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Review Articles

Simulation of Shoulder Dystocia for Skill Acquisition and Competency Assessment

A Systematic Review and Gap Analysis

Gurewitsch Allen, Edith D. MD, MBA

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Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: August 2018 - Volume 13 - Issue 4 - p 268-283
doi: 10.1097/SIH.0000000000000292
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Shoulder dystocia, the obstructed delivery of an infant's shoulders and body after emergence of the head in the final moments of birth (Fig. 1), occurs unpredictably as an obstetric emergency in 1 in 20 to 30 term vaginal deliveries.1–3 Prompt recognition and expeditious, skillful performance of specialized delivery maneuvers (Fig. 2) are required to mitigate against injury to the newborn's brachial plexus nerves that control movement and sensation of the upper extremity. Brachial plexus injuries complicate up to 40% of deliveries affected by shoulder dystocia.4 Permanent neonatal brachial plexus injury related to shoulder dystocia is a leading cause of litigation against obstetric providers in the United States, with 60% of lawsuits resulting in median payouts up to four times that of all other malpractice claims.5

Impaction of the fetal shoulder against the maternal pubic symphysis obstructs delivery of the body; if unrecognized, forceful attempts at delivery can stretch and injure the brachial plexus nerves that control arm movement. Retrieved from:
Maneuvers to alleviate shoulder dystocia can be categorized as indirect—where the locus of manipulation is maternal (eg, McRoberts and suprapubic pressure)—or direct—where the locus of manipulation is fetal (eg, Rubin, modified Woods screw or delivery of the posterior arm). Direct manipulation avoids placing traction on the fetal head, an action that increases the risk of injury to the brachial plexus. Retrieved from:

The largest prospective study of clinician-applied traction at more than 30,000 consecutive vaginal deliveries in Sweden demonstrates an increased likelihood of obstetric brachial plexus palsy with increasing levels of self-reported traction6 and a positive correlation between higher levels of traction and the number of nerve roots affected.7 Despite a near-universal association between permanent brachial plexus palsy and antecedent shoulder dystocia,8–11 the clinician's role in mitigating the risk of injury continues to be debated—most vigorously in countries where litigation against providers is commonplace.4 The Agency for Healthcare Research and Quality recognizes a link between malpractice liability risk and the resistance of providers to examine root causes of patient harm.12 For maternity care specifically, exposure to liability risk has been linked to a 5.3% annual reduction in obstetric provider workforce.13,14 These sobering facts threaten continued training in and delivery of quality obstetric care unless reliable methods to reduce adverse outcomes from shoulder dystocia can be demonstrated and widely disseminated. Any objective assessment of provider competence in managing shoulder dystocia will depend on scientifically sound evidence of an inverse relationship between technical skill and the occurrence of injury.

Even before competency in management of shoulder dystocia can be assessed, there must be dependable processes for acquiring necessary skills. The unpredictable and emergent nature of shoulder dystocia challenges educators' ability to consistently train and credential obstetric providers in shoulder dystocia management if they rely solely on this emergency's actual occurrence during routine care. As a result, shoulder dystocia management has become a commonly used scenario for simulation-based instruction within obstetrics education. Simulation allows trainees to be exposed to realistic challenges and consequences of shoulder dystocia in a safe, controlled teaching environment.15

The greatest validation of any simulation-based medical education is to demonstrate a significant clinical impact16 on quality metrics, such as reduced rates of actual birth injury. For management of shoulder dystocia specifically, several investigators have achieved success in transferring skills mastered with simulation training to clinical practice.17–21 Not only have rates of brachial plexus injury been reduced by 66%18,20 to 90%17; permanent neonatal brachial plexus injuries have even been eliminated altogether when training is repeated annually.22 Professional liability insurance carriers increasingly are mandating simulation-based rehearsal and competency assessment of their covered obstetric providers' shoulder dystocia management skills,23,24 no doubt spurred by these impressive results, which include reductions in malpractice claims filed.25 Nonetheless, other investigators have not demonstrated these benefits of simulation training for shoulder dystocia management,26,27 which raises questions about the comparative effectiveness of differing simulation training schemes and instructional content used among successful and unsuccessful interventions.28

