Obstetrics & Gynecology:
Improving Neonatal Outcome Through Practical Shoulder Dystocia Training
Draycott, Timothy J. MD1; Crofts, Joanna F. BMBS1; Ash, Jonathan P. MBBS1; Wilson, Louise V. MBChB2; Yard, Elaine RM1; Sibanda, Thabani MSc1; Whitelaw, Andrew MD3
From the 1Department of Obstetrics and Gynaecology, North Bristol NHS Trust, Southmead Hospital, Bristol, United Kingdom; the 2Department of Obstetrics and Gynaecology, United Bristol NHS Trust, St. Michael’s Hospital, Bristol, United Kingdom; and the 3University of Bristol, Bristol, United Kingdom.
Presented at the Institute of Healthcare Improvement Conference, December 9–12, 2007, Orlando, Florida.
The authors thank Denise Ellis (Registered Midwife) and Cathy Winter (Registered Midwife), who aided the research by searching the STORK maternity database.
Corresponding author: Dr. Timothy Draycott, Consultant Obstetrician, Department of Obstetrics and Gynaecology, North Bristol NHS Trust, Southmead Hospital, Bristol, BS10 5NB, UK; e-mail: firstname.lastname@example.org.
Financial Disclosure Dr. Draycott has been a consultant to Limbs and Things Ltd (Bristol, UK), manufacturers of the PROMPT Birthing Simulator. The other authors have no potential conflicts of interest to disclose.
OBJECTIVE: To compare the management of and neonatal injury associated with shoulder dystocia before and after introduction of mandatory shoulder dystocia simulation training.
METHODS: This was a retrospective, observational study comparing the management and neonatal outcome of births complicated by shoulder dystocia before (January 1996 to December 1999) and after (January 2001 to December 2004) the introduction of shoulder dystocia training at Southmead Hospital, Bristol, United Kingdom. The management of shoulder dystocia and associated neonatal injuries were compared pretraining and posttraining through a review of intrapartum and postpartum records of term, cephalic, singleton births in which difficulty with the shoulders was recorded during the two study periods.
RESULTS: There were 15,908 and 13,117 eligible births pretraining and posttraining, respectively. The shoulder dystocia rates were similar: pretraining 324 (2.04%) and posttraining 262 (2.00%) (P=.813). After training was introduced, clinical management improved: McRoberts’ position, pretraining 95/324 (29.3%) to 229/262 (87.4%) posttraining (P<.001); suprapubic pressure 90/324 (27.8%) to 119/262 (45.4%) (P<.001); internal rotational maneuver 22/324 (6.8%) to 29/262 (11.1%) (P=.020); delivery of posterior arm 24/324 (7.4%) to 52/262 (19.8%) (P<.001); no recognized maneuvers performed 174/324 (50.9%) to 21/262 (8.0%) (P<.001); documented excessive traction 54/324 (16.7%) to 24/262 (9.2%) (P=.010). There was a significant reduction in neonatal injury at birth after shoulder dystocia: 30/324 (9.3%) to 6/262 (2.3%) (relative risk 0.25 [confidence interval 0.11–0.57]).
CONCLUSION: The introduction of shoulder dystocia training for all maternity staff was associated with improved management and neonatal outcomes of births complicated by shoulder dystocia.
LEVEL OF EVIDENCE: II
Shoulder dystocia is an uncommon and largely unpredictable event1,2 with serious potential morbidity for both mother and baby, particularly obstetric brachial plexus injury,3–6 which may be exacerbated by inappropriate management.7–9 Training for shoulder dystocia has been shown to improve the management of simulated shoulder dystocia.10–12 Shoulder dystocia training is now mandated by the Clinical Negligence Scheme for Trusts in the United Kingdom13 and recommended by the Joint Commission on Accreditation of Healthcare Organizations in the United States,14 but there is currently no evidence of any associated improvement in neonatal outcome.6 Indeed, a recent study from a U.K. hospital reports a significant increase in the rate of brachial plexus injuries associated with shoulder dystocia between 1991 and 2005 despite the introduction of training.15
The aim of this study was to compare the management of shoulder dystocia and neonatal injury associated with shoulder dystocia before and after the introduction of shoulder dystocia training for all staff in a single maternity unit.
