Twin Vaginal Delivery Date Time Program Length 10:10

Appendix 1. Twin Delivery STRATUS Curriculum

Date Time Program length 10:10 - 11:55 AM 105 minutes

Duration Session Title Content Parallel Number Faculty Room requirements / Format Description session of Learners 10 Introduction: Taking of pretest, No 16 6 Classroom minutes Twin Vaginal review of didactic Delivery format, and basic review of eligibility criteria for twin vaginal delivery 30 Twin Patient Simulated Yes 6 2 Classroom, Setup with Minutes Counseling: conversation of table and two chairs at standardized front, otherwise no patient supplies needed. (attending) with resident counseling about laboring with vertex/vertex and vertex/nonvertex twins 30 Vertex Simulated Yes 5 2 OR Minutes Second Twin delivery of vertex second twin reviewing general twin management principles 30 Nonvertex Skill station for Yes 5 2 MicroSim Minutes Second Twin delivery of nonvertex second twin 5 Wrap up / Taking or post- No 16 6 Minutes Evaluations test survey

Easter SR, Gardner R, Barrett J, Robinson JN, Carusi D. Simulation to improve trainee knowledge and comfort about twin vaginal birth. Obstet Gynecol 2016; 128.

The authors provided this information as a supplement to their article.

Easter SR, Gardner R, Barrett J, Robinson JN, Carusi D. Simulation to improve trainee knowledge and comfort about twin vaginal birth. Obstet Gynecol 2016; 128.

The authors provided this information as a supplement to their article.

Twin Vaginal Delivery Simulation:

Case Title: Twin Vaginal Delivery Simulation

Lead Faculty/ Course Name: Nicole A. Smith MD, MPH Director: Title/Position: Division of Maternal-Fetal Medicine Additional Faculty: Name: Roxane Gardner MD, MPH (Please include names where available) Title/Position: Department of Obstetrics, Gynecology, and Reproductive Biology

Case Summary 31 yo G1P0 with 36 week vertex-vertex Di-Di twins presenting in spontaneous labor. Estimated weights 2500 gms for each and concordantly grown, no maternal issues this pregnancy. Scenario begins after uncomplicated delivery of first twin with one physician scanning, one physician assisting, and one acting as delivering physician.

Clinical Diagnosis Bradycardia of second twin

Educational Objectives Following this session, the participants should be able to: of this case: 1. Describe general principles of team management in twin delivery including communication to nursing and anesthesia staff.

2. Display appropriate use of ultrasound for twin delivery.

3. Display options for expedited delivery of second twin including operative vaginal delivery, internal podalic version and breech extraction, and cesarean delivery. Venue OR

Total Time 30 mins: Case=10 min + Debriefing=5 min + Repeat Case=10 min + Debriefing=5 min

Number/role of Patient: Delivering MD Confederate: Nurse / Participants: Noelle Assistant MD Noelle loader US MD Patient Information Name: Noelle DOB: 9/10/1983 Meds: Prenatal vitamin Age: 31 Allergies: NKDA Gender: F Easter SR, Gardner R, Barrett J, Robinson JN, Carusi D. Simulation to improve trainee knowledge and comfort about twin vaginal birth. Obstet Gynecol 2016; 128.

The authors provided this information as a supplement to their article.

PMH: None PSH: IVF Procedures

Case ‘Narrative’ ‘Flow’:

Prior to Start You are beginning your shift on Labor and Delivery and prior to completing signout are paged to the operating room for a delivery. You are accompanied by two obstetric colleagues for assistance in management of the patient. Anesthesia and nursing staff are already in the operating room with the patient. Patient is hooked up to maternal and fetal monitors with routine vaginal delivery kit open and bed broken with patient in lithotomy position.

Trigger: Vitals / Status: Learner actions/ Comments: Phase 1: Assessment Physician enters the room and begins Fetal heart When learner asks for more of Clinical to assess the clinical situation by tracing category clinical information, nurse Situation asking for more information. assess 1 for both twins, shares the following clinical clinical situation and asks Noelle with scenario: Assistant MD delivers first twin and stable vital passes off to pediatricians. signs. “Noelle is a 31 yo G1P0 who presented in labor at 36 weeks with IVF Di-Di twins. This pregnancy has been uncomplicated with concordant growth of approximately 2500 grams of each twin. She has had a normal labor curve, reassuring tracings for each babies, and was just transferred to OR for delivery of her vertex/vertex twins.”

