A C TA Obstetricia et Gynecologica

AOGS RE V I EW AR TIC LE

Educational strategies in performing cesarean section

KRISTINE MADSEN1, LENE GRØNBECK1, CHRISTIAN RIFBJERG LARSEN2, JEANETT ØSTERGAARD1,
THOMAS BERGHOLT2, JENS LANGHOFF-ROOS1 & JETTE LED SØRENSEN1
1
Department of Obstetrics and Gynecology, Juliane Marie Centre for Women, Children and Reproduction, Rigshospitalet,
University Hospital of Copenhagen, Copenhagen, and 2Department of Obstetrics and Gynecology, University Hospital of
Copenhagen, Hillerød Hospital, Hillerød, Denmark

Key words Abstract

Cesarean section, surgical training, trainee,
learning curve, assessment, Objective
Structured Assessment of Technical Skills
Correspondence
Kristine Madsen, Department of Obstetrics
and Gynecology, Rigshospitalet, Blegdamsvej
9, Copenhagen Ø, Denmark. E-mail:
kmadsen1979@gmail.com
Conflict of interest
The authors report no conflicts of interest.
Please cite this article as: Madsen K,
Grønbeck L, Larsen CR, Østergaard J,
Bergholt T, Langhoff-Roos J, Sørensen JL.
Educational strategies in performing cesarean
section. Acta Obstet Gynecol Scand
2013; 92:256–263.
Received: 28 May 2012
Accepted: 7 November 2012
DOI: 10.1111/aogs.12055
Cesarean section is a common operation and one of the first surgeries performed
independently by trainees/residents in obstetrics and gynecology. Determination
of trainees’ technical skills level is dependent upon subjective faculty assessment.
Based on three studies on learning curves in cesarean section, it is recommended
that trainees perform between 10–15 and 40 supervised cesarean sections before
operating independently. Surgical technical skills of trainees/residents may be
assessed by Objective Structured Assessment of Technical Skills (OSATS), which
provides a foundation for constructive feedback during surgical training. The
Danish, Swedish and British Obstetric and Gynecological Societies’ guidelines on
cesarean section were reviewed regarding cesarean section surgical technique.
Placental removal by traction on the umbilical cord is recommended uniformly;
however, the Danish guidelines recommend one-layer uterine incision closure,
whereas the Swedish and British guidelines recommend two-layer closure.
Maternal complications at cesarean section increase when the primary surgeon is
a trainee/resident rather than an experienced surgeon. Basic surgical proficien-
cies regarding instruments, sutures and surgical technique as well as basic anat-
omy, should be verified before entering a training program for cesarean section.
Such a training program for technical and non-technical skills in cesarean sec-
tion should include theoretical instruction, video tutorials, practical experience
and direct supervision. Development of a specific OSATS for cesarean section is
recommended. Training must be individually structured accommodating the
differences in trainees’ competencies. Before clinical training in the operating
room begins, all trainees must attain standardized cognitive and technical skills.
CS, Cesarean section; NOTTS, Non Technical Skills for
Abbreviations:
Surgeons; OSATS, Objective Structured Assessment of Technical Skills.

In surgical education it is important to reduce com-

plications to a minimum. A training tradition of “see
Introduction
one, do one, teach one” is now considered insufficient
Cesarean section (CS) is a common open abdominal sur- to ensure patient safety, and consequently new training
gical procedure. In Denmark 21% of the children born in
2011 were delivered by CS (1). Cesarean section is one of
the first operations performed independently by trainees
in obstetrics and gynecology. Even though CS differs Key Message
from other open surgical procedures, various similarities Structured and validated education and assessment
also exist. Hence CS may be used for teaching basic prac- methods should be used at cesarean section and basic
tical anatomy and surgical proficiency regarding instru- surgical skills training should be verified.
ments, sutures and surgical techniques.

