Shoulder dystocia is a highly unpredictable and largely unpreventable event with potentially serious consequences for mother and neonate.1,2 It is often managed inappropriately, with suboptimal care having been identified in 66% of perinatal deaths3 and 46% of cases of brachial plexus injury related to shoulder dystocia.4
Shoulder dystocia training has been recommended in both he United States and the United Kingdom,3,5–8 and recent evidence suggests that management of simulated shoulder dystocia can be improved by practical training.9–11 The assessment intervals were very short, however, and it is not known whether there is decay in skills over time. The American Joint Commission for Accreditation of Healthcare Organizations7 gives no guidance on frequency of practical training and in the UK, the Clinical Negligence Scheme for Trusts5 has arbitrarily mandated annual shoulder dystocia training for all staff. The aim of this study was to estimate the decay of skills at 6 and 12 months after structured training for shoulder dystocia.
MATERIALS AND METHODS
This study forms part of a large randomized, controlled trial (Simulation and Fire-drill Evaluation; SaFE), commissioned by the Department of Health of England and Wales to investigate obstetric emergency training. As part of the SaFE study, each participant managed a standardized shoulder dystocia scenario before training and 3 weeks, 6 months, and 12 months after training (Fig. 1). We have previously reported our findings at 3 weeks.9
Participants (junior and senior midwives and junior and senior doctors) were recruited from six hospitals in the Southwest of England. Details of the exclusion criteria, power calculation, and recruitment have been previously published.9 To simulate severe shoulder dystocia a prototype PROMPT Birthing Trainer (Limbs and Things Ltd, Bristol, UK) was integrated with a patient–actor on a delivery bed. Participants were taken individually into a delivery room, given a standardized description of the scenario, and asked to complete the delivery. Detail of the assessment scenario has been previously published.9 The simulation was continued until either delivery of the posterior arm, the participant chose to stop, or 5 minutes had elapsed. The force applied during delivery and key events (start of simulation, key delivery maneuvers, end of drill) were logged contemporaneously to a specifically designed computer program during each scenario. The management of the simulated shoulder dystocia was assessed using the following outcome criteria: 1) success or failure of delivery, 2) the head-to-body delivery time, 3) performance of appropriate actions, 4) force applied, and 5) communication. Immediately after each simulation, the patient–actor subjectively assessed the quality of communication during delivery using a five-point Likert scale. “Good” communication was defined as score of four or five. All participants attended obstetric emergency training, which included a 40-minute practical workshop on the management of shoulder dystocia. Ethical approval was granted by the Regional Research Ethics Committee, and five Local Research Ethics Committees granted site-specific approval. Research and Development approval was granted by each Healthcare Trust.
Statistical analyses of the changes from the posttraining assessment to 6 and 12 months included two-tailed McNemar tests (to compare proportions) and Wilcoxon signed ranks test (to compare delivery times and peak force measurements). A Mann-Whitney U test was used to compare delivery times between participants who had and had not required further training. A 5% level of significance was used throughout.
The flow of participants through the study is illustrated in Figure 1. Fifteen junior doctors who were recruited to the study worked in obstetrics for only 6 months because they were on the General Practice Training Scheme and were no longer working in obstetrics (and will never work in acute obstetrics in the future) at the time of the 6- and 12-month assessments. These have been excluded from all analyses shown below. Of the remaining 125 participants (7 junior obstetricians, 23 senior obstetricians, 47 junior midwives, 48 senior midwives), analysis has been restricted to those who were evaluated 3 weeks posttraining (n=118). Of the 118, follow-up was available for 95 (80.5%) at 6 months and 82 (69.5%) at 12 months (Fig. 2).
For each simulation, a full data set was available for analysis on basic actions, delivery of posterior arm, delivery, patient communication, and head-to-body delivery interval. Force data were available for analysis from 97% (115 of 118) of 3-week, 98% (93 of 95) of 6-month, and 95% (78 of 82) of 12-month posttraining evaluations. Loss in the remainder was due to a fault in the data collection system not recording force in all simulations. In two other 3-week posttraining simulations, the force applied was above the maximal range (250 N) of the strain gauge; the peak forces recorded for these two cases were obviously the lower limits of the actual peak forces.
The whole group was analyzed and three subgroups were defined for further analysis (Table 1). The cohort was divided into three distinct groups because decay in performance may be influenced by initial performance gain. The groupings were group 1, those participants that could deliver the neonate before training (56 of 118, 47.5%); group 2, participants that successfully learned to effect delivery (unable to deliver before training but achieved delivery 3 weeks posttraining) (41 of 118, 34.7%); and group 3, participants who were unable to achieve deliver 3 weeks after initial training (21 of 118, 17.8%). It was deemed unethical to leave these 21 participants unable to manage severe simulated shoulder dystocia, and additional training was offered to them.
Before training, 60 of 122 (49%) achieved delivery, and 97 of 118 (82.2%) were able to deliver after initial training. Eighty of 95 (84%) and 75 of 82 (85%) were able to deliver at 6 and 12 months, respectively. Of all of those who could achieve delivery after training, 71 of 80 (89%) successfully delivered the neonate at 6 months, and 64 of 68 (94%) delivered at 12 months. The outcomes for the three subgroups are given in Tables 2–4.
