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Observations From 450 Shoulder Dystocia Simulations: Lessons for Skills Training

Crofts, Joanna F. BM, BS1; Fox, Robert MB2; Ellis, Denise RM3; Winter, Catherine RM3; Hinshaw, Kim RM4; Draycott, Timothy J. MD3

doi: 10.1097/AOG.0b013e3181865f55
Current Commentary

Poor neonatal outcomes after shoulder dystocia have been associated with inappropriate management. Until there are significant developments in the prediction and subsequent prevention of shoulder dystocia, improving shoulder dystocia management through practical training may be the most effective method of reducing the associated morbidity and mortality. Four hundred fifty simulated shoulder dystocia scenarios, managed by 95 midwives and 45 doctors from six U.K. hospitals during the course of 1 year, were video recorded during a study of obstetric emergency training. Analysis of recorded data revealed that, before training, 57% were unable to deliver the baby, almost two thirds failed to call for pediatric support, and 1 in 27 used fundal pressure. Recurring difficulties in management were observed: poor communication, inability to gain internal access, confusion over internal maneuvers, and the application of excessive traction. Significant improvements in management were observed after training and persisted up to 1 year after training. The lessons learned from this study can inform and improve future training and management. This article describes difficulties encountered by the participants and discusses how training may be focused to address these problems.

Difficulties were observed during the management of 450 simulated shoulder dystocias; practical training can address these issues.

From the Departments of Obstetrics and Gynaecology, 1Musgrove Park Hospital, Taunton, 2Taunton and Somerset NHS Trust, Musgrove Park Hospital, Taunton, 3North Bristol NHS Trust, Southmead Hospital, Bristol, and 4Sunderland Royal Hospital, Sunderland, United Kingdom.

See related editorial on page 746.

The SaFE Study was funded by the Patient Safety Research Programme, Department of Health, United Kingdom.

The authors thank Christine Bartlett (Midwife), Karen Cloud (Midwife), Maureen Harris (Midwife), Sarah Fitzpatrick (Midwife), Bryony Strachan (Consultant Obstetrician and Gynaecologist), Stephanie Withers (Midwife), and Valentine Akande (Consultant Obstetrician and Gynaecologist) for evaluation; Fiona Donald (Consultant Obstetric Anaesthetist), Mark James (Consultant Obstetrician and Gynaecologist), and Imogen Montague (Consultant Obstetrician and Gynaecologist) for training; and Cheltenham General Hospital (Penny Watson [Midwife] and Anne McCrum [Consultant Obstetrician and Gynaecologist]), Gloucestershire Royal Hospital (Sarah Read [Midwife]), Taunton and Somerset Hospital (Heather Smart [Midwife] and Melanie Robson [Consultant Obstetrician and Gynaecologist]), Royal Devon and Exeter Hospital (Katie Harrison [Midwife] and Neil Liversedge [Consultant Obstetrician and Gynaecologist]), and Royal Cornwall Hospital (Joanne Crocker [Midwife] and Simon Grant [Consultant Obstetrician and Gynaecologist]) for hospital support.

Corresponding author: Dr. Joanna Crofts, Special Registrar in Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, Musgrove Park Hospital, Taunton, UK; e-mail:

Financial Disclosure Dr. Draycott initiated the design of the mannequin used in the study, and since 2007 he has been a consultant to Limbs & Things Ltd (Bristol, UK), manufacturers of the PROMPT Birthing Simulator. The other authors have no potential conflicts of interest to disclose.

© 2008 The American College of Obstetricians and Gynecologists