, Smith, M. Obstetric forceps training using visual feedback and the isometric strength testing unit. Obstet Gynecol 2005; 105: 377–82.CrossRefGoogle ScholarPubMed
65 Dupuis, O, Moreau, R, Silveira, R, Pham, MT, Zentner, A, Cucherat, M et al. A new obstetric forceps for the training of junior doctors: a comparison of the spatial dispersion of forceps blade trajectories between junior and senior obstetricians. Am J Obstet Gynecol 2006; 194: 1524–531.CrossRefGoogle ScholarPubMed
66 Moreau, R, Jardin, A, Pham, MT, Redarce, T, Olaby, O, Dupuis, O. A new kind of training for obstetric residents: simulator training. Conf Proc IEEE Eng Med Biol Soc 2006; 1: 4416–419.Google ScholarPubMed
67 Sielhorst, T, Obst, T, Burgkart, R, Riener, R, Navab, N. An augmented reality delivery simulator for medical training. Presented at Augmented Environments for Medical Imaging Workshop AMI-ARCS 2004; Sept 30th, Rennes, 2004. Scholar
68 Lapeer, RJ. A mechanical contact model for the simulation of obstetric forceps delivery in a virtual/augmented environment. Stud Health Technol Inform 2005; 111: 284–89.Google Scholar
69 Hickson, GB, Clayton, EW, Entman, SS, Miller, CS, Githens, PB, Whettengoldstein, K et al. Obstetricians prior malpractice experience and patients satisfaction with care. JAMA 1994; 272: 1583–587.CrossRefGoogle ScholarPubMed
70 White, AA, Pichert, JW, Bledsoe, SH, Irwin, C, Entman, SS. Cause and effect analysis of closed claims in obstetrics and gynecology. Obstet Gynecol 2005; 105: 10311038.CrossRefGoogle Scholar
71 Siassakos, D, Clark, J, Sibanda, T, Attilakos, G, Jefferys, A, Cullen, L et al. A prospective study of maternal satisfaction with operative birth: seniority matters? Int J Gynecol Obstet 2009; 107 (Supplement 2): S339.Google Scholar
72 Siassakos, D, Draycott, T, O'Brien, K, Kenyon, C, Bartlett, C, Fox, R. Exploratory randomized controlled trial of hybrid obstetric simulation training for undergraduate students. Simul Healthc 2010; Publish Ahead of Print: 10.1097/SIH.1090b1013e3181d1093ee1090b.CrossRefGoogle ScholarPubMed
73 Barnfield, S, Brooks, A, Bisson, D, Akande, A, Draycott, T. Mannequins can be used to assess competencies for ventouse deliveries. Simul Health 2007; 2: 209.Google Scholar
74 Burr, R, Johanson, R, Wyatt, J, Watt, I, Jones, P. A randomised trial of an intervention package designed to promote external cephalic version at term. Eur J Obstet Gynecol Reprod Biol 2001; 100: 3640.CrossRefGoogle ScholarPubMed
75 Palomaki, O, Luukkaala, T, Luoto, R, Tuimala, R. Intrapartum cardiotocography – the dilemma of interpretational variation. J Perinat Med 2006; 34: 298302.CrossRefGoogle ScholarPubMed
76 Blix, E, Oian, P. Interobserver agreements in assessing 549 labor admission tests after a standardized training program. Acta Obstet Gynecol Scand 2005; 84: 10871092.Google Scholar
77 Berglund, S, Pettersson, H, Cnattingius, S, Grunewald, C. How often is a low Apgar score the result of substandard care during labour? BJOG 2010; 117: 968–78.CrossRefGoogle ScholarPubMed
78 Sibanda, T, Sibanda, N, Siassakos, D, Sivananthan, S, Robinson, Z, Winter, C et al. Prospective evaluation of a continuous monitoring and quality-improvement system for reducing adverse neonatal outcomes. Am J Obstet Gynecol 2009; 201: 480. e481486.CrossRefGoogle ScholarPubMed
79 Collins, DE. Multidisciplinary teamwork approach in labor and delivery and electronic fetal monitoring education: a medical-legal perspective. J Perinat Neonatal Nurs 2008; 22: 125–32.CrossRefGoogle ScholarPubMed
80 Murphy, AA, Halamek, LP, Lyell, DJ, Druzin, ML. Training and competency assessment in electronic fetal monitoring: a national survey. Obstet Gynecol 2003; 101: 1243–248.Google ScholarPubMed