ª 2012 The Authors

256 Acta Obstetricia et Gynecologica Scandinavica ª 2012 Nordic Federation of Societies of Obstetrics and Gynecology 92 (2013) 256–263
K. Madsen et al.
methods must be introduced (2). Many gynecological
procedures are increasingly performed by laparoscopy,
resulting in a reduced amount of open abdominal pro-
cedures. This calls for greater attention when applying
CS in the training of general surgical skills and open
surgical procedures. It is important to provide struc-
tured teaching, assessment and feedback for trainees in
performing CS.
This review investigates the current literature on surgical
training in CS and provides an update on existing knowl-
edge of training, assessment and feedback of technical and
non-technical surgical skills. Elements to be included in a
future training program for CS are identified.
Material and methods
We searched the PubMed database using the following
search string; “Cesarean section and learning curve”,
“assessment and surgical training and open surgery”, “OS-
ATS” (i.e. Objective Structured Assessment of Technical
Skills), “video assessment and surgical training”, “non tech-
nical skills for surgeons”, “motion analysis and ICSAD” (i.
e. Imperial College Surgical Assessment Device), “cesarean
section and surgical technique and Cochrane review”, “risk
factors for maternal complications in cesarean section”,
and “assessment in surgical training in obstetrics”.
The following MeSH terms were used in the search
strategy; “Cesarean Section”, (“Cesarean Section/educa-
tion” OR “Cesarean Section/methods” OR “Cesarean Sec-
tion/trends”), (“Educational Measurement/methods” OR
“Educational Measurement/trends”), (“Surgical Proce-
dures, Operative/education” OR “Surgical Procedures,
Operative/methods” OR “Surgical Procedures, Operative/
trends”), “Clinical Competence”, (“Obstetric Surgical
Procedures/adverse effects” OR “Obstetric Surgical Proce-
dures/education” OR “Obstetric Surgical Procedures/
methods” OR “Obstetric Surgical Procedures/standards”
OR “Obstetric Surgical Procedures/trends”).
The “related citations” in PubMed and reference lists of
the retrieved articles were reviewed. The articles were
screened by title and abstract and, if relevant, the full text
was reviewed. Any uncertainty relating to study eligibility
was discussed in the group until consensus was reached. We
had no restrictions on publication year or study design, and
included articles in Scandinavian languages, English and
German. The literature search was updated in April 2012.
Results
Cesarean section training – learning curves
We identified three studies about CS training, all focusing
on learning curves (3–5). A learning curve is a graphical
ª 2012 The Authors
Acta Obstetricia et Gynecologica Scandinavica ª 2012 Nordic Federation of Societies of Obstetrics and Gynecology 92 (2013) 256–263
Educational strategies in cesarean section
representation of the rate of learning and it demonstrates
the time taken or the number of procedures that trainees
perform to attain a certain skills level. A training program
that shortens and improves the learning curves of train-
ees/residents could possibly reduce costs and improve
patient safety in terms of fewer errors and complications
(5,6).
Fok et al. (3) retrospectively investigated the learning
curves in CS for 10 trainees. Each trainee initially assisted
at a mean of 29 CS (range 21–49) and performed 24
(range 14–42) supervised sections. The following 50 CS
(emergency and elective), which they did independently,
were examined. The total operative time was significantly
reduced from 52.2 to 39.6 min between the first five CS
and the last five CS performed. A significant difference in
the learning curves for incision-to-delivery time was
established between the first five operations compared
with the rest. A more rapid learning curve was demon-
strated when performing elective vs. emergency CS, how-
ever, high-risk sections were not included. It was
estimated that each trainee must perform approximately
40 CS under varying levels of supervision before master-
ing the procedure independently. This was based on data
on incision-to-delivery time interval and total operative
time in minutes, as well as subjective assessment by the
supervising surgeon (3).
M€ uller and Zimmerman (4) investigated learning
curves related to CS performed by 15 trainees. The train-
ees were excluded from performing emergency and high-
risk sections, including for placenta previa and repeat CS.
The change from the steep to the flat part of the learning
curves was determined visually and defined as the end of
the initial learning phase. No objective assessment of
surgical skills was made, and the visual estimation was an
imprecise measurement of surgical skills and could poten-
