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Using Simulation Training to Improve Shoulder Dystocia Documentation

Goffman, Dena MD; Heo, Hye MD; Chazotte, Cynthia MD; Merkatz, Irwin R. MD; Bernstein, Peter S. MD, MPH

doi: 10.1097/AOG.0b013e31818c177b
Original Research

OBJECTIVE: To estimate whether shoulder dystocia documentation could be improved with a simulation-based educational experience.

METHODS: Obstetricians at our institution (n=71) participated in an unanticipated simulated shoulder dystocia followed by an educational debriefing session. A second shoulder dystocia simulation was completed at a later date. Delivery notes were a required component of each simulation. Notes were evaluated using a standardized checklist for 16 key components. One point was awarded for each element present. Wilcoxon signed rank tests were used to compare documentation between simulations.

RESULTS: Participants consisted of 43 (61%) attending and 28 (39%) resident physicians. Ages ranged from 25–63 years (mean±standard deviation 37.0±9.0), and 75% were female. Years of obstetric experience for our attendings ranged from 4 to 31 years (14.5±8.1). Documentation scores were significantly improved after training. Attendings’ baseline documentation scores were 8.5±2.2 and improved to 9.4±2.3, P=.03. Residents’ documentation scores also improved (9.0±2.1 compared with 10.6±2.2, P=.001). In particular, improvement was seen in two components of documentation: 1) providers present for shoulder dystocia (P=.007) and 2) which shoulder was anterior (P<.001). No improvement was seen in standard delivery note components (eg, date, time) or infant characteristics (eg, weight, Apgar scores).

CONCLUSION: Although we showed a significant improvement in the quality of documentation through this simulation program, notes were still suboptimal. Use of standardized forms for shoulder dystocia delivery notes may provide the best solution to ensure appropriate documentation.


Simulation training results in improved shoulder dystocia documentation; however, additional methods may be needed to ensure inclusion of crucial details for these deliveries.

From the Department of Obstetrics, Gynecology and Women’s Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York.

Presented at the American College of Obstetricians and Gynecologists 56th Annual Clinical Meeting, New Orleans, Louisiana, May 3–7, 2008.

Corresponding author: Dena Goffman, MD, Department of Obstetrics, Gynecology and Women’s Health, Montefiore Medical Center, 1825 Eastchester Road, Bronx, NY 10461; e-mail:

Financial Disclosure The authors have no potential conflicts of interest to disclose.

A malpractice crisis exists in obstetrics,1–4 and shoulder dystocia is a leading cause of allegations in our specialty.1,2,5 Notes from these deliveries often lack critical elements of documentation.6 Documentation of the appropriate management of a shoulder dystocia delivery can be used to demonstrate standard of care management and decrease the potential for successful malpractice litigation.4,7 Finding a way to improve documentation of the management of these complex deliveries is critical to reducing medical malpractice liability.

Simulation training is being increasingly incorporated into the fields of obstetrics and gynecology.8,9 Evidence is accumulating suggesting improved performance in subsequent simulations for obstetric emergencies.10–14 Deering et al6 showed that residents’ documentation of a simulated shoulder dystocia delivery often lacked critical elements. To date, no data exist to support the use of simulation to improve documentation deficiencies.

Our study objective was to estimate whether a simulation-based educational program could be used to review critical components of documentation and improve resident and attending documentation in subsequent simulated shoulder dystocia deliveries. Our null hypothesis was that there would be no difference in simulated shoulder dystocia delivery notes before and after our intervention.

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Resident and full-time faculty attending physicians at a large university-based hospital participated in a new shoulder dystocia simulation program that commenced in October of 2006, and initial participation was completed in July of 2007. Simulations were performed using a combination of human actors and a modified NOELLE full-sized female anthropomorphic robotic birth simulator (Gaumard Scientific, Coral Gables, FL) in a fully stocked mock labor and delivery suite. Control or delay of delivery of the simulated infant was achieved manually by one of the physician/actors. All simulations were digitally recorded for analysis and education purposes. This investigation was reviewed by our institutional review board and granted exempt status.

Subjects arrived for their simulation exercise without prior notice of the type of simulation to be performed. Subject numbers were assigned, and background information was collected, including gender, age, job title, and total completed years practicing obstetrics and gynecology (including residency). Participants were then given a brief introduction to our simulation study and instructed to treat the experience as a real situation and to proceed as they would with a real patient. Subjects were then urgently called into the room by our labor and delivery nurse for an imminent delivery where a shoulder dystocia ensued. Upon completion of the simulated delivery, subjects were provided with infant weight, Apgar scores, head-to-body interval for delivery, and a mock chart including a full admission note, history, and physical examination. Subjects were required to write a delivery note documenting the events of delivery. Physicians were asked to include everything they would include in a real shoulder dystocia delivery note, even if a particular detail was difficult to simulate.

After the initial simulation, group training/debriefing sessions were conducted. Each training sessions consisted of 1) shoulder dystocia background, 2) a review of the basic maneuvers and a basic algorithm for management of shoulder dystocia, 3) a discussion on optimizing team performance during an obstetrical emergency, and 4) a review of the key components of documentation. At a later date, each provider participated in a second standardized shoulder dystocia simulation, followed by another delivery note.

