A stitch in time saves nine

‘A stitch in time saves nine.’ 

How simple educational training videos can positively impact the outcome of a surgical procedure in a low resource setting.

Perinatal Morbidity and Mortality in Low Resource Settings:
Over 95% of perinatal morbidity and mortality occurs in low resource settings where dissemination and training of novel interventions is challenging.

Free educational video resource of transabdominal cerclage (TAC):
A team at Kings College London recently developed an educational video describing transabdominal cerclage (TAC) insertion.  Research by the team has showed that TAC is effective in women with multiple failed previous cerclages.  Despite this, it remains an uncommonly utilised procedure globally.

Learning a new technique by viewing the video:
Their video, which has been shared globally as a free educational resource, was viewed by an experienced Consultant Obstetrician based in Mwanza, Tanzania pre-publication.  This consultant was experienced in performing vaginal cerclage but had never previously inserted a TAC.  After studying the video, he performed the technique in two cases, which are described below.  His experience demonstrates the effectiveness of video-based learning as an educational tool.

Patient 1:

The first patient, a 29-year-old, was referred for recurrent pregnancy loss. She had suffered 6 late miscarriages (16 to 23+6 weeks’ gestation) when she was originally referred to Bugando Medical Centre in 2017. After referral, she had 3 further pregnancies. The first 2 were managed with rescue cerclage at 15 and 14 weeks’ gestation respectively, due to mid-trimester cervical dilatation. Both of these attempts failed and the patient suffered from late miscarriage. In her next (9th) pregnancy a history indicated high cervical cerclage was inserted at 14 weeks’ gestation, but she miscarried at 17 weeks’.

On 5th March 2019, the obstetrician inserted transabdominal cerclage into the woman’s non-gravid uterus, emulating the technique he had observed in the video, without additional practice or training.  A #1 nylon suture was used at the level of the isthmus, with the second suture 1 cm below as described in the video.  The woman made a good recovery post operatively and was discharged 2 days later. In her 10th pregnancy she had normal booking and anomaly scans.  A cervical length measurement at 24 weeks’ gestation was 32mm and she was given antenatal corticosteroids for fetal lung maturation.  She did not have any additional bedrest during this time.  She took folic acid, ferrous sulphate, antimalarial and deworming medications for the duration of her pregnancy.  At 35 weeks’ gestation the woman was admitted with lower abdominal pain and spotting per vagina, and remained as an inpatient for a week.  The backache and lower abdominal pain persisted, and the decision was made for an elective caesarean section at 36 weeks’ gestation.  On 12th May 2020 a baby boy weighing 2.2kg with APGARS of 8, then 10 at 1 and 5 minutes respectively was delivered by lower segment caesarean section.  The cerclage, seen intra-operatively, was left in situ.  The woman made a good recovery post-operatively and she and the baby were discharged on day 5.

Patient 2:
Following the first successful case the same obstetrician offered a transabdominal cerclage to another woman. This 37-year-old woman had had three second trimester miscarriages, an elective section with a live baby, followed by five failed cerclages. A transabdominal cerclage was inserted and she was delivered at 37 weeks’ gestation by caesarean section due to lower abdominal pain. She gave birth to a baby weighing 3kg with APGARS of 8 and 10 at 1 and 5 minutes respectively.

TAC the treatment of choice for women with failed vaginal cerclage:
TAC is the treatment of choice for women with failed vaginal cerclage.  It is superior to low vaginal cerclage in reducing the risk of preterm birth and fetal loss. Both of the patients from Tanzania, described above, had a significant number of miscarriages, and recurrent failed cervical cerclage, with associated physical and mental distress. In both cases inserting a TAC, an intervention the surgeon learnt through studying a video, led to a successful pregnancy outcome.

Video as a useful training method for reducing poor pregnancy outcomes:
In the examples described above, it is evident that using a video to demonstrate a surgical technique provide a valuable training method.  In countries where maternal mortality is highest, such as Africa and Asia, access to adequate training, especially in newer surgical techniques, is rare. Improving training in novel surgical interventions through cost-effective methods like video tutorials could reach a wide audience of clinicians and reduce poor pregnancy outcomes in these settings.

 The process of the surgical technique of TAC:
Inserting a TAC is not technically difficult.  Basic gynaecological surgical skills are sufficient to emulate the technique after watching the video, without previous experience of the procedure and no special equipment or technology is required. The cases described highlight the effectiveness of this simple method of education and training, despite challenges intrinsic to a low resource setting.

Collaboration and Communication:
International meetings and communication between clinicians can help bring knowledge of new research and technology to these settings more rapidly. In addition, video-based educational resources could be incorporated into future surgical training curriculums to facilitate global dissemination.

This anecdotal example from Tanzania reflects how simple educational videos can be utilised to deliver surgical training and increase access to surgical skills globally, with improved patient outcomes.

Read the full article in the American Journal of Obstetrics & Gynecology here.

Scroll to Top