This retrospective, observational study compares the management and neonatal outcome of births complicated by shoulder dystocia before and after the introduction of shoulder dystocia training during a multiprofessional, 1-day obstetric emergency training course established at Southmead Hospital in 2000.16 Annual attendance by all midwifery and obstetric staff was mandated by hospital management. The training course included a 30-minute practical session on shoulder dystocia management, run jointly by a midwife and an obstetrician, for multiprofessional groups of five to eight staff. All training was performed on a prototype shoulder dystocia training mannequin (PROMPT Birthing Trainer, Limbs and Things Ltd, Bristol, United Kingdom, Prototype II from 2000 until August 2003 and Prototype III from September 2003 onward) (Fig. 1). Training covered risk factors, recognition, demonstration of resolution maneuvers, and documentation of shoulder dystocia, as well as a simulated shoulder dystocia scenario. The training aimed to simplify the management of shoulder dystocia using a stepwise approach of calling for help, McRoberts’ position, suprapubic pressure, and internal maneuvers (delivery of the posterior arm or rotation of the fetal shoulders). Eponymous maneuvers (eg, Woods’ screw, Rubin II) were simplified to demonstrate their mechanical concepts (ie, rotation of the fetal shoulders out of the anterior-posterior diameter of the pelvis and into the oblique by pressure on the posterior fetal shoulder) rather than relying on memorization of their original descriptions.
All infants born during the 9-year period from January 1, 1996, to December 31, 2004, were identified using a standard U.K.-based maternity database (STORK). Training was commenced in July 2000; therefore all births during 2000 were excluded. Births between January 1, 1996, and December 31, 1999, were analyzed as “before training,” and births between January 1, 2001, and December 31, 2004, were analyzed as “after training.” Infants were excluded from analysis if they were born by cesarean delivery or if they were breech presentation, twins or higher multiples, premature (gestation less than 37 weeks), stillborn, or not born at Southmead Hospital.
Maternal notes in which “difficulty with the shoulders” had been recorded on the STORK maternity database were obtained from the medical records department. Maternal intrapartum notes were reviewed for evidence of shoulder dystocia (shoulder dystocia, tight/difficult shoulders, traction, additional maneuvers used) by an obstetrician (J.C., J.A., L.W.). If shoulder dystocia was confirmed, data regarding the management of shoulder dystocia (maneuvers used, traction, head-to-body delivery time, anterior fetal shoulder at the time of the dystocia, and grade of the accoucheur at the time of delivery of the head and body) were collected using a standardized maternal form. The maternal postnatal notes were reviewed by an obstetrician (J.C., J.A., L.W.) for any evidence of suspected neonatal injury (decreased arm movement, suspected fracture, other). Where the maternal notes were suggestive of neonatal injury, neonatal notes were obtained from medical records and reviewed by a neonatologist (A.W.). Details of any neonatal injury were recorded (injury and duration) using a standardized neonatal form.
Results are reported in proportions (%), with P values, relative risks, and 95% confidence intervals where appropriate. χ2 testing was used in all comparisons of proportions, and the Student’s t test was used for all continuous outcome variables. A 5% level of significance was used throughout. The statistical software used was Stata 8 (StataCorp LP, College Station, TX).
Ethical committee approval was obtained from the North Bristol NHS Trust Local Research Ethics Committee.
There were 20,635 births during the pretraining period and 18,585 births during the posttraining period at Southmead Hospital, Bristol, United Kingdom. Of these births 15,908 (77.09%) and 13,117 (70.58%) met the eligibility criteria pretraining and posttraining, respectively. Figure 2 shows the births and exclusions. The proportion of infants born by elective and emergency cesarean section was higher in the posttraining period (Fig. 2). “Difficulty with the shoulders” was recorded in 402 (2.53%) eligible deliveries pretraining and 318 (2.42%) posttraining; of these, maternal notes were available for review in 359 (89.3%) pretraining and 280 (88.1%) posttraining deliveries. Shoulder dystocia was confirmed in 324 (90.3%) pretraining notes and 262 (93.6%) posttraining notes reviewed.