Whether the impetus for mandating simulation-based skills acquisition and competency assessment for management of shoulder dystocia is to examine and respond to presumed root causes of sentinel events such as permanent brachial plexus injury or is externally incentivized by malpractice insurers, meeting the demand for quality shoulder dystocia simulation will require rapid scaling up of access with considerable investment of time and resources.29,30 Thus, it is crucial that evidence for shoulder dystocia simulation training's effectiveness—whether educational, clinical, or cost—is evaluated and its limitations and gaps identified. Many previous reviews of the literature on simulation-based training for shoulder dystocia management skills acquisition and competency assessment are ad hoc rather than systematic.29,31,32 Smith31 concluded that team training and institutional protocols for shoulder dystocia should be an integral part of safety initiatives to improve technical skills and team performance. Others consider the evidence as part of several obstetric emergencies that can be effectively simulated.33–40 There are three systematic reviews of general obstetric simulation; all focus on multiple complications. A review by Cooper et al41 includes shoulder dystocia within its table of previous simulation studies; they conclude that simulation is a critical component of obstetric curricula because it enhances clinical practice and reduces the time to gain competence. Merién et al42 and Lapkin et al43 conclude that simulation is useful for reducing errors, improving behavior, and increasing knowledge and critical thinking skills.

Only one study devoted specifically to shoulder dystocia includes a systematic review, but it focuses exclusively on the role of episiotomy in shoulder dystocia management.44 No study to date has performed a systematic review of the role of simulation specifically for shoulder dystocia management. The other ad hoc reviews specifically on shoulder dystocia simulation training cite evidence for its variable clinical impact,33–40 but none differentiate curricular elements between effective and ineffective simulation-based training content.

Thus, the objectives of this systematic review are two-fold: (1) to assess critically the current evidence for simulation of shoulder dystocia as an efficient and effective tool for provider skill acquisition and competency assessment and (2) to identify gaps in current knowledge about the comparative effectiveness of varied simulation-based educational content. The available research is appraised for its differentiation of curricular emphasis on use of rotational maneuvers, limiting clinician-applied force and assessment of time to relieve the obstruction, because these three elements of training are hypothesized—based on the effect of traction, technique, and head-to-body interval on injury45–49—to correlate with successful translation of simulation effectiveness to actual patient outcomes. Herein, the status of shoulder dystocia simulation as a training method is evaluated and lingering questions are identified. The latter is intended to set the research agenda needed to inform widespread evidence-based implementation of shoulder dystocia simulation for obstetric providers' skill acquisition and competency assessment.


PubMed, Scopus, and CINAHL Plus databases were searched using the following terms: “simulation AND shoulder dystocia,” “obstetric simulation training,” “shoulder dystocia training,” and “‘shoulder dystocia’ AND ‘systematic review’.” Snowball sampling was performed to identify additional relevant literature from the bibliographies of relevant articles yielded from the initial search. Articles were included for abstract review if they were published between 2003 and 2017 (within the last 15 years) and their full-length text was available online in English. Each abstract was then reviewed, and final articles were selected for in-depth analysis if they presented original research on simulation-based training specifically for shoulder dystocia, involved trainee participants, and included identified metrics subjected to statistical analysis. Where studies included simulation of multiple obstetric emergencies, articles were included if the results of the shoulder dystocia simulation were evaluated separately. Those articles describing interprofessional training were retained if clinicians who perform deliveries (ie, midwives and/or physicians, either practicing or in training) were among the participants. Conference abstracts, ad hoc reviews, letters, commentaries, and narrative-only descriptions of simulation without data collection or analysis were excluded.