tially affect the outcome measures. For both the total
operation time and the incision-delivery time, the steep
part of the curve ended after 20 CS. Hence, they
estimated that an average of 20 supervised average-risk
CS would provide a level of competence compatible with
sufficient patient safety (4).
Soergel et al. (5) analyzed elective and emergency CS
performed by 22 novice trainees (with no experience) and
23 experienced surgeons (>300 CS). The incision-to-suture
time and incision-to-delivery time were significantly higher
in operations performed by trainees compared with
experienced surgeons. Trainees would rarely perform the
CS with any expected fetal complications or distress,
thereby potentially increasing the speed of the learning
curves. The point in the learning curves where the steep
part proceeds to the flatter part determined the completion
of the basic learning process. The learning curves reached a
flatter part after 10 to 15 CS regarding both total operation
257
Educational strategies in cesarean section
time and incision-to-delivery time. Supervision and contin-
uing evaluation by experienced surgeons were recom-
mended because the learning process is individual. This
was illustrated by variations in the data for incision-to-
delivery time for the trainees (5).
Training of surgical skills
Trainees’ or residents’ surgical skills levels are often deter-
mined on the basis of subjective assessment at the end of
a trainee/resident post. Trainees’ performance outside the
operating theatre and personality traits may affect the
assessment (7). Elapsed time in training, log books, num-
ber of performed procedures and procedural time are
used to determine the skills level of trainees. These
parameters are indirect measures of surgical technical
skills, and do not assess the quality of the performance
(2,6,8,9).
Trainees/residents may not acquire all the necessary
skills in a clinical setting. The concept of a “pre-trained
novice” was introduced where trainees learned basic tech-
nical skills and completed the early learning curves in a
simulated environment. This should potentially result in
improved patient safety and learning efficacy in a sub-
sequent analogous clinical situation (10).
Surgical skills acquired by distributed practice trans-
ferred better from simulated environments to a live ani-
mal model, compared with skills acquired by massed
practice (11). The quality and amount of expert feedback
received during the learning process has been described
as essential for the acquisition of technical skills. Feedback
at the completion of a task (summary feedback) was
superior to feedback given while the task occurred (con-
current feedback) regarding technical skills retention
(suturing and instrument knot-tying) among medical stu-
dents (12). Specific training of supervising surgeons
should be provided to obtain more structured feedback
for trainees.
During an operation the supervising surgeon must
maintain overall control of the procedure, while still
allowing the trainee hands-on experience to obtain proce-
dure proficiency. Surgical training should be based on
progressive independence where the supervision of train-
ees is withdrawn as their skills increase (13).
Instruction video clips were displayed to trainees dur-
ing the surgical procedure in INVEST (INtraoperative
Video-Enhanced Surgical Training). This allowed trainees
to subsequently perform the procedural task instead of
the supervisor taking over. The method demonstrated
significant difference in skill acquisition on the OSATS
rating scale (14). In a laboratory-based course on intuba-
tion procedures, the addition of a short video instruction
substantially improved performance (15). A possible
258 Acta Obstetricia et Gynecologica Scandinavica ª 2012 Nordic Federation of Societies of Obstetrics and Gynecology 92 (2013) 256–263
K. Madsen et al.
future role of videos in CS training remains to be inves-
tigated.
Assessment in surgical training
Surgical skills are a combination of cognitive factors,
including knowledge and decision making, technical
skills, communication and leadership skills (8). It is
important to distinguish learning from assessment of
technical skills; learning refers to acquiring new skills,
whereas assessment is the evaluation of these skills.
Assessment methods should be objective, standardized,
feasible, valid, reliable, practical and cost-efficient (6).
Definitions regarding assessment are listed in Table 1.
Methods for objective assessment of trainees’ technical
skills provide a foundation for constructive feedback
when new surgical procedures are taught (10). Global
rating scales like OSATS, procedure-specific checklists
and video assessment are thoroughly validated
methods.