There was no significant difference in the proportion of births coded for “difficulty with shoulders” or with confirmed shoulder dystocia before and after the introduction of training (Table 1). Women delivering in the posttraining period were older and had a higher body mass index than those delivering in the pretraining period. Women were also more likely to be primiparous, have their labor induced, and have an instrumental delivery in the posttraining period. There was no difference in the gestational age at delivery, although babies born in the posttraining period were on average 14 g lighter than those born pretraining. The incidence of maternal diabetes mellitus was higher in the posttraining period (Table 1), although there was no difference in the rate of diabetes mellitus in births complicated by shoulder dystocia.
In births complicated by shoulder dystocia, the mean birth weight was lower by an average of 99 g in the posttraining period, but there was no significant difference in the gestational age at delivery or the rate of spontaneous labor between the two study periods (Table 2). The instrumental delivery rate was higher in births complicated by shoulder dystocia in the posttraining period.
The documented management of shoulder dystocia was significantly different after the introduction of training (Table 3). Before training, none of the maneuvers recommended for the resolution of shoulder dystocia (McRoberts’ position, suprapubic pressure, internal rotation, delivery of the posterior arm, All- Fours-Maneuvers) were used in 50% of shoulder dystocias, whereas after training, at least one recommended maneuver was used in more than 90% of cases of shoulder dystocia. There was also a significant reduction in the proportion of shoulder dystocias in which “excessive traction” (any record of traction not preceded by minimal, mild, routine, or normal) was documented. Examples of excessive traction documentation included “very hard pull on shoulders,” “three good pulls,” “came with very hard tug,” “a lot of downward traction needed to release anterior shoulder,” “shoulders not delivered despite a lot of traction to head, head first rotated to right and then left,” and “two good pulls combined with firm downward traction.” The documentation of inappropriate use of fundal pressure, lithotomy, and left lateral positioning also was reduced after the introduction of training.
After the introduction of training, there was a significant reduction in the proportion of babies born with an obstetric brachial palsy injury (Table 4, Fig. 3). Persistent obstetric brachial plexus injuries (injuries still present at 6 and 12 months of age) were less common after training was introduced but did not reach statistical significance. Posttraining reductions in neonatal fractures and low 5-minute Apgar scores also were not statistically significant.
The introduction of annual, mandatory, multiprofessional obstetric emergency training for all maternity staff at Southmead Hospital, Bristol, was associated with improved management of and clinical outcome after shoulder dystocia. Three previous studies10–12 have illustrated that the management of simulated shoulder dystocia can be improved with training; however this study demonstrates that shoulder dystocia training can be associated with improved clinical outcomes.
The Confidential Enquiry into Stillbirths and Deaths in Infancy,9 the National Health Service of England and Wales Litigation Authority,7 and the SaFE study11 all identified a common theme regarding shoulder dystocia: failure to perform (and document) standard maneuvers. Our data concur; before the instigation of training, at least one recommended shoulder dystocia resolution maneuver was used in only 49% of births complicated by shoulder dystocia, increasing significantly to 92% after training.
Inappropriate actions, eg, fundal pressure and excessive traction, may also result in harm.17 Before training, fundal pressure was documented in 1.5% cases of shoulder dystocia and 7% of injuries; it was not documented at all after training. Excessive traction was documented in 17% and 9% of shoulder dystocias pretraining and posttraining, respectively.
The reported incidence of neonatal complications associated with shoulder dystocia is wide because of the subjective diagnostic criteria. Studies analyzing more than 200 cases of shoulder dystocia report incidences of obstetric brachial plexus injury at birth of 8.3%,15 8.5%,18 13.3 %,19 and 16.8 %.4 In our study, the rate of obstetric brachial plexus injury at birth was 7.0% before training and 2.3% after training. Rates of permanent obstetric brachial plexus injury associated with shoulder dystocia of 1.4%4 and 0.5%20 have been reported previously. Before training, our rate of permanent obstetric brachial plexus injuries after shoulder dystocia was 1.8%; after training, the incidence was 0.8%.