81 Keith, RD, Beckley, S, Garibaldi, JM, Westgate, JA, Ifeachor, EC, Greene, KR. A multicentre comparative study of 17 experts and an intelligent computer system for managing labour using the cardiotocogram. Br J Obstet Gynaecol 1995; 102: 688700.CrossRefGoogle ScholarPubMed
82 MacDonald, D, Grant, A, Sheridan-Pereira, M, Boylan, P, Chalmers, I. The Dublin randomized controlled trial of intrapartum fetal heart rate monitoring. Am J Obstet Gynecol 1985; 152: 524–39.CrossRefGoogle ScholarPubMed
83 Tuffnell, D, Haw, WL, Wilkinson, K. How long does a fetal scalp blood sample take? BJOG 2006; 113: 332–34.CrossRefGoogle ScholarPubMed
84 Westgren, M, Kruger, K, Ek, S, Grunevald, C, Kublickas, M, Naka, K et al. Lactate compared with pH analysis at fetal scalp blood sampling: a prospective randomised study. Br J Obstet Gynaecol 1998; 105: 2933.CrossRefGoogle Scholar
85 Royal College of Obstetricians and Gynaecologists. Basic Practical Skills in Obstetrics and Gynaecology. London: RCOG Press; 2007.Google ScholarPubMed
86 Buchmann, EJ, Libhaber, E. Accuracy of cervical assessment in the active phase of labour. BJOG 2007; 114: 833–37.CrossRefGoogle ScholarPubMed
87 Nizard, J, Haberman, S, Paltieli, Y, Gonen, R, Ohel, G, Nicholson, D et al. How reliable is the determination of cervical dilation? Comparison of vaginal examination with spatial position-tracking ruler. Am J Obstet Gynecol 2009; 200: 402 e401404.CrossRefGoogle ScholarPubMed
88 Phelps, JY, Higby, K, Smyth, MH, Ward, JA, Arredondo, F, Mayer, AR. Accuracy and intraobserver variability of simulated cervical dilatation measurements. Am J Obstet Gynecol 1995; 173: 942–45.CrossRefGoogle ScholarPubMed
89 Huhn, KA, Brost, BC. Accuracy of simulated cervical dilation and effacement measurements among practitioners. Am J Obstet Gynecol 2004; 191: 1797–799.CrossRefGoogle ScholarPubMed
90 Dupuis, O, Silveira, R, Zentner, A, Dittmar, A, Gaucherand, P, Cucherat, M et al. Birth simulator: reliability of transvaginal assessment of fetal head station as defined by the American College of Obstetricians and Gynecologists classification. Am J Obstet Gynecol 2005; 192: 868–74.CrossRefGoogle ScholarPubMed
91 Lathrop, A, Winningham, B, VandeVusse, L. Simulation-based learning for midwives: background and pilot implementation. J Midwifery Women's Health 2007; 52: 492–98.CrossRefGoogle ScholarPubMed
92 Haskvitz, LM, Koop, EC. Students struggling in clinical? A new role for the patient simulator. J Nurs Educ 2004; 43: 181–84.Google ScholarPubMed
93 Clark, J, Siassakos, D, Draycott, T. Vaginal examination at full dilatation: is a high fidelity mannequin useful for testing and training this skill? Published abstract from SESAM: Society in Europe for Simulation Applied to Medicine. Hatfield; 2008.Google Scholar
94 Sherer, DM, Miodovnik, M, Bradley, KS, Langer, O. Intrapartum fetal head position I: comparison between transvaginal digital examination and transabdominal ultrasound assessment during the active stage of labor. Ultrasound Obstet Gynecol 2002; 19: 258–63.CrossRefGoogle ScholarPubMed
95 Sultan, AH, Kamm, MA, Hudson, CN. Obstetric perineal trauma: An audit of training. J Obstet Gynaecol 1995; 15: 1923.CrossRefGoogle Scholar
96 Andrews, V, Thakar, R, Sultan, AH. Structured hands-on training in repair of obstetric anal sphincter injuries (OASIS): an audit of clinical practice. Int Urogynecol J Pelvic Floor Dysfunct 2009; 20: 193–99.CrossRefGoogle Scholar
Cited by

Send article to Kindle

To send this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats

Send article to Dropbox

To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

Available formats

Send article to Google Drive

To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

Available formats

Reply to: Submit a response

Please enter your response.

Your details

Please enter a valid email address.

Conflicting interests

Do you have any conflicting interests? *