|Shoulder Dystocia Training
A shoulder dystocia drill is a practice run-through by a labor and delivery unit of a mock shoulder dystocia delivery. Because shoulder dystocia—like most severe obstetrical emergencies—occurs too infrequently for skill to be developed in handling it properly just by routine work on the Labor and Delivery floor, training with shoulder dystocia drills has been suggested both as a practice protocol and as a teaching technique for all members of the obstetrical team. Some authors have stated that it is the obligation of every delivery unit and every obstetrician to participate in routine shoulder dystocia drills as part of obstetrical readiness. There are now several excellent videos on line –including one produced by the American College of Obstetricians and Gynecologists (ACOG) -- AVL 103 -- that describe and visually demonstrate model shoulder dystocia drills.
There have been multiple reports in the recent obstetrical literature by units that have instituted such drills, with surprisingly varied results. One has to be aware when reading this literature as to whether the improvements claimed are from real shoulder dystocia deliveries or are only improvements in drill performance.
Draycott and Crofts from England were among the first to implement and study the results of shoulder dystocia simulation. In 2005 they develop a unique manikin for training and investigated its effectiveness in improving performance of physicians and students in initiating the correct steps for shoulder dystocia resolution. They found that the management of shoulder dystocia improved following training with the manikin. There was a reduction in both the head-to-body delivery duration and in maximum applied delivery forces. They specifically noted that after training no subject applied of delivery force greater than 100 Newtons.
Draycott (2008) then took the next step: He compared the management of shoulder dystocia and neonatal outcomes before and after introduction of his shoulder dystocia training program in live births at a hospital in southwest England. He was able to show for the first time with real deliveries that there was a significant reduction in neonatal injury from shoulder dystocia--9.3% compared to 2.3%--after the introduction of a shoulder dystocia training program for all maternity staff. Subsequently Deering (2011) demonstrated similar findings in the United States
Grobman (2011) studied the results of the implementation of a shoulder dystocia protocol focused on total team response. His group measured the results of shoulder dystocia deliveries in three six-month periods, one before, one during, and one after the protocol was established. Complete and consistent documentation increased from 14% to 92% while the incidence of brachial plexus palsy fell from 10.1% to 4.0% and finally to 2.6%. Thus study confirmed the utility of a shoulder dystocia training program for labor and delivery units.
Inglis (2011) implemented a training program for shoulder dystocia for his entire maternity staff. His group found that the overall incidence of obstetrical brachial plexus injury from vaginally deliveries decreased from 0.4% (pretraining) to 0.14% (post training). Interestingly, after shoulder dystocia training there was a decrease in the use of McRoberts maneuver and an increase in the use of posterior arm delivery and the Rubins maneuver.
But not all studies on shoulder dystocia simulation training have shown the same successful results described above:
Walsh (2011) compared two time periods—1994-1998 and 2004-2008. The second time period was after there had been a specific staff training program in the management of shoulder dystocia. He found that the incidence of brachial plexus injury remained unchanged: 1.5 per 1000 deliveries in the earlier group and 1.7 per 1000 deliveries after the training program had been implemented.
Comeau (2014) reported on a group of 17 obstetrical residents who were offered a training program in the documentation of shoulder dystocia deliveries. Assessed as a group, there were no differences in the completeness of documentation before and after the simulation session.
Kim (2016) initiated a program of mandatory shoulder dystocia simulation training for obstetrical providers at the University of Minnesota in Minneapolis. While this program resulted in an increase in the identification of shoulder dystocia events, there was no decrease in adverse maternal or neonatal outcomes. He concluded that provider training alone does not impact adverse maternal and neonatal outcomes.
Although practicing and preparing for any emergency is always a good idea, it is not clear whether a formalized drill performed at regular intervals is necessary to provide good care. What is necessary, however, is that obstetricians, obstetrical nurses, and everyone involved with deliveries know that any vaginal delivery can suddenly turn into a shoulder dystocia emergency. They therefore must be aware of and able to perform the steps necessary to resolve this emergency in an orderly, efficient manner.
Copyright © 2017 Henry Lerner