Phase 2: Delivery of After receiving the clinical information, Fetal heart Nurse assists Noelle with Presenting Noelle complains of pelvic pressure tracing category uncomplicated delivery of Twin and the urge to push. Physician 1 for both twins, presenting twin, takes baby and checks patient and fetus is crowning. Noelle with reloads in a vertex presentation stable vital with high station as baby B. signs.

Phase 3: Assessment

Easter SR, Gardner R, Barrett J, Robinson JN, Carusi D. Simulation to improve trainee knowledge and comfort about twin vaginal birth. Obstet Gynecol 2016; 128.

The authors provided this information as a supplement to their article.

of Second Physician returns attention to second Noelle with When learner performs exam Twin fetus and performs exam to assess stable vital he/she announces findings to second twin. signs. No the room of full dilation, intact tracing available membranes, vertex for second fetus. presentation, and 0 station.

If no findings are announced nurse prompts learner to describe findings.

Physician then assesses fetal status If learner requests fetal heart by requesting fetal heart rate check check from nurse, states she is preferably by ultrasound. unable to find the fetal heart.

If requests sonographic assessment of fetal heart rate, colleague performs ultrasound and image of fetal bradycardia to 60s on screen.

Phase 4: Physician announces fetal Noelle with If learner calls for emergent Delivery of bradycardia and need for expedited stable vital cesarean delivery anesthesia Second Twin delivery. Articulates plan for signs, FHT responds she does not have a expedited delivery. remains in 60s surgical level and will need on projected general anesthesia. Plan may include cesarean delivery, ultrasound Anesthesiologist asks if there operative vaginal delivery with high image as long as are any other options for vacuum preferred over forceps for this ultrasound still expedited delivery. scenario, and internal podalic version being used. and breech extraction. If learner calls for forceps or vacuum for delivery that is readily provided by assistant.

If learner makes plan for operative vaginal delivery or internal podalic version and breech extraction without addressing patient, Noelle or nurse ask “What’s going on, is my baby okay?”.

Scenario End Scenario ends with liveborn female infant, apgars 6 and 9, and first twin stable doing skin to skin with a stable Noelle. Easter SR, Gardner R, Barrett J, Robinson JN, Carusi D. Simulation to improve trainee knowledge and comfort about twin vaginal birth. Obstet Gynecol 2016; 128.

The authors provided this information as a supplement to their article.

Desired Learning Objectives: Learner Actions 1. Identify and quickly acquire necessary clinical information for safe management of vaginal delivery.

2. Quickly and accurately assess fetal presentation, station, and status using a combination of physical exam and ultrasound.

3. Articulate options for expedited delivery of a second twin with goal of avoid cesarean delivery if possible.

4. Appropriately counsel patient about delivery options within a time-constrained situation and execute simulated delivery of choice.

5. Utilize supporting staff for management of twin delivery and demonstrate appropriate communication techniques to maximize patient safety in a high acuity setting. Cues for Patient asks “what is happening, is everything okay” if updates on exam, fetal status, or plan patient and for delivery are not provided. /or confederates Patient consents to “whatever is safest for baby” if asked about mode of delivery.

If CS called, anesthesia expresses concern about room setup and analgesia. Setup Equipment (examples): Quantity STRATUS to Faculty to required provide provide

Noelle 1 1

Pelvic Trainer Babies 2 2

Delivery Kit (with Boots for PPE) 1 1

Forceps 1 1

Vacuum 1 1 Video of US Findings to Display on Screen 1 1 Sonosite Ultrasound 1 1

Easter SR, Gardner R, Barrett J, Robinson JN, Carusi D. Simulation to improve trainee knowledge and comfort about twin vaginal birth. Obstet Gynecol 2016; 128.

The authors provided this information as a supplement to their article.