The selected articles were analyzed for study design, types and number of participants, outcomes of interest, primary metrics used, and whether specific instructional elements such as emphasis on limiting delivery force, prioritization of rotational maneuvers, and evaluation of time were described. Several national guidelines on management of shoulder dystocia50–54 and published educational objectives for simulation training55 also were consulted if they were designated within the selected studies as the curricular basis for the specific training provided during the study. The educational paradigms of prescriptive and proscriptive instruction served as the theoretical framework for the analysis; “prescriptive” and “proscriptive” were defined respectively as positive or directed teaching of “what to do” and negative teaching or deliberate demonstration of common errors in technique that would increase the risk of injury (ie, specific instruction in “what NOT to do”).


Of 794 initial search returns, 190 non-overlapping titles met initial search criteria for abstract review. A secondary search of the OVID Medline and Google Scholar databases did not yield any titles not already identified, and only one additional article was identified from bibliographies. From the 190 abstracts reviewed, a total of 45 separate articles describing original research on simulation of shoulder dystocia for training purposes met inclusion criteria for in-depth qualitative systematic review. Three foci of educational research on this topic were classifiable as follows: evaluation of learner performance (LE) by trainers (Table 1, 23 articles), evaluation of the simulation program (SE) by participants (Table 2, 8 articles), and the clinical impact (CI) of systematic simulation-based training on actual outcomes of shoulder dystocia (Table 3, 14 articles). Thirty-eight articles were primary analyses; another seven were secondary analyses of parent studies. Specific prescriptive instruction was described far more commonly (30/38 primary articles, 79%) than was proscriptive instruction (16/38 primary articles, 42%). In the CI-focused articles (6/12 primary articles, 50%), description of specific elements of proscriptive instruction occurred more commonly than it did among SE-focused (3/8 primary articles, 38%) and LE-focused (7/18 primary articles, 39%) articles.

Summary of Original Research of Simulation-Based Training for Shoulder Dystocia—Learner Evaluation
Summary of Original Research of Simulation-Based Training for Shoulder Dystocia—Simulation Evaluation
Summary of Original Research of Simulation-Based Training for Shoulder Dystocia—Clinical Impact

Although not the first publication on the matter,15,56 the most extensive knowledge on shoulder dystocia simulation training to date derives from the Simulation and Fire-drill Evaluation (SaFE) Study, a large randomized controlled trial of obstetric simulation training commissioned by the Department of Health of England and Wales.58 Although the scope and success of this comprehensive simulation training program are undeniable, it also dominates the literature34—accounting for 11 (24%) of the 45 articles reviewed here. Indeed, these authors collectively have published most of the original research evaluating multiple aspects of simulation-based training specifically for shoulder dystocia management, including study design and randomization,58 development of assessment instruments,57,59,88 training of trainers,59,65 didactic content described,58,89 learner evaluation metrics (eg, force measurement, documentation, communication, skill retention),58,60,63,89 evaluation of instructional elements (eg, simulator type, setting, teamwork),58,59 lessons learned,63 and translational clinical results.17,22 Only recently have other national-level efforts at simulation-based training been replicated,69,72,87 which included additional analyses of clinical impact,86 skill retention,87 and cost-effectiveness.30


Which Maneuvers to Use? A Prescriptive Approach

Self-reported confidence in the technical performance of maneuvers improves when learners are exposed to simulation training.77,80 Most studies of simulation training employ a prescriptive approach, directing participants through a specified sequence of maneuvers; however, they vary in their emphasis on specific techniques. Nine (39%) of 23 studies that evaluated learner performance (Table 1) between participants who did or did not receive training15,66,67,69,74 or in the same participants before and after training58,59,64,72 did not specify a distinct protocol or algorithm to be used; yet the use of specific maneuvers was scored by raters, and use of posterior arm delivery demarcated the successful resolution of shoulder dystocia in all studies of learner performance. By contrast, among eight studies where the quality and utility of simulation were evaluated by the participants (Table 2), only three (38%) specified the sequence of maneuvers to be followed,73,76,78 whereas the remainder involved systematic review and rehearsal of all maneuvers without predetermined expectations about sequence or independent recollection.