The original OSATS was introduced by Martin et al.
(16) and included the following assessment criteria:
respect for tissue, time and motion, instrument han-
dling, knowledge of instruments, use of assistants, flow
of operation and knowledge of specific procedure. Sev-
eral studies have since used an OSATS scale entailing a
global-rating part for general surgical skills and a check-
list part for procedure-specific skills. OSATS was devel-
oped for use in simulated settings, and was tested in
simulated open procedures and on live anesthetized ani-
mals (16–18). It is an objective examination in surgical
training, which measures surgical competence and dem-
onstrates excellent construct validity (7). Several other
studies demonstrated similar results (17–19). The Royal
Table 1. Definitions regarding assessment (8,19).
Construct validity The extent to which a test measures what it is
supposed to measure, and the extent a test
discriminates between various performance
levels
Content validity The extent to which the subject being measured,
is actually measured by the assessment method
Concurrent validity The extent to which the result of the
assessment method correlates with a standard
or other test which measures the same trait
Predictive validity The ability of the assessment method to predict
future performance
Reliability The extent to which the test is consistent in its
outcome
Inter-rater reliability refers to the agreement
between two or more observers testing the
same subject
ª 2012 The Authors
K. Madsen et al.
College of Obstetricians and Gynaecologists has created
a modified OSATS for CS, but its validity has not been
investigated (20).
Checklists are a dichotomy list, typically yes/no, and can
be procedure-specific or general. They are used for objec-
tively rating a performance during direct observation, and
usually require observation of the entire surgical procedure.
However, checklists can be imprecise, and if all compo-
nents of a procedure are weighed equally on the checklist,
trainees may omit important steps and still obtain a high
score. Global rating scales demonstrated superior reliability
and validity compared with checklists (6,21).
Video assessment is a reliable and valid method of
assessing basic tissue handling skills in open procedures
and has, for instance, been described in open inguinal
hernia repairs. The method offers anonymity and raters
can be located remotely from the procedure, thereby
increasing assessment objectivity (21). Video assessment
can distinguish between individuals with widely different
experience, whereas subtle variations may not show (19).
Video assessment can be rather time-consuming, how-
ever. New research demonstrated that junior staff are as
able to perform assessment and feedback as qualified
senior staff (22). This may increase the usefulness of the
method. Video assessment can be used in conjunction
with global rating scales or checklists.
Non-technical skills in surgery
Non-technical qualities are important for surgical out-
come, patient safety and operating room dynamics, but
formal teaching is often inadequate and neglected. Non-
technical skills can be taught by simulation in realistic
surroundings, and the entire multi-professional surgical
staff may be included, resulting in improved communica-
tion and teamwork (6,23,24).
Several behavioral rating systems for evaluating sur-
geons’ non-technical skills exist: The Non Technical Skills
for Surgeons (NOTTS), Non-Technical Skills Scale (NO-
TECHS) and Observational Teamwork Assessment for
Surgery (OTAS). The NOTTS system entails five catego-
ries of skills: situation awareness, decision making, task
management, communication, and teamwork and leader-
ship. The taxonomy includes a behavioral marker system
with examples of good and poor behavior within each
skills category (6,10,24,25).
Both technical and non-technical skills may be
impaired by stress in the operating room. Increased stress
was identified among primary operators and junior sur-
geons compared with assistants and senior surgeons.
Distractions, time pressure, bleeding and increased com-
plexity of a procedure added to the stress. Clear evidence
was lacking, but there was a tendency towards excessive
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Acta Obstetricia et Gynecologica Scandinavica ª 2012 Nordic Federation of Societies of Obstetrics and Gynecology 92 (2013) 256–263
Educational strategies in cesarean section
stress compromising surgical performance among novice
surgeons (26). Non-technical skills like leadership and
decision making were impaired during simulated crises,
such as hemorrhage or cardiac arrest (27).
In CS non-technical skills are very important. The pro-
cedure is often performed under acute circumstances,