Head-to-body intervals for those able to deliver the neonate after additional training were significantly longer than delivery times of those who were competent 3 weeks after training: median head-to-body time 186 seconds compared with 130 seconds (P=.008) at 6 months; 178 seconds compared with 129 seconds (P = .040) at 12 months (Mann-Whitney U test).
This is a report of long-term follow-up after practical training for an obstetric emergency, taught with medical simulation. These data should be reflective of real life because they derived from a multi-professional group, taken from a large health region, studied with the aid of a single high-fidelity mannequin. Interpretation of follow-up studies can be limited by drop-out of participants but we were able to follow up 81% of participants at 6 months and 70% at 12 months. A consideration for the interpretation of this study is that some participants may have experienced shoulder dystocia during follow-up, whereas others did not. Some participants may also have sought out additional shoulder dystocia training during the study period. Data were not collected on participants’ clinical or training experience during the study period. This was a pragmatic study, and participants could not be prevented from pursuing self-directed learning during the study period. However, the prototype PROMPT Birthing Trainer used in our evaluations was not available to the participants to use for any additional training for the duration of the study. Shoulder dystocia is a rare obstetric emergency, and it is unlikely many participants would have gained significant experience of actual shoulder dystocia during the study period.12 We believe that this remains true to life; self-directed learning based on past or predicted clinical encounters cannot and should not be prevented. The 6- and 12-month evaluation dates were not a surprise to participants, with evaluation dates booked in advance to optimize follow-up. However, participants were deliberately not told that one of the three simulated obstetric emergencies they would manage would be shoulder dystocia; nevertheless, some participants may have predicted the simulated emergency and revised its management. Nevertheless, we believe these are robust data on the retention of learned skills which should inform the frequency and nature of practical shoulder dystocia training.
Participants who had been able to deliver the neonate before training were more likely to attend all four assessment sessions (70%) compared with just 40% of those who had been unable to deliver the neonate before training. The reduced follow-up of poor performers introduces bias but does not negate the findings of this study. Moreover, this highlights an important issue for trainers; staff who are initially lacking competency may be less motivated to attend further training.
Although it was not a primary intention of the study, it is important to record that, of those who had been unable to deliver the fetus after initial training (group 3), 60% were able to achieve delivery 6 months after remedial tuition, and at 12 months, 79% were able to deliver the fetus. As a group they were less efficient in achieving delivery (on average approximately 40 seconds slower), but they performed the basic actions well, and they were also good communicators. These findings show that about one in five requires more training and that a high proportion of this number is able to acquire and retain the skills needed to manage shoulder dystocia. It could be that some learn more slowly, require a different style of, or individualized, training. Perhaps it is a reflection of well-established differences in individual’s learning styles.13 Further study is required to answer that question.
These results show that for the majority of staff, a 40-minute practical shoulder dystocia training session was sufficient to gain and sustain the skills required to manage a simulated scenario of severe shoulder dystocia. As one might expect, 1 year after the first evaluation, 94% of participants who had been able to achieve delivery could still do so. Nevertheless, among participants who had achieved delivery after the training, there was a small but clinically significant number of participants who unable to deliver the fetus at 6 and 12 months. The participants were predominantly in the group of 41 who had learned to deliver the neonate successfully during training (group 2); 17% (95% confidence interval 6–35%) and 12% (95% confidence interval 3–31%) failed to deliver the fetus at 6 and 12 months.
Among the first two subgroups, there was no change in the performance of basic actions, which were generally performed well, over time. Similarly, there was no significant decline in delivery interval, maximal force used, or patient communication. Even so, it was evident that care was not ideal throughout the two groups, with 5% to 10% consistently unable to perform all basic actions and a trend to a reduction in the proportion of staff unable to deliver the posterior arm. In addition, many applied a maximal force of more than 100 N. Optimizing the management of shoulder dystocia, especially for severe cases when advanced maneuvers (such as delivery of the posterior arm) are important, remains a challenge for all doctors and midwives.
The most important aspect of training is ensuring that initial training is effective. Three studies have each found that practical shoulder dystocia training improves the management of simulated shoulder dystocia.9–11 The question remains of what is the optimal interval between training sessions? For those who are initially competent, annual training is probably adequate, but for those who gain proficiency during initial training or with remedial teaching, it would seem prudent to check competency every 3 to 6 months until skill retention is established. However, at present it remains unknown whether the competent management of a simulated shoulder dystocia equates to competent management of a real-life shoulder dystocia.
In conclusion, in this study of learning decay after practical training for shoulder dystocia, skill retention was high, even for those who had failed to deliver the neonate after initial training and subsequently underwent additional, individualized, training. Those with good skill levels before initial training performed best of all. Those who had responded well to initial training generally retained their skills, but 17% were unable to deliver the neonate at 6 months. We advise that annual training is adequate for those who are proficient before training, but additional training sessions should be arranged for those who lacked competency before training, and posttraining competency should be evaluated. If difficulties remain after initial training, individualized training should be given to ensure all staff have acquired the skills to manage severe shoulder dystocia adequately.
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