Ethical concerns limit the feasibility of testing in vivo the relative efficacy of different maneuvers for their impact on fetal injury. Experimental findings in the biomedical engineering laboratory48 and biomechanical analysis90 suggest that shoulder dystocia maneuvers that involve direct manipulation of the fetal trunk by the birth attendant (eg, Rubin maneuver and delivery of the posterior arm) have a mechanical advantage over indirect maneuvers where the mother is acted upon by nondelivering members of the team or by laypersons (eg, application of suprapubic pressure and McRoberts positioning). The latter achieves delivery of the fetal body by traction on the fetal head; the former eschews pulling on the head (Fig. 2). Furthermore, determining the alignment of the fetal shoulders by direct palpation and then manually adjusting the fetus' shoulder span to an oblique orientation within the pelvis before application of traction to the fetal head (Rubin maneuver)48 and delivery of the posterior arm,91 each reduces strain on the brachial plexus compared with McRoberts or laterally applied traction. Prioritizing a rotational maneuver early in a management algorithm for shoulder dystocia during simulation-based drills decreases the incidence of brachial plexus injury in the clinical setting,18 whereas emphasis on use of McRoberts maneuver is associated with an increase in actual brachial plexus injuries.27

A Question of Clinician-Applied Traction Force

Despite controversy about its role in every type of neonatal brachial plexus palsy,4 it is considered axiomatic and prudent to limit the traction applied to the fetus' head during attempts to relieve shoulder dystocia.52,54 Nevertheless, the extent to which application of traction is emphasized or addressed at all in shoulder dystocia simulation training varies considerably among the different studies, and its specific inclusion in guidelines and educational objectives has evolved over time.50–52,54 A comparison of the original national guidelines50,51 reveals significant differences in management recommendations between the United States and the United Kingdom,92 which persist even after revision. The updated American national guidelines downplay the relationship of clinician-applied traction to brachial plexus injury.4,54 In contrast, British national guidelines for management of shoulder dystocia have been updated to include a joint recommendation by the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists for annual skill drills for all birth attendants. In addition, the original statement that “routine traction in an axial direction may be employed to diagnose shoulder dystocia”51 was redacted to add the following caveat: “but any other traction should be avoided.”52 The recent American Congress of Obstetricians and Gynecologists Simulations Consortium's Learning Objectives for Shoulder Dystocia only mentions use of “appropriate” traction in the recognition and diagnosis of shoulder dystocia;55 limiting of concomitant traction applied during other maneuvers is not addressed.

The difference in emphasis on clinician-applied traction likely is attributable to the varying assessment of its significance that has emerged from simulation training research. Among the five studies where applied traction force was assessed, studies using a subjective assessment by the evaluator found no difference in applied force15 or did not specify whether force patterns differed64,66 between trained and untrained participants. However, marked differences in level of force used before and after training57,89 and in patterns of force used during different maneuvers68 were found in those studies where applied force was measured objectively by a strain gauge embedded within the mannequin. It is noteworthy that several studies showing a positive impact of simulation training on rate of actual fetal injury after shoulder dystocia used the objective force measurement during training,17,22,85 whereas those showing no difference in outcomes of actual shoulder dystocia did not include an assessment of clinician-applied traction during training.26,27 Only one study evaluating the value of simulation to learners makes specific mention of the magnitude and direction of traction force to be applied, but this was assessed by participants only subjectively (ie, no force measurements were taken).76 In those studies where force was measured, the amount of force exerted was only provided to participants retrospectively during debriefing.57,58,68 To date, there has not been a direct comparison of objective and subjective assessments of simulation-trained clinicians' applied traction nor between real-time and after-the-fact disclosure of force measurements to trainees.

