Tim Draycott

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

Change in knowledge of midwives and obstetricians following obstetric emergency training: a randomised controlled trial of local hospital, simulation centre and teamwork training

Objectives  To explore the effect of obstetric emergency training on knowledge. Furthermore, to assess if acquisition of knowledge is influenced by the training setting or teamwork training.

Evaluating the Impact of Simulation on Translational Patient Outcomes

Introduction: A long and rich research legacy shows that under the right conditions, simulation-based medical education (SBME) is a powerful intervention to increase medical learner competence. SBME translational science demonstrates that results achieved in the educational laboratory (T1) transfer to improved downstream patient care practices (T2) and improved patient and public health (T3). Method: This is a qualitative synthesis of SBME translational science research (TSR) that employs a critical review approach to literature aggregation. Results: Evidence from SBME and health services research programs that are thematic, sustained, and cumulative shows that measured outcomes can be achieved at T1, T2, and T3 levels. There is also evidence that SBME TSR can yield a favorable return on financial investment and contributes to long-term retention of acquired clinical skills. The review identifies best practices in SBME TSR, presents challenges and critical gaps in the field, and sets forth a TSR agenda for SBME. Conclusions: Rigorous SBME TSR can contribute to better patient care and improved patient safety. Consensus conference outcomes and recommendations should be presented and used judiciously.

Retrospective cohort study of diagnosis–delivery interval with umbilical cord prolapse: the effect of team training

Objective  To determine whether the introduction of multi‐professional simulation training was associated with improvements in the management of cord prolapse, in particular, the diagnosis–delivery interval (DDI).

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

The active components of effective training in obstetric emergencies

Confidential enquiries into poor perinatal outcomes have identified deficiencies in team working as a common factor and have recommended team training in the management of obstetric emergencies. Isolated aviation‐based team training programmes have not been associated with improved perinatal outcomes when applied to labour ward settings, whereas obstetric‐specific training interventions with integrated teamwork have been associated with clinical improvements. This commentary reviews obstetric emergency training programmes from hospitals that have demonstrated improved outcomes to determine the active components of effective training. The common features identified were: institution‐level incentives to train; multi‐professional training of all staff in their units; teamwork training integrated with clinical teaching and use of high fidelity simulation models. Local training also appeared to facilitate self‐directed infrastructural change.

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.

Carbetocin versus oxytocin for the prevention of postpartum haemorrhage following caesarean section: the results of a double‐blind randomised trial

Please cite this paper as: Attilakos G, Psaroudakis D, Ash J, Buchanan R, Winter C, Donald F, Hunt L, Draycott T. Carbetocin versus oxytocin for the prevention of postpartum haemorrhage following caesarean section: the results of a double‐blind randomised trial. BJOG 2010;117:929–936.

The management of a simulated emergency: Better teamwork, better performance

OBJECTIVES To determine whether team performance in a simulated emergency is related to generic teamwork skills and behaviours. METHODS Design - Cross-sectional analysis of data from the Simulation and Fire-drill Evaluation (SaFE) randomised controlled trial. Setting - Six secondary and tertiary Maternity Units in Southwest England. Participants - 140 healthcare professionals, in 24 teams. Assessment - Blinded analysis of recorded simulations. Main outcome measures - Correlation of team performance (efficiency conducting key clinical actions, including the administration of an essential drug, magnesium), and generic teamwork scores (using a validated tool that assesses skills and behaviours, by Weller et al.). RESULTS There was significant positive correlation between clinical efficiency and teamwork scores across all three dimensions; skills (Kendalls tau(b)=0.54, p<0.001), behaviours (tau(b)=0.41, p=0.001), and overall score (tau(b)=0.51, p<0.001). Better teams administered the essential drug 2½min more quickly (Mann-Whitney U, p<0.001). CONCLUSIONS The clinical conduct of a simulated emergency was strongly linked to generic measures of teamwork. Further studies are needed to elucidate which aspects of team working are critical for team performance, to better inform training programs for multi-professional team working.