Nonvertex Second Twin Skills Session:

Program / Session Title: Nonvertex Second Twin Delivery

Lead Faculty/ Course Name: Julian Robinson MD Director: Title/Position: Chief of Obstetrics, Division of Maternal-Fetal Medicine Additional Faculty: Name: Katherine Economy MD, MPH (Please include names where available) Title/Position: Division of Maternal-Fetal Medicine

Goal of the session: Successfully perform simulated breech extraction of second twin

Educational Objectives: Following this session, the participants should be able to:

1. Demonstrate routine breech extraction maneuvers including proper hand placement on fetal pelvis, loveset maneuvers for delivery of arms, and delivery of fetal head. 2. Grasp foot of breech twin and distinguish it from other extremities. 3. Describe and demonstrate maneuvers for reduction of nuchal arms. 4. Describe and demonstrate maneuvers for difficult delivery of aftercoming head including use of suprapubic pressure and placement and use of Piper forceps. Participants: Number: 6 per Session (3 Total Sessions)

Discipline: Ob-Gyn Level of training: PGY1 to PGY4 Content Description Delivery of nonvertex second twin with practice of routine breech extraction maneuvers and complex scenarios including nuchal arms and head entrapment. Rooms required: 1. Microsim Room versus Arcade (General description of ideal spaces. STRATUS will assign suitable rooms.)

Simulation Specialists: None

Easter SR, Gardner R, Barrett J, Robinson JN, Carusi D. Simulation to improve trainee knowledge and comfort about twin vaginal birth. Obstet Gynecol 2016; 128.

The authors provided this information as a supplement to their article.

Will there be Industry NO involvement? (If YES, there will be a requirement to contact the Office of Industry Interactions) Specific equipment Station Equipment Quantity STRATUS Faculty to required: to provide provide Breech Twin PROMPT Birthing 1 1 Simulator with PROMPT Baby Complex Gaumard Childbirth 2 1 1 (Piper Breech Simulator Pelvis with forceps Model Baby and Piper from L&D) Forceps Breech in Gaumard Childbirth 2 1 1 (plastic Amnion Simulator Pelvis with bag) Model Baby in Plastic Bag to Simulate Amnion

Easter SR, Gardner R, Barrett J, Robinson JN, Carusi D. Simulation to improve trainee knowledge and comfort about twin vaginal birth. Obstet Gynecol 2016; 128.

The authors provided this information as a supplement to their article.

Counseling about Twin Delivery Skills Session:

Program / Session Title: Twin Delivery Counseling

Lead Faculty/ Course Name: Sarah E. Little MD, MPH Director: Title/position: Division of Maternal Fetal Medicine

Additional Faculty: Name: Daniela Carusi MD MSc (Please include names where available) Title/position: Division of Maternal Fetal Medicine, Faculty Serving as Standardized Patient

Goal of the session: Counseling patients about mode of delivery for twins.

Educational Objectives: Following this session, the participants should be able to:

1. Describe general labor principles for twin delivery (epidural, continuous monitoring) including rates of vaginal birth.

2. Describe range of possibilities for twin delivery, including operative vaginal delivery, particularly as applicable to the second twin. Articulate rates and safety of breech extraction, external cephalic version, internal podalic version, and cesarean section for the second twin after vaginal delivery of the first.

3. Address concerns regarding intrapartum change in presentation for twins including rate of presentation change and options for delivery.

4. Using data from published studies as a guide, address specific issues of neonatal safety for twin vaginal birth compared to elective cesarean delivery. State criteria for candidacy for attempted twin vaginal birth and anticipated outcomes for first compared to second twins.

5. Discuss increased maternal morbidity for twin pregnancies and intrapartum strategies to mitigate these risks. Contextualize decision making about twin vaginal birth in terms of maternal morbidity for current pregnancy and for future fertility goals. Participants: Number: 6 per Session (3 Total Sessions)

Discipline: Ob-Gyn Level of training: PGY1 to PGY4

Easter SR, Gardner R, Barrett J, Robinson JN, Carusi D. Simulation to improve trainee knowledge and comfort about twin vaginal birth. Obstet Gynecol 2016; 128.