Time as a Factor

Shoulder dystocia is considered an emergency because failure to timely resolve the obstructed delivery of the infant can result in neonatal asphyxia or even death. The precise amount of time that can safely elapse before asphyxial insult occurs is unknown, but it is estimated to be at least 6 minutes for an otherwise healthy fetus.93 Because nearly every maneuver for shoulder dystocia can be executed in a matter of seconds, time to resolution of shoulder dystocia is another objective metric for provider competence15,58,60,66 and considered a critical element for documentation.56,62,71,94 Only the SaFE study used an a priori limit of 5 minutes to complete delivery58; other studies of learners' performance of simulated shoulder dystocia maneuvers15,58,72 allowed participants to continue until either posterior arm delivery was performed or no further maneuvers were attempted. In all these studies, a shorter head-to-body delivery interval time was considered evidence of learners' skill acquisition.

The deliberate insertion of a hands-off period in which no action is taken until the next uterine contraction occurs after delivery of the head has been advocated as a method to reduce the incidence of shoulder dystocia95,96 and has been shown to have no significant clinical effect on neonatal Apgar scores or cord blood pH level.97,98 Inglis et al18 incorporated this into an algorithm along with adjustment of the shoulder position to oblique orientation before application of traction. They noted only a 30-second increase in recorded head-to-body interval during actual shoulder dystocia after the introduction of simulation-based drills using these principles, while simultaneously increasing the use of Rubin's maneuver from 17% to 32% and reducing the incidence of brachial plexus injury from 30% to 10.7%.18 Gurewitsch Allen et al20 recently reported similar results using the same principles.

The Value of Team-Based and Repeated Training

Evidence for the value of simulation training for development of individual participants' technical and nontechnical skills, confidence, and competence is more positive compared with evidence of its value for team-based responses to shoulder dystocia. Neither the SaFE study59 nor the randomized controlled trial of team training by Fransen et al86 found a difference in either team-member knowledge59 or clinical impact69 between simulations that included teamwork and those that did not. Similarly, Walsh et al26 did not observe a change in clinical outcomes with the introduction of team-based training. On the other hand, Grobman et al19 found that team training was associated with positive clinical outcomes, and improved work environment was demonstrated by Sørensen et al.77 Recent secondary analyses of team-based simulation training for obstetric emergencies, including shoulder dystocia, have also shown positive clinical impact on adverse outcomes.86,87 Paradoxically, it is noteworthy that the assessment tools used for evaluation of teamwork have been validated and standardized to a far greater extent than have those used to assess provider skill, either for obstetric emergencies in general or for shoulder dystocia management in particular. The latter represents an important gap in knowledge about reliability and validity of simulation-based competency assessment.

Those few studies that assess long-term skills retention22,60,70,73,77,81,87 also have yielded mixed results; however, repetition of training before reassessment and length of time between training sessions varied widely. Where studied, the overall impact of repeat simulation training on skills acquisition and retention by novices tended to be greater than by experienced personnel who already demonstrated greater competence at initial training.60

Learning From Error

The Role of Proscriptive Instruction

Medical simulation is touted for its ability to uncover systematic error, which in turn can be used to improve subsequent performance—either at the individual or at the team level—during training99 and in actual clinical practice.19 Only four studies have addressed directly the types of errors specifically identified during simulation training for shoulder dystocia.18,61,63,100 Protocols for team management of shoulder dystocia have been developed using quantitative methods such as targeted interviews with providers and iterative rehearsals100; unit-wide dissemination of the protocol to all labor and delivery personnel was achieved with simulation on site.18,63,100 Deficiencies in communication63,100 and documentation,61,100 as well as errors in performing maneuvers61,63 were reported commonly. However, only Crofts et al63 specifically cited use of excessive traction as an error and only Inglis et al18 included a deliberate “hands-off” procedure upon initial recognition of shoulder dystocia. From an educational standpoint, a corollary to proscriptive instruction NOT to apply too much traction is NOT to apply any traction too soon. Thus, the conscious limiting of traction applied to the head and purposely awaiting a brief period of time in which no action should be taken (eg, manually assisting external rotation of the fetal head) are proscriptive instructions, requiring the preceptor to specify what not to do. This differs from identifying errors of omission, which are corrected with prescriptive instruction demonstrating each technique. Errors of commission, such as using improper technique or applying traction in excess of that normally used, may or may not materialize during a given shoulder dystocia simulation; thus, correction or emphasis on specific avoidance of such errors will occur only intermittently during simulation training unless purposely included in the instructional content.65,70 To date, the effectiveness of prescriptive versus proscriptive elements of instruction has not been compared directly.

