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

Abstract

Objective To investigate management and outcomes of incidences of shoulder dystocia in the 12 years following the introduction of an obstetric emergencies training programme.Design Interrupted time-series study comparing management and neonatal outcome of births complicated by shoulder dystocia over three 4-year periods: (i) Pre-training (1996-99) Method A bi-monthly multi-professional 1-day intrapartum emergencies training course, that included a 30-minute practical session on shoulder dystocia management, commenced in 2000.Main Outcomes Neonatal morbidity (brachial plexus injury, humeral fracture, clavicular fracture, 5-minute Apgar score <7) and documented management of shoulder dystocia (resolution manoeuvres performed, traction applied, head-to-body delivery interval).Results Compliance with national guidance improved with continued training. At least one recognised resolution manoeuvre was used in 99.8% (561/562) of cases of shoulder dystocia in the late training period, demonstrating a continued improvement from 46.3% (150/324, P < 0.001) pre-training, and 92% (241/262, P < 0.001) in the early training period. In parallel there was reduction in the brachial plexus injury at birth (24/324 [7.4%, P < 0.01], pre-training, 6/262 [2.3%] early training, and 7/562 [1.3%] late training.Conclusions There are significant benefits to long-term, embedded training programmes with improvements in both management and outcomes. A decade after the introduction of training there were no cases of brachial plexus injury lasting over 12 months in 562 cases of shoulder dystocia.

Myths and realities of training in obstetric emergencies

“…There is proof of principle that some training for obstetric emergencies is associated with improvements in outcome [14, 23,34,47]. However, there is a dearth of data on the effect of local context.…”

“…In one long-term study of training for SD, there was a 70% reduction in brachial plexus injury after 4 years of training, and there was a 100% reduction in permanent injury after more than a decade of training [47]. Over 85% of staff were trained annually during a period of 12 years.…”

“…Training for SD is a good example of the possibly conflicting effects of the use of different training mannequins: there are some reports of improvements in neonatal outcomes after training [33, 35,36,47], whereas other training has been associated with no change in outcomes [16], or even an increase in poor neonatal outcomes, after training had been introduced [18]. One of the important differences in the training between these programmes was the training model used.…”

“…One of the important differences in the training between these programmes was the training model used. The Bristol group [47,80] employed the PROMPT trainer that had been demonstrated to have advantages for training in a randomised trial of training for SD [31,81], whereas the Oxford group did not [18]. It is not clear what mannequins were employed in the other studies.…”

Ten years of simulation-based shoulder dystocia training- impact on obstetric outcome, clinical management, staff confidence, and the pedagogical practice - a time series study

“…In contrast an Australian retrospective cohort study reported an overall improvement in some clinical outcomes (Apgar at 1 minute, umbilical cord lactate, and average length of infant’s stay in clinic) after a single day of training for the trainers at eight different maternity units [9]. Crofts et al found significant benefits of a long-term multiprofessional 1-day training course with improvements in clinical outcomes, including the prevalence of brachial plexus injury due to shoulder dystocia [10]. Comparable results concerning a decrease in obstetric brachial plexus injury was found after introduction of a shoulder dystocia training protocol [11, 12].…”