The authors provided this information as a supplement to their article.

Content Description Two standardized patient scenarios for counseling about twin mode of delivery. The first with vertex-vertex twins averse to risk, the second with vertex-transverse twins and strong desire for vaginal delivery (see prompts below). Rooms required: 1. Classroom (General description of ideal spaces. STRATUS will assign suitable rooms.)

Simulation Specialists: None

Easter SR, Gardner R, Barrett J, Robinson JN, Carusi D. Simulation to improve trainee knowledge and comfort about twin vaginal birth. Obstet Gynecol 2016; 128.

The authors provided this information as a supplement to their article.

Your First Clinic Patient 37 yo G3P0020 at 32 weeks with IVF Di-Di twins presenting for a routine prenatal visit. Your plan today was to talk about mode of delivery. Her pregnancy has been uncomplicated to date, and ultrasound today shows:

Baby A: Alive Normal Amniotic Fluid Estimated Weight: 1700 gms (50%ile) Vertex Presentation Biophysical Profile: 8/8

Baby B: Alive Normal Amniotic Fluid Estimated Weight: 1500 gms (40%ile) Vertex Presentation Biophysical Profile: 8/8

Easter SR, Gardner R, Barrett J, Robinson JN, Carusi D. Simulation to improve trainee knowledge and comfort about twin vaginal birth. Obstet Gynecol 2016; 128.

The authors provided this information as a supplement to their article.

Your Next Clinic Patient 37 yo G3P0020 at 32 weeks with spontaneous Mo-Di twins presenting for a routine prenatal visit. Your plan today was to talk about mode of delivery. Her pregnancy has been uncomplicated to date despite its monochorionicity, and ultrasound today shows:

Baby A: Alive Normal Amniotic Fluid Estimated Weight: 1700 gms (50%ile) Vertex Presentation Biophysical Profile: 8/8

Baby B: Alive Normal Amniotic Fluid Estimated Weight: 1500 gms (40%ile) Transverse Presentation Biophysical Profile: 8/8

Easter SR, Gardner R, Barrett J, Robinson JN, Carusi D. Simulation to improve trainee knowledge and comfort about twin vaginal birth. Obstet Gynecol 2016; 128.

The authors provided this information as a supplement to their article.

Twin STRATUS Pretest This pretest is part of a research study. The completion of this survey is entirely voluntary and will not affect your evaluation or ability to participate in any way. 1. What is your mother’s birthday? ______

2. What is your current level of training? PGY ______

3. Have you ever participated in the Twin STRATUS before? Yes No

4. You are counseling a patient about mode of delivery for her 36 week Di‐Di well‐grown, concordant vertex/vertex twins in the office. How would you respond to the following questions:  What is my chance that both twins deliver vaginally? ______Percent  What is my risk that the first twin delivers vaginally and the second by cesarean? ______Percent  What is the risk of my second twin changing to breech or transverse presentation during labor and delivery? ______Percent

5. How would the following numbers change if your patient had 36 week Di‐Di well‐grown, concordant vertex/nonvertex twins?  What is my chance that both twins deliver vaginally? ______Percent  What is my risk that the first twin delivers vaginally and the second by cesarean? ______Percent  What is the chance of my second twin changing to vertex presentation during labor and delivery? ______Percent

6. Approximately how many of the following have you done in your training? (Best estimate is great).  Vaginal delivery of twins ______ Cesarean delivery of twins during a trial of labor ______ Elective cesarean delivery for twins ______ Combined delivery for twins (cesarean for the second twin after vaginal delivery of the first) ______

7. Which of the following would you feel ready to perform?  Breech Extraction of Second Twin: Yes / No  External Cephalic Version of Second Twin: Yes / No  Internal Podalic Version of Second Twin: Yes / No

Easter SR, Gardner R, Barrett J, Robinson JN, Carusi D. Simulation to improve trainee knowledge and comfort about twin vaginal birth. Obstet Gynecol 2016; 128.

The authors provided this information as a supplement to their article.