attended by more than one specialist and involving two
patients (the parturient and fetus). In addition, nervous-
ness and anticipation prevail among patients and rela-
tives. These factors may all add to stress in the operating
room, thereby increasing the need for good non-technical
skills of surgeons in order to control the situation.
Surgical technique and complications in cesarean
section
The Danish, Swedish and British obstetric and gynecolog-
ical societies’ guidelines on CS were reviewed, to deter-
mine if consensus existed regarding CS surgical technique
(Table 2). Several similarities between the guidelines were
present, and placental removal by traction on umbilical
cord was uniformly agreed on. However, one-layer clo-
sure of the uterine incision was recommended by the
Danish guidelines whereas the Swedish and British Socie-
ties recommended two-layer closure (28–31).
The techniques used at CS are more surgically trau-
matic compared with other abdominal procedures such
as hysterectomy and oophorectomy, and the difficulty of
CS varies. Several publications recommend the surgical
technique in CS to be based on a transverse lower
abdominal wall opening using a Joel-Cohen type of
method (29,32,33).
In a recent study, the risk of major obstetric hemor-
rhage was increased at CS carried out by junior trainees
(with under three years of specialist training) compared
with senior obstetricians (19.6% vs. 13.1%) (34). Another
study confirmed that CS performed by a trainee rather
than a senior surgeon was associated with a significantly
higher risk of postoperative maternal complications (35).
Discussion
Creating a training program for cesarean section
A surgical training program for performing CS must
include teaching of technical and non-technical skills. The
training must be individually structured according to
trainees’ competencies. Before trainees/residents begin
clinical training and perform actual operations, they must
demonstrate cognitive skills regarding sutures and instru-
ments as well as knowledge of the steps in performing
CS. During clinical training the trainees must acquire
technical skills and learn to perform CS in accordance
259
260
Table 2. The most common maternal cesarean section complications and recommendations to reduce complication rates.
Information source
Danish Society of Obstetrics and
Complications Gynecology guidelines (29,38)
Abdominal wound Antibiotic prophylaxis (ampicillin
infection or first-generation cephalosporin)
Either before surgery or after
clamping of umbilical cord
Endometritis Removal of placenta by traction
on umbilical cord
Antibiotic prophylaxis
Urinary infection Antibiotic prophylaxis
Uterine rupture in One-layer closure
subsequent pregnancy
Uterine rupture after Recommendation: Interpregnancy
one-layer closure interval over 24 months
Seroma, wound
disruption, hematoma
Thromboembolic In elective CS; early ambulation
prophylaxis In acute CS; only with additional
risk factors: subcutaneous heparin
three days postpartum
Abbreviation: CS, cesarean section.
Acta Obstetricia et Gynecologica Scandinavica ª 2012 Nordic Federation of Societies of Obstetrics and Gynecology 92 (2013) 256–263
ª 2012 The Authors
Swedish Society of Obstetrics and
Gynecology guidelines (30,39)
Antibiotic prophylaxis in emergency
CS. Only with special indications in
elective CS
Removal of placenta by traction on
umbilical cord
Antibiotic prophylaxis in acute CS
Antibiotic prophylaxis in acute CS
Two-layer closure of uterine incision
with continuous suture
Recommendation: Interpregnancy
interval over 18–24 months
Suturing of subcutaneous layer if
over 2 cm
Thromboprophylaxis with
low-molecular-weight heparin
depending on maternal
risk factors
Royal College of Obstetricians and
Gynaecologists guidelines (United
Kingdom) (31,40)
Antibiotic prophylaxis (ampicillin or
first-generation cephalosporin)
Removal of placenta by traction on
umbilical cord
Antibiotic prophylaxis
Antibiotic prophylaxis
Two-layer closure of uterine incision
Suturing of subcutaneous layer
if over 2 cm
In elective CS; early ambulation, and
with two or more additional risk
factors: subcutaneous heparin
minimum seven days postpartum
For acute CS; subcutaneous heparin
for minimum seven days
Cochrane review, Hofmeyr et al. (33)
Antibiotic prophylaxis (ampicillin or first-generation
Educational strategies in cesarean section
cephalosporin)
Chlorhexidine for skin preparation
No hair removal or depilatory creams or clipping
instead of shaving
Removal of placenta by traction on umbilical cord
Antibiotic prophylaxis
Antibiotic prophylaxis
One-layer closure either interrupted or continuous
locking suture
Closure of subcutaneous tissue
No evidence for thromboprophylaxis
K. Madsen et al.
K. Madsen et al. Educational strategies in cesarean section

