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We congratulate Kim et al on developing a shoulder dystocia training program that included video instruction, a didactic portion and a simulation training session including force measurement, followed by a study aimed at evaluating the impact of the training on actual clinical outcomes.1 Their observed two-fold increase in shoulder dystocia incidence is consistent with some other studies,2, 3 and more in line with prospective clinical studies that report an incidence of ~ 4% among term vaginal deliveries.4, 5 It further suggests improved recognition of shoulder impaction in the final stages of delivery in the clinical setting following simulation-based training.
Ultimately, the patient safety goal of shoulder dystocia simulation training for should be the reduction in shoulder dystocia-associated brachial plexus injuries. We would be interested to learn if there was a higher correlation between brachial plexus injuries and shoulder dystocia after training than before.
Compared to other force training studies, Kim et al did not find a similar decrease in brachial plexus injuries.6-8 We offer a hypothesis as to why that might be.
We believe that demonstrating what 100 N feels during simulation, even with admonishing the trainee not to use that much traction, is not effective at reducing injury. One reason is that memory of that much traction once experienced is short-lived, and clinicians tend to underestimate the traction they apply during a difficu...
We believe that demonstrating what 100 N feels during simulation, even with admonishing the trainee not to use that much traction, is not effective at reducing injury. One reason is that memory of that much traction once experienced is short-lived, and clinicians tend to underestimate the traction they apply during a difficult delivery.9 In force training studies that demonstrate a clinical impact on shoulder dystocia-associated brachial plexus injury, providers were allowed to proceed with the delivery and were critiqued afterward. Often they went far beyond 100 N of traction. Gurewitsch Allen et al allowed trainees to prospectively estimate increasing levels of traction using a fetal head attached to a force measuring system; the trainees became better at estimating their own traction with repeated rehearsals.8
In still other studies where a decrease in brachial plexus injury incidence was observed after introducing a simulation-based intervention, a specific protocol was taught. Inglis et al. reduced their brachial plexus injury incidence by 2/3 after introducing a mandatory protocol (Code D) for all shoulder dystocia deliveries that began with a hands off period, a call for help, identifying fetal shoulder position and a rotation of the shoulders into the oblique pelvic diameter.10 These initial steps were considered mandatory before allowing for clinical judgement to be used concerning which additional shoulder dystocia maneuvers to employ. We previously demonstrated that rotation of fetal shoulders is mechanically advantageous over McRoberts;11 this is likely why Inglis et al were successful. Grobman, et al. was able to reduce brachial plexus incidence by a more than 80% introducing a team-based shoulder dystocia protocol, utilizing low-fidelity simulation (i.e., without force-training) and requiring prospective tracking of time elapsed during the head-to-body delivery interval.12
A systematic review of simulation-based training for shoulder dystocia identifies strengths and gaps in curricular content of differing training programs.13 We believe variation in clinical outcomes associated shoulder dystocia training programs is likely reflective of the differences in the curricular elements of each simulation program. The key is finding the simulation program that is most cost-effective and provides the best clinical outcome.
We again congratulate the important gains achieved by Kim et al in creating a training system that raises awareness of shoulder dystocia and recognition of the complication. Their lack of favorable impact on brachial plexus injuries should not discourage their continuing efforts.
1. Kim T, Vogel RI, Das K. Simulation in shoulder dystocia: does it change outcomes?. BMJ Simulation and Technology Enhanced Learning. 2018 Mar 29:bmjstel-2017.
2. van de Ven J, van Deursen FJ, van Runnard Heimel PJ, Mol BW, Oei SG. Effectiveness of team training in managing shoulder dystocia: a retrospective study. The Journal of Maternal-Fetal & Neonatal Medicine. 2016 Oct 1;29(19):3167-71.
3. Nguyen T, Fox NS, Friedman Jr F, Sandler R, Rebarber A. The sequential effect of computerized delivery charting and simulation training on shoulder dystocia documentation. The Journal of Maternal-Fetal & Neonatal Medicine. 2011 Nov 1;24(11):1357-61
4. Spong CY, Beall M, Rodrigues D, Ross MG. An objective definition of shoulder dystocia: Prolonged head-to-body delivery intervals and/or the use of ancillary obstetric maneuvers. Obstet Gynecol. 1995 September 01;86(3):433-6
5. Beall MH, Spong C, McKay J, Ross MG. Objective definition of shoulder dystocia: A prospective evaluation. Obstet Gynecol. 1998 October 01;179(4):934-7.
6. Draycott TJ, Crofts JF, Ash JP, Wilson LV, Yard E, Sibanda T, et al. Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol. 2008;112(1):14-20.
7. Crofts JF, Lenguerrand E, Bentham GL, Tawfik S, Claireaux HA, Odd D, et al. Prevention of brachial plexus injury-12 years of shoulder dystocia training: An interrupted time-series study. Brit J Obstet Gynaec. 2015;123(1):111-8.
8. Gurewitsch Allen ED, Brown Will SE. Improving shoulder dystocia management and outcomes with a targeted quality assurance program. Am J Perinatol. 2017;34:1088-96.
9. Creasy RK, Resnik R, Iams JD. Maternal-fetal medicine: Principles and practice. In: 5th ed. Philadelphia: W.B. Saunders Company; 2004. p.671,677, 678.
10 Gurewitsch ED, Kim EJ, Yang JH, Outland KE, McDonald MK, Allen RH. Comparing McRoberts' and Rubin's maneuvers for initial management of shoulder dystocia: an objective evaluation. Am J Obstet Gynecol. 2005 Jan 1;192(1):153-60.
11. Inglis SR, Feier N, Chetiyaar JB, Naylor MH, Sumersille M, Cervellione KL, Predanic M. Effects of shoulder dystocia training on the incidence of brachial plexus injury. American journal of obstetrics and gynecology. 2011 Apr 1;204(4):322-e1.
12. Grobman WA, Miller D, Burke C, Hornbogen A, Tam K, Costello R. Outcomes associated with introduction of a shoulder dystocia protocol. Obstet Gynecol. 2011;205(6):513-7.
13. Gurewitsch Allen ED. Simulation of Shoulder Dystocia for Skill Acquisition and Competency Assessment: A Systematic Review and Gap Analysis. Simulat Healthc. 2018 Aug 1;13(4):268-83.