We classified a birth to have been complicated by shoulder dystocia if “shoulder dystocia” was documented, additional maneuvers were used after delivery of the fetal head,21 traction more than routine was applied, or there was documentation of “difficult” or “tight” shoulders. Our retrospective review relies on midwifery coding of “difficulty with the shoulders” onto the STORK maternity database after a birth complicated by shoulder dystocia. We acknowledge that not all cases of shoulder dystocia will have been identified through the database; however, the recording of shoulder dystocia on the maternity database did not change during the study period, and the STORK Maternity Information database used is recognized to be largely accurate and consistently recorded.22
A further potential criticism of the study methodology is the reliance on documentation to determine management; some staff may have learned to more carefully document their care due to an increased awareness of the medico-legal implications. A prospective study of the potential benefits of training for shoulder dystocia could address this confounder.
The introduction of training coincided with other changes, including an increase in consultant (attending) cover.13 The impact of this, however, is likely to be small—only 1.5% of posttraining births complicated by shoulder dystocia were delivered by a consultant.
Shoulder dystocia is an unpredictable, acute, life-threatening emergency, and therefore it is difficult to train staff during the actual event. Management involves practical skills, and hence practical training is intuitive; however, training has been repeatedly recommended since 199623 without any evidence that it is associated with improved clinical outcome. A recent retrospective review of shoulder dystocia cases from 1991 to 2005 (with training from 2001) in one U.K. hospital reports improvements in clinical management of shoulder dystocia after the introduction of training (McRoberts’ position used in 51% and 91% cases of shoulder dystocia pretraining and posttraining, respectively); however, there was a significant increase in the rate of obstetric brachial plexus injury, from 5% in 1991 to 10% in 2005.15 Similar increases have been reported in other U.K. hospitals: 0.7% in 199524 to 25% in 2003.25 Our data compare favorably; the rate of obstetric brachial plexus injury associated with shoulder dystocia was 8.1% in 1995 and 3.3% in 2004 (Fig. 3). The differences in training employed in these hospitals need to be explored further to determine the “active ingredients of effective training.” Our shoulder dystocia training may have been effective because 100% of staff were trained and/or because the training was situated where the emergency occurs, utilized a high fidelity model, and simplified the actions required to safely deliver the infant.
Shoulder dystocia is largely unpredictable and unpreventable. Therefore, practical training of all staff may be the single most effective method of optimizing neonatal outcomes after this difficult and potentially dangerous obstetric complication.
1. Gross TL, Sokol RJ, Williams T, Thompson K. Shoulder dystocia: a fetal-physician risk. Am J Obstet Gynecol 1987;156:1408–18.
2. Ouzounian JG, Gherman RB. Shoulder dystocia: are historic risk factors reliable predictors? Am J Obstet Gynecol 2005;192:1933–5.
3. Acker DB, Sachs BP, Friedman EA. Risk factors for shoulder dystocia. Obstet Gynecol 1985;66:762–8.
4. Gherman RB, Ouzounian JG, Goodwin TM. Obstetric maneuvers for shoulder dystocia and associated fetal morbidity. Am J Obstet Gynecol 1998;178:1126–30.
5. Gherman RB, Ouzounian JG, Satin AJ, Goodwin TM, Phelan JP. A comparison of shoulder dystocia-associated transient and permanent brachial plexus palsies. Obstet Gynecol 2003;102:544–8.
6. Evans-Jones G, Kay SP, Weindling AM, Cranny G, Ward A, Bradshaw A, et al. Congenital brachial palsy: incidence, causes, and outcome in the United Kingdom and Republic of Ireland. Arch Dis Child Fetal Neonatal Ed 2003;88:F185–9.
7. National Health Service Litigation Authority. Summary of substandard care in cases of brachial plexus injury. NHSLA Journal 2003;2:ix–xi.
8. Allen R, Sorab J, Gonik B. Risk factors for shoulder dystocia: an engineering study of clinician-applied forces. Obstet Gynecol 1991;77:352–5.
9. Hope P, Breslin S, Lamont L, Lucas A, Martin D, Moore I, et al. Fatal shoulder dystocia: a review of 56 cases reported to the Confidential Enquiry into Stillbirths and Deaths in Infancy. Br J Obstet Gynaecol 1998;105:1256–61.
10. Crofts JF, Attilakos G, Read M, Sibanda T, Draycott TJ. Shoulder dystocia training using a new birth training mannequin. BJOG 2005;112:997–9.
