Educational strategies in performing cesarean section.

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 proficiencies regarding instruments, sutures and surgical technique as well as basic anatomy, should be verified before entering a training program for cesarean section. Such a training program for technical and non-technical skills in cesarean section 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.