8. Under which conditions would you not allow vertex/vertex twins to labor? Enter “none” if you have no cutoff.  Gestational age less than ______weeks.  Estimated fetal weight of smallest twin less than ______grams.  Estimated weight discordance greater than ______percent with second twin larger than first.

9. Under which conditions would you not allow vertex/nonvertex twins to labor?  Gestational age less than ______weeks.  Estimated fetal weight of smallest twin less than ______grams.  Estimated weight discordance greater than ______percent with second twin larger than first.

10. Would you benefit from training in twin delivery, particularly related to second twin management and breech extraction? (Choose all that apply) a. Yes, more didactic training b. Yes, more simulator training c. Yes, more hands on training with patients d. No, feel comfortable with my skill set

11. If a patient asks for an elective cesarean section for vertex‐vertex twins, you would feel: a. Uncomfortable and would strongly counsel her to reconsider. b. Uncomfortable but willing to do the procedure without strong counseling. c. Neutral about mode of delivery for these twins. d. Comfortable as this is your preferred mode of delivery for twins.

Easter SR, Gardner R, Barrett J, Robinson JN, Carusi D. Simulation to improve trainee knowledge and comfort about twin vaginal birth. Obstet Gynecol 2016; 128.

The authors provided this information as a supplement to their article.

Twin STRATUS Post Test This post‐test is part of a research study. The completion of this survey is entirely voluntary and will not affect your evaluation or ability to participate in any way. 1. What is your mother’s birthday? ______

2. You are counseling a patient about mode of delivery for her 36 week Di‐Di well‐grown, concordant vertex/vertex twins in the office. How would you respond to the following questions:  What is my chance that both twins deliver vaginally? ______Percent  What is my risk that the first twin delivers vaginally and the second by cesarean? ______Percent  What is the risk of my second twin changing to breech or transverse presentation during labor and delivery? ______Percent

3. How would the following numbers change if your patient had 36 week Di‐Di well‐grown, concordant vertex/nonvertex twins?  What is my chance that both twins deliver vaginally? ______Percent  What is my risk that the first twin delivers vaginally and the second by cesarean? ______Percent  What is the chance of my second twin changing to vertex presentation during labor and delivery? ______Percent

4. Which of the following would you feel ready to perform?  Breech Extraction of Second Twin: Yes / No  External Cephalic Version of Second Twin: Yes / No  Internal Podalic Version of Second Twin: Yes / No

5. Under which conditions would you not allow vertex/vertex twins to labor? Enter “none” if you have no cutoff.  Gestational age less than ______weeks.  Estimated fetal weight of smallest twin less than ______grams.  Estimated weight discordance greater than ______percent with second twin larger than first.

6. Under which conditions would you not allow vertex/nonvertex twins to labor?  Gestational age less than ______weeks.  Estimated fetal weight of smallest twin less than ______grams.  Estimated weight discordance greater than ______percent with second twin larger than first.

Easter SR, Gardner R, Barrett J, Robinson JN, Carusi D. Simulation to improve trainee knowledge and comfort about twin vaginal birth. Obstet Gynecol 2016; 128.

The authors provided this information as a supplement to their article.

7. If a patient asks for an elective cesarean section for vertex‐vertex twins, you would feel: e. Uncomfortable and would strongly counsel her to reconsider. f. Uncomfortable but willing to do the procedure without strong counseling. g. Neutral about mode of delivery for these twins. h. Comfortable as this is your preferred mode of delivery for twins.

8. Please rate how prepared you feel after today’s STRATUS to put these skills into practice compared to your prior skillset:

Significantly Less The Same as More Significantly Less Comfortable Before Prepared More Comfortable Prepared Counseling about Vertex/Vertex Twin Delivery Counseling about Vertex/Nonvertex Twin Delivery Second Stage Management of Twin Delivery Operative Vaginal Delivery for Second Twin Breech Extraction for Second Twin Management of Complicated Breech Extraction of Second Twin

Easter SR, Gardner R, Barrett J, Robinson JN, Carusi D. Simulation to improve trainee knowledge and comfort about twin vaginal birth. Obstet Gynecol 2016; 128.

The authors provided this information as a supplement to their article.