Feedback to Learners

In 8 (21%) of 37 primary-analysis original reports on shoulder dystocia simulation for training and competency assessment, evaluation of participant performance, documentation accuracy, and detection of errors was made retroactively, using careful analysis of videotaped sessions,15,56,58,61–63,66,72 whereas only six (16%) simultaneously included a checklist that was completed by the preceptor in real time during simulation.15,61,62,64,65,87 Goffman et al64 relied on real-time scoring, referring to the videotapes only to adjudicate between incongruous scores by independent observers. The SaFE study used only real-time recording of objective time points (eg, performance of specific maneuvers, head-to-body interval) to assist with time-based analysis of objective force measurement data.58,63,89 Viewing of videotapes as part of debriefing immediately after simulation training was used in only two studies.64,73 However, a direct comparison of real-time versus retroactive assessment for validity and interrater reliability has not been made.


This review analyzes simulation of shoulder dystocia specifically and reveals significant differences in simulation curricula and metrics, as well as several critical gaps in current knowledge: (1) prescriptive instruction prioritizing maneuvers shown to decrease strain on the brachial plexus is inconsistently used. (2) Proscriptive instruction to avoid placing excessive and laterally directed traction on the head or to observe a brief hands-off period before attempting traction is infrequently explicit. (3) Neither relative effectiveness nor potential interaction between prescriptive and proscriptive elements of instruction has been examined directly. (4) Reliability and validity of costly high-fidelity mannequins capable of objective measurement of clinician-applied traction force as compared with subjective assessment of provider competence are unknown.

Several limitations of this systematic review must be acknowledged. As is true of most qualitative research methods, the chosen theoretical framework as the basis for this analysis reflects the perspective and expertise of the single author; interaction between the research findings and the researchers—whether singular or multiple—cannot be avoided. Most of the original research on simulation for shoulder dystocia management predates the relatively recent emphasis on standardized simulation-based research reporting. Thus, it is possible, if not likely, that a simulation-based curriculum may have included such topics as limiting traction and effective time management, but these may not have been explicitly stated in the article. Furthermore, in every CI-focused study, the methods for calculating actual clinical rates of brachial plexus injury and the periods over which this relatively uncommon complication was observed were not standardized; thus, the reasons for inconsistent translation of simulation results to actual clinical results cannot be directly attributed to the differences in curricular content systematically reviewed herein. This would require formal experimentation with explicit reporting standards.

Finally, the most glaring deficiency in simulation-based training is the lack of standardization and validation of specific curricular content. Development of cognitive aids in this area will require iterative steps, and evaluation of several key research questions before use of simulation for skills acquisition and competency assessment can be considered valid, reliable, sufficiently standardized, and high quality to be used for certification purposes: How does the deliberate inclusion of specific demonstrations of applying excessive traction or using improper technique impact learners' skills acquisition and competency assessment? Is there an interaction between prescriptive and proscriptive instructional methods? Is there a difference in skills acquisition and/or competency assessment when simulation-based training uses real-time versus retroactive evaluation metrics? Is subjective assessment of provider performance comparable with objective metrics such as force measurement? These questions will require further study to inform widespread evidence-based implementation of shoulder dystocia simulation for clinically translatable skill acquisition and competency assessment.


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Prescriptive instruction; proscriptive instruction; virtual reality simulation; haptic simulation; high-fidelity mannequins; brachial plexus injury; risk management

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