11. Crofts JF, Bartlett C, Ellis D, Hunt LP, Fox R, Draycott TJ. Training for shoulder dystocia: a trial of simulation using low-fidelity and high-fidelity mannequins. Obstet Gynecol 2006;108:1477–85.
12. Deering S, Poggi S, Macedonia C, Gherman R, Satin AJ. Improving resident competency in the management of shoulder dystocia with simulation training. Obstet Gynecol 2004;103:1224–8.
15. MacKenzie IZ, Shah M, Lean K, Dutton S, Newdick H, Tucker DE. Management of shoulder dystocia: trends in incidence and maternal and neonatal morbidity. Obstet Gynecol 2007;110:1059–68.
16. Draycott T, Sibanda T, Owen L, Akande V, Winter C, Reading S, et al. Does training in obstetric emergencies improve neonatal outcome? BJOG 2006;113:177–82.
17. Gross SJ, Shime J, Farine D. Shoulder dystocia: predictors and outcome. A five-year review. Am J Obstet Gynecol 1987;156:334–6.
18. McFarland MB, Langer O, Piper JM, Berkus MD. Perinatal outcome and the type and number of maneuvers in shoulder dystocia. Int J Gynaecol Obstet 1996;55:219–24.
19. Mehta SH, Blackwell SC, Hendler I, Bujold E, Sorokin Y, Ager J, et al. Accuracy of estimated fetal weight in shoulder dystocia and neonatal birth injury. Am J Obstet Gynecol 2005;192:1877–80.
20. Nocon JJ, McKenzie DK, Thomas LJ, Hansell RS. Shoulder dystocia: an analysis of risks and obstetric maneuvers. Am J Obstet Gynecol
21. Resnick R.. Management of shoulder dystocia girdle. Clin Obstet Gynecol 1980;23:559–64.
22. Cleary R, Beard RW, Coles J, Devlin HB, Hopkins A, Roberts S, et al. The quality of routinely collected maternity data. Br J Obstet Gynaecol 1994;101:1042–7.
24. Olugbile A, Mascarenhas L. Review of shoulder dystocia at the Birmingham Women’s Hospital. J Obstet Gynaecol 2000;20:267–70.
25. Heazell AE, Judge JK, Bhatti NR. A retrospective study to determine if umbilical cord pH correlates with duration of delay between delivery of the head and body in shoulder dystocia. J Obstet Gynaecol 2004;24:776–7.
This article has been cited 42 time(s).
Academic Emergency MedicineEvaluating Educational Interventions in Emergency MedicineAcademic Emergency Medicine
Journal of PerinatologyResponse times for emergency cesarean delivery: use of simulation drills to assess and improve obstetric team performanceJournal of Perinatology
Anaesthesia and Intensive Care
Simulation training for rare medications in the intensive care unit-a study with bivalirudin
Anaesthesia and Intensive Care, 41(2):
Seminars in PerinatologySimulation: Improving patient outcomesSeminars in Perinatology
Seminars in PerinatologyObstetric emergency simulationSeminars in Perinatology
Seminars in PerinatologyThe use of simulation in maternal-fetal medicine procedure trainingSeminars in Perinatology
Obstetrics and Gynecology Clinics of North AmericaShoulder DystociaObstetrics and Gynecology Clinics of North America
Journal of Obstetrics and Gynaecology ResearchOpen knot-tying skills: Resident skills assessedJournal of Obstetrics and Gynaecology Research
Pediatric Clinics of North AmericaAdvances in Recognition, Resuscitation, and Stabilization of the Critically III ChildPediatric Clinics of North America
Emergency Medicine JournalManaging patient deterioration: assessing teamwork and individual performanceEmergency Medicine Journal
Otolaryngology-Head and Neck SurgeryA Systematic Review of Simulators in OtolaryngologyOtolaryngology-Head and Neck Surgery
Journal of General Internal MedicinePatient Outcomes in Simulation-Based Medical Education: A Systematic ReviewJournal of General Internal Medicine
Revista Medica De Chile
Simulation in medical education: a synopsis
Revista Medica De Chile, 141(1):
Canadian Journal of Anesthesia-Journal Canadien D AnesthesieReview article: Simulation: a means to address and improve patient safetyCanadian Journal of Anesthesia-Journal Canadien D Anesthesie
PediatricsInterns' Success With Clinical Procedures in Infants After Simulation TrainingPediatrics
Journal of Continuing Education in the Health ProfessionsSimulation for Maintenance of Certification in Anesthesiology: The First Two YearsJournal of Continuing Education in the Health Professions
