Original Research Simulation to Improve Trainee Knowledge and Comfort About Twin Vaginal Birth Sarah Rae Easter, MD, Roxane Gardner, MD, MPH, Jon Barrett, MBBCh, MD, Julian N. Robinson, MD, and Daniela Carusi, MD, MSc OBJECTIVE: To describe a simulation-based curriculum on twin vaginal delivery and evaluate its effects on trainee knowledge and comfort about twin vaginal birth. METHODS: Trainees participated in a three-part simu- lation consisting of a patient counseling session, a twin delivery scenario, and a breech extraction skills station. Consenting trainees completed a 21-item presimulation survey and a 22-item postsimulation survey assessing knowledge, experience, attitudes, and comfort sur- rounding twin vaginal birth. Presimulation and postsi- mulation results were compared using univariate analysis. Our primary outcomes were change in knowl- edge and comfort before and after the simulation. RESULTS: Twenty-four obstetrics and gynecology resi- dents consented to participation with 18 postsimulation surveys available for comparison (75%). Trainees esti- mated their participation in 445 twin deliveries (median 19, range 0–52) with only 20.4% of these as vaginal births. Participants reported a need for more didactic or simu- lated training on this topic (64% and 88%, respectively). Knowledge about twin delivery improved after the sim- ulation (33.3% compared with 58.3% questions correct, P, .01). Before training, 33.3% of participants reported they would strongly counsel a patient to attempt vaginal birth instead of elective cesarean delivery for twins com- pared with 50% after training (P5 .52). Personal comfort with performing a breech extraction of a nonvertex sec- ond twin improved from 5.5% to 66.7% after the simu- lation (P, .01). CONCLUSION: Resident exposure to twin vaginal birth is infrequent and variable with a demonstrable need for more training. Our contemporary obstetric climate is prioritizing vaginal birth despite less frequent operative obstetric interventions. We describe a reproducible twin delivery simulation associated with a favorable effect on resident knowledge and comfort levels. (Obstet Gynecol 2016;128:34S–9S) DOI: 10.1097/AOG.0000000000001598 T he rate of cesarean delivery for twins rose from 54% in 1995 to 75% in 2008. 1 This steady increase coupled with new neonatal safety data underscore the importance of increasing rates of vaginal twin birth because planned vaginal birth has similar adverse neonatal outcomes as planned cesarean delivery. 2 Training in operative vaginal delivery and breech extraction has been highlighted as an area of need within obstetrics and gynecology training programs and as an adjunct to decreasing primary cesarean delivery. 3,4 However, few contemporary educational programs have developed curricula to address the skill acquisition and manual dexterity required for trainees managing twin delivery. 5,6 Obstetric simulation has a well-defined role in improving health care provider management of high-acuity, low-frequency events. 7,8 The success of such programs in conjunction with the shift to the Next Accreditation System by the Accreditation Council for Graduate Medical Education has led to renewed interest in the role of simulation in medical education. 9,10 The need for improved training in twin delivery coupled with rising twin cesarean delivery rates makes this high-acuity, low-frequency event ideal for simulation. The aim of this study is to create a simulation-based From the Division of Maternal-Fetal Medicine and the Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women’s Hospital, Har- vard Medical School, Boston, Massachusetts; and the Division of Maternal-Fetal Medicine, Sunnybrook Health Science Center, Toronto, Ontario, Canada. Presented at the Council on Resident Education in Obstetrics and Gynecology and Association of Professors of Gynecology and Obstetrics Annual Meeting, March 2– 5, 2016, New Orleans, Louisiana. The abstract presentation was the recipient of the Third Place Poster Award. The authors thank Katherine E. Economy, MD, MPH, Sarah E. Little, MD, MPH, and Nicole A. Smith, MD, MPH, for their integral role as expert instruct- ing faculty in the simulation. Corresponding author: Sarah Rae Easter, MD, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02215; e-mail: sreaster@partners.org. Financial Disclosure The authors did not report any potential conflicts of interest. © 2016 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0029-7844/16 34S VOL. 128, NO. 4 (SUPPLEMENT), OCTOBER 2016 OBSTETRICS & GYNECOLOGY Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.