Joanna F. Crofts

Improving neonatal outcome through practical shoulder dystocia training

OBJECTIVE: To compare the management of and neonatal injury associated with shoulder dystocia before and after introduction of mandatory shoulder dystocia simulation training. METHODS: This was a retrospective, observational study comparing the management and neonatal outcome of births complicated by shoulder dystocia before (January 1996 to December 1999) and after (January 2001 to December 2004) the introduction of shoulder dystocia training at Southmead Hospital, Bristol, United Kingdom. The management of shoulder dystocia and associated neonatal injuries were compared pretraining and posttraining through a review of intrapartum and postpartum records of term, cephalic, singleton births in which difficulty with the shoulders was recorded during the two study periods. RESULTS: There were 15,908 and 13,117 eligible births pretraining and posttraining, respectively. The shoulder dystocia rates were similar: pretraining 324 (2.04%) and posttraining 262 (2.00%) (P=.813). After training was introduced, clinical management improved: McRoberts’ position, pretraining 95/324 (29.3%) to 229/262 (87.4%) posttraining (P<.001); suprapubic pressure 90/324 (27.8%) to 119/262 (45.4%) (P<.001); internal rotational maneuver 22/324 (6.8%) to 29/262 (11.1%) (P=.020); delivery of posterior arm 24/324 (7.4%) to 52/262 (19.8%) (P<.001); no recognized maneuvers performed 174/324 (50.9%) to 21/262 (8.0%) (P<.001); documented excessive traction 54/324 (16.7%) to 24/262 (9.2%) (P=.010). There was a significant reduction in neonatal injury at birth after shoulder dystocia: 30/324 (9.3%) to 6/262 (2.3%) (relative risk 0.25 [confidence interval 0.11–0.57]). CONCLUSION: The introduction of shoulder dystocia training for all maternity staff was associated with improved management and neonatal outcomes of births complicated by shoulder dystocia. LEVEL OF EVIDENCE: II

Training for shoulder dystocia: a trial of simulation using low-fidelity and high-fidelity mannequins.

OBJECTIVE: To evaluate the effectiveness of simulation training for shoulder dystocia management and compare training using a high-fidelity mannequin with that using traditional devices. METHODS: Training was undertaken in six hospitals and a medical simulation center in the United Kingdom. Midwives and obstetricians working for participating hospitals were eligible for inclusion. One hundred forty participants (45 doctors, 95 midwives) were randomized to training with a high-fidelity training mannequin (incorporating force perception training) or traditional low-fidelity mannequins. Performance was assessed pre- and posttraining, using a videoed, standardized shoulder dystocia simulation. Outcome measures were delivery, head-to-body delivery time, use of appropriate and inappropriate actions, force applied, and communication. RESULTS: One hundred thirty-two participants completed the posttraining assessment. All training was associated with improved performance: use of basic maneuvers 114 of 140 (81.4%) to 125 of 132 (94.7%) (P=.002), successful deliveries 60 of 140 (42.9%) to 110 of 132 (83.3%) (P<.001), good communication with the patient 79 of 139 (56.8%) to 109 of 132 (82.6%) (P<.001), pre- and posttraining, respectively. Training with the high-fidelity mannequin was associated with a higher successful delivery rate than training with traditional devices: 94% compared with 72% (odds ratio 6.53, 95% confidence interval 2.05–20.81; P=.002). Total applied force was significantly lower for those who had undergone force training (2,030 Newton seconds versus 2,916 Newton seconds; P=.006) but there was no significant difference in the peak applied force 102 Newtons versus 112 Newtons (P=.242). CONCLUSION: This study verifies the need for shoulder dystocia training; before training only 43% participants could achieve delivery. All training with mannequins improved the management of simulated shoulder dystocia. Training on a high-fidelity mannequin, including force perception teaching, offered additional training benefits. LEVEL OF EVIDENCE: I

Hospital, simulation center, and teamwork training for eclampsia management: a randomized controlled trial.

OBJECTIVE: To compare the effectiveness of training for eclampsia in local hospitals and a regional simulation center, with and without teamwork theory. METHODS: This study is a randomized controlled trial of training in local hospitals and in a simulation center in the United Kingdom. Midwives and obstetricians working at participating hospitals were randomly assigned to 24 teams. Teams were randomly allocated to training in local hospitals or at a simulation center, and to teamwork theory or not. Performance was evaluated before and after training with a standardized eclampsia scenario captured on video. Outcome measures were completion of tasks, time to completion of tasks, administration of magnesium sulfate, and quality of teamwork. RESULTS: Training was associated with an increase in completion of basic tasks; 87% before training and 100% afterward. Basic tasks were completed more quickly; 55 seconds compared with 27 seconds, P=.012. The magnesium sulfate loading dose was administered by 61% of teams before training and by 92% afterward (P=.040). There was a shorter median time to administration (116 seconds less; P=.011). Training at the simulation center was not associated with additional improvement. Teamwork generally improved (median global score rose from 2.5 to 4.0; P<.001) but there was no additional benefit from teamwork training. CONCLUSION: Training resulted in enhanced performance with higher rates of completion for basic tasks, shorter times to administration of magnesium sulfate, and improved teamwork. There was no additional benefit from training in a simulation center, and none from teamwork theory. CLINICAL TRIAL REGISTRATION: ISRCTN, http://isrctn.org, ISRCTN67906788, reference number 0270030 LEVEL OF EVIDENCE: I