Journal of Continuing Education in the Health ProfessionsJudicious Use of Simulation Technology in Continuing Medical EducationJournal of Continuing Education in the Health Professions
Best Practice & Research Clinical Obstetrics & GynaecologyReducing risk in maternity by optimising teamwork and leadership: an evidence-based approach to save mothers and babiesBest Practice & Research Clinical Obstetrics & Gynaecology
ViszeralmedizinTeam Resource Management in Surgery and EndoscopyViszeralmedizin
Medical Education OnlineTeaching medical students a clinical approach to altered mental status: simulation enhances traditional curriculumMedical Education Online
Women and BirthSimulation based learning in midwifery education: A systematic reviewWomen and Birth
Women and BirthManaging women with acute physiological deterioration: Student midwives performance in a simulated settingWomen and Birth
Bjog-An International Journal of Obstetrics and GynaecologyTransgenerational effects of prenatal exposure to the Dutch famine Author's ReplyBjog-An International Journal of Obstetrics and Gynaecology
Bjog-An International Journal of Obstetrics and GynaecologyA simple tool to measure patient perceptions of operative birthBjog-An International Journal of Obstetrics and Gynaecology
British Journal of AnaesthesiaEfficacy of high-fidelity simulation debriefing on the performance of practicing anaesthetists in simulated scenariosBritish Journal of Anaesthesia
Mount Sinai Journal of MedicineAchieving a Safety Culture in ObstetricsMount Sinai Journal of Medicine
ResuscitationComparison of sudden cardiac arrest resuscitation performance data obtained from in-hospital incident chart review and in situ high-fidelity medical simulationResuscitation
Mount Sinai Journal of MedicineThe Utility of Simulation in Medical Education: What is the Evidence?Mount Sinai Journal of Medicine
Best Practice & Research in Clinical Obstetrics & GynaecologySevere chronic morbidity following childbirthBest Practice & Research in Clinical Obstetrics & Gynaecology
Journal of Thoracic and Cardiovascular SurgerySimulation in cardiothoracic surgery: A paradigm shift in education?Journal of Thoracic and Cardiovascular Surgery
International Journal of Gynecology & ObstetricsObstetric care in low-resource settings: What, who, and how to overcome challenges to scale up?International Journal of Gynecology & Obstetrics
Medical EducationA critical review of simulation-based medical education research: 2003-2009Medical Education
Bjog-An International Journal of Obstetrics and GynaecologyPROMPT education and development: saving mothers' and babies' lives in resource poor settingsBjog-An International Journal of Obstetrics and Gynaecology
Best Practice & Research in Clinical Obstetrics & GynaecologyCommon errors and remedies in managing postpartum haemorrhageBest Practice & Research in Clinical Obstetrics & Gynaecology
Bjog-An International Journal of Obstetrics and GynaecologyThe active components of effective training in obstetric emergenciesBjog-An International Journal of Obstetrics and Gynaecology
Journal of Obstetrics and GynaecologyContent analysis of team communication in an obstetric emergency scenarioJournal of Obstetrics and Gynaecology
Journal of Midwifery & Womens HealthPerineal Injury in Nulliparous Women Giving Birth at a Community Hospital: Reduced Risk in Births Attended by Certified Nurse-MidwivesJournal of Midwifery & Womens Health
Pediatric Clinics of North AmericaThe Emerging Role of Simulation Education to Achieve Patient Safety Translating Deliberate Practice and Debriefing to Save LivesPediatric Clinics of North America
International Journal of Gynecology & ObstetricsRetention of factual knowledge after practical training for intrapartum emergenciesInternational Journal of Gynecology & Obstetrics
Obstetrics & GynecologyObservations From 450 Shoulder Dystocia Simulations: Lessons for Skills TrainingObstetrics & Gynecology
© 2008 The American College of Obstetricians and Gynecologists