Each delivery note was evaluated by two independent physicians for 16 key components of documentation.6 Seven routine delivery note components were evaluated, including date, time, infant birth weight, Apgar scores, cord gases sent, estimated blood loss, and presence of/type of anesthesia. Nine components specific to shoulder dystocia were evaluated, including classification as shoulder dystocia, documentation of all providers present, documentation of which shoulder was anterior, the amount of time it took to deliver the shoulder, documentation of all maneuvers used, the correct order of maneuvers used, comments on condition of infant extremities, documentation that pediatric staff was called for the delivery, and documentation of a conversation with the patient explaining dystocia. All of these elements were stressed during the educational debriefing session held after the first simulation exercise.

Statistical analysis was performed using SPSS statistical software (SPSS Inc., Chicago, IL). Comparison of continuous variables was performed using Wilcoxon signed rank tests. Dichotomous variables were analyzed using the χ2 analysis or Fisher exact test. P<.05 was considered significant.

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Seventy-one of a potential 86 physicians (83%) completed the study. Exclusions were six never able to attend due to scheduling, eight completed one simulation but unable to complete their second simulation due to scheduling, and one physician refused participation. The study population included 43 (61%) attending and 28 (39%) resident physicians. Overall, ages ranged from 25–63 years (mean±standard deviation 37.0±9.0), and 75% were female. Years of obstetric experience for our attendings ranged from 4 to 31 years (14.5±8.1). Details of the study population are presented in Table 1.

Table 1

Table 1

Overall documentation scores (maximal score of 16) were improved for both residents (pretraining mean±standard deviation [SD] 9.0±2.1 compared with posttraining mean±SD 10.6±2.2, P=.001) and attendings (pretraining mean±SD 8.5±2.2 compared with posttraining mean±SD 9.4±2.3, P=.03). Documentation of elements specific to shoulder dystocia (maximal score of 9) were also improved for both residents (pretraining mean±SD 5.0±1.5 compared with posttraining mean±SD 6.0±1.4, P=.016) and attendings (pretraining mean±SD 4.5±1.2 compared with posttraining mean±SD 6.0±1.5, P≤.001). There was no statistically significant improvement in any one of the routine delivery note components (see Materials and Methods). Improvement was seen in some individual components of documentation specific to shoulder dystocia (Table 2).

Table 2

Table 2

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Obstetric emergency simulations provide a unique opportunity to evaluate the accuracy and adequacy of documentation for these complicated deliveries. Looking critically at documentation in the simulated environment may help us to discover deficiencies and develop approaches for improvement.

Because we are increasingly using simulation in obstetrics and gynecology, it is important to consider for what simulation training works well and when, in fact, the labor and cost of simulation may not be worth the investment. We have previously shown that physician performance improves with simulation experience when performing a simulated shoulder dystocia and that physician satisfaction with this sort of training is high.14 In this study, we have shown that through our simulation training intervention we were able to improve shoulder dystocia documentation, but not to the level we had hoped. Delivery notes after our education intervention were still suboptimal. This is important information as it guides us moving forward.

As we strive for improvement in the quality of documentation, simulation training offers some benefit, however; we clearly need to do more than simulation-based education alone. Given the fact that documentation of standard of care practice is crucial, we must consider other strategies that are immediately available and able to be implemented to ensure accurate and complete documentation of these events. Based on our results, we believe that use of standardized forms for shoulder dystocia delivery notes may be the best solution to ensure appropriate documentation. We have implemented this strategy on our labor and delivery unit and plan to evaluate its effectiveness.

A potential limitation of our study design is one that arises for all simulation studies. It is impossible to know whether performance or documentation in the simulated environment accurately reflects what is seen in the clinical environment. It is reassuring that components like date and Apgar scores were reliably included in our simulated delivery notes. In our institution, newborn weights are not obtained until the infant reaches the nursery, so the fact that only about 40% of providers included the newborn weight is also consistent with what is seen in practice at our institution. Significant improvement was seen in two specific shoulder dystocia documentation components that were stressed in our intervention: documentation of providers present and documentation of which shoulder was anterior. However, scores for other components of shoulder dystocia documentation, similarly stressed in our intervention, did not improve (documentation that pediatrics was called for delivery, documentation of the condition of infants extremities, and documentation of a conversation with the patient explaining the events of delivery). We speculate that these components represent actions that are less easily simulated and therefore were not well documented in this study. For example, physicians were unlikely to engage in an explanation of the shoulder dystocia delivery with the simulator and therefore did not document such a conversation with the patient.

Our simulation program was useful to uncover important deficiencies in documentation that may place obstetricians at considerable medical–legal risk. However, while beneficial, our simulation-based educational intervention alone was not adequate to eradicate these documentation deficiencies. Although we will continue to highlight and teach the importance of documentation in our simulation program, we believe that a simple intervention such as a standardized form completed after a complicated delivery may be a more practical way to ensure adequate documentation, rather than expecting a provider to remember all of the necessary elements of documentation without guidance after a stressful event such as a shoulder dystocia. By implementing a standardized shoulder dystocia delivery note, we hope to aid physicians in creating an accurate and meticulous description of an obstetric event in the medical record, which may be invaluable in reconstructing the event should it be necessary in the future.

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© 2008 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.