Management of Shoulder Dystocia : Skill Retention 6 and 12 Months After Training

OBJECTIVE: To assess skill retention 6 and 12 months after shoulder dystocia training. METHODS: Midwives and doctors from six United Kingdom hospitals attended a 40-minute workshop on shoulder dystocia management. Participants managed a standardized simulation before and 3 weeks, 6 months, and 12 months afterward. Outcome measures were delivery, head-to-body delivery time, performance of appropriate actions, force applied, and quality of communication. RESULTS: A total of 122 participants were recruited. One hundred eighteen were evaluated 3 weeks posttraining, for whom follow-up was available for 95 (81%) at 6 months and 82 (70%) at 12 months. Before training, 60 of 122 (49%) achieved delivery, 97 of 118 (82%) were able to deliver after initial training, 80 of 95 (84%) were able to deliver at 6 months, and 75 of 82 (85%) were able to deliver at 12 months. Twenty-one (18%) who could not deliver 3 weeks after training were offered additional training; of these, 11 of 14 (79%) achieved delivery at 12 months. Among those who could deliver 3 weeks posttraining, there was no deterioration in the performance of basic actions, delivery interval, force application, and patient communication. Those who were proficient before initial training performed best at follow-up, but skill retention was also good in those who learned to deliver during initial training. Eighteen percent could not deliver after initial training and required additional individualized tuition; the large majority retained their newly acquired skills at 6 and 12 months. CONCLUSION: Overall, training resulted in a sustained improvement in performance. Annual training seems adequate for those already proficient before training, but more frequent rehearsal is advisable for those initially lacking competency until skill acquisition is achieved. LEVEL OF EVIDENCE: II

Clinical efficiency in a simulated emergency and relationship to team behaviours: a multisite cross‐sectional study

Please cite this paper as: Siassakos D, Bristowe K, Draycott T, Angouri J, Hambly H, Winter C, Crofts J, Hunt L, Fox R. Clinical efficiency in a simulated emergency and relationship to team behaviours: a multisite cross‐sectional study. BJOG 2011;118:596–607.

Observations from 450 shoulder dystocia simulations: lessons for skills training

Poor neonatal outcomes after shoulder dystocia have been associated with inappropriate management. Until there are significant developments in the prediction and subsequent prevention of shoulder dystocia, improving shoulder dystocia management through practical training may be the most effective method of reducing the associated morbidity and mortality. Four hundred fifty simulated shoulder dystocia scenarios, managed by 95 midwives and 45 doctors from six U.K. hospitals during the course of 1 year, were video recorded during a study of obstetric emergency training. Analysis of recorded data revealed that, before training, 57% were unable to deliver the baby, almost two thirds failed to call for pediatric support, and 1 in 27 used fundal pressure. Recurring difficulties in management were observed: poor communication, inability to gain internal access, confusion over internal maneuvers, and the application of excessive traction. Significant improvements in management were observed after training and persisted up to 1 year after training. The lessons learned from this study can inform and improve future training and management. This article describes difficulties encountered by the participants and discusses how training may be focused to address these problems.

Prevention of brachial plexus injury—12 years of shoulder dystocia training: an interrupted time‐series study

To investigate management and outcomes of incidences of shoulder dystocia in the 12 years following the introduction of an obstetric emergencies training programme.

The use of simulation to teach clinical skills in obstetrics

Obstetrical practice demands sensitivity, clinical skill, and acumen. Obstetrical emergencies are rare occurrences and are most appropriately dealt with by experienced staff. Simulation provides an opportunity to gain this experience without patient risk and furthermore builds confidence and satisfaction amongst learners. There is an abundance of evidence to show the effectiveness of simulation training. Simulation has been demonstrated to reduce errors, increase knowledge, skills, communication and team working, and improve perinatal outcomes. Further research to measure the effect of training to identify what works, where and at what cost is needed. We explore the evidence for the use of simulation-based training across a broad range of obstetrical emergencies, promote collaboration amongst disciplines and discuss the formal introduction of simulation training into a curriculum. Reducing preventable harm in obstetrics is a priority for families and society at large and this article endeavors to highlight the role that simulation has to play.

Practical simulation training for maternity care—where we are and where next

Please cite this paper as: Crofts J, Winter C, Sowter M. Practical simulation training for maternity care—where we are and where next. BJOG 2011; 118 (Suppl. 3): 11–16.

Retention of factual knowledge after practical training for intrapartum emergencies

To determine knowledge retention 1 year after training for intrapartum emergencies.