Table 3. Framework for a training program for teaching trainees/residents in performing cesarean section.

Training strategies Content Assessment method

Cognitive component
Self study Practical anatomy and physiology Cognitive testing before surgery
Books and guidelines Suture material and technique
E-learning Instruments and instrument handling
Visual material incl. video Pre-operative factors with relevance
or slideshows for surgery
Formalized teaching Steps in the surgical procedure
In small groups Post-operative complications
In lectures

Technical component
Formalized teaching and Suture and instrument technique Objective Structured Assessment of
practice One-hand and two-hand knot tying Technical Skills (OSATS) (16) rating
In small groups Tissue identification and respect scale and procedure specific checklist
At bench stations Actual cesarean sections Video assessment of surgical procedure
Performing cesarean sections (parts of/entire operation)
In operating room with supervisor

Non-technical component
Self study Non-technical skills of surgeons The Non Technical Skills for Surgeons
Literature, articles (NOTTS) (25)
Formalized teaching OSATS procedure specific checklist
In small groups 360° feedback
In simulated environment
with surgical staff

with current recommendations. They will need to receive
feedback throughout training for improving their perfor-
mance. Cesarean section may be used for learning basic
practical anatomy even though some structures and tissue
may differ during pregnancy. Trainees/residents must
demonstrate predefined standardized technical and non-
technical skills before they are allowed to operate without
a supervising senior surgeon. After the completion of
training, it may be interesting to examine how well the
trainees retain their surgical skills. The surgical training
program should include theoretical instructions, video
tutorials, practical experience and direct supervision. The
value and importance of each of these elements alone or
in combination with each other should be investigated in
future research. The proposed training program is out-
lined in Table 3.
Future perspectives for developing a cesarean
section training program
Our group was encouraged to design the framework for a CS
training program, as previously only three studies were pub-
lished on surgical training regarding CS. The final training
program should be developed in collaboration with national
and, if possible, international guideline groups, as well as
with specialists from obstetric and gynecological units.
Structured and validated education and assessment
should be used at CS and also basic surgical skills train-
ing. An OSATS should be specifically designed for assess-
ment during CS. The Delphi method is an anonymous
process whereby expert opinion from remote locations
can be collected and analyzed until group consensus is
achieved, and it would be a good approach to obtain
consensus on an OSATS for CS (36). The CS OSATS
should be investigated to determine if it demonstrates
content and construct validity, so it can discriminate
between novices, intermediary trainees and experts.
The assessment methods described in this article were
tested in simulated settings, in live animal models or in
open surgical procedures (such as inguinal hernia repairs)
(7,16,21). It was never established if these assessment
methods directly apply to CS, thus warranting future
studies to investigate this area.
Patient safety should not be compromised when teach-
ing trainees. The outcome of the procedure should be the
same, whether it was performed by a supervised trainee/
resident or the supervising surgeon. This emphasizes the
need for appropriate supervisor intervention in surgical
training (8,37).
Acknowledgments
We are grateful to the librarians at the Royal Library of
Copenhagen, and the Medical Research Library at Rigs-
hospitalet, Copenhagen University Hospital, Copenhagen,
Denmark for assistance with the search strategy.
Funding
No funding was obtained.

ª 2012 The Authors

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Educational strategies in cesarean section
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