Simulation in shoulder dystocia: does it change outcomes?

Abstract

BackgroundShoulder dystocia is an obstetrical emergency that requires immediate and appropriate provider response to decrease neonatal morbidity.ObjectiveTo determine whether institution of shoulder dystocia simulation training improves maternal and neonatal outcomes at delivery.Study designThis retrospective cohort study compared maternal and neonatal outcomes before (1 September 2008–31 December 2009) and after (1 January 2010–31 December 2014) a mandatory shoulder dystocia simulation curriculum was instituted. Χ2 and Fisher’s exact tests along with multivariate logistic regression models were conducted to adjust for potential confounding.ResultsOf 8930 vaginal deliveries that met eligibility criteria over the 6-year period, 299 (3.3%) deliveries were complicated by a shoulder dystocia. The adjusted frequency of shoulder dystocia was approximately two times higher after training implementation (1.9% vs 3.8%; adjusted OR=1.80 (1.23 to 2.65), p=0.003). Neonatal outcomes such as brachial plexus injury (5.0% vs 7.7%; p=0.75), clavicle fracture (5.0% vs 4.6%; p=1.00) and humerus fracture (0.0% vs 1.9%; p=1.00) were not statistically different after training. Additionally, no significant differences in episiotomy (5.0% vs 4.6%; p=1.00), postpartum haemorrhage (10.0% vs 12.4%; p=0.80) and severe perineal laceration (10.0% vs 6.6%; p=0.50) were observed.ConclusionsThe overall frequency of shoulder dystocia reportedly doubled after training despite stable operative vaginal delivery and caesarean delivery rates. No significant improvements were seen in maternal or neonatal outcomes after simulation training. As shoulder dystocias are rare events, simulation training may not necessarily improve neonatal outcomes, but it may increase overall provider awareness and intervention.

Interventions to decrease complications after shoulder dystocia: a systematic review and Bayesian meta-analysis

“…NOS bias assessment categorized 10 studies as of poor quality, 12,21,24e31 2 as of fair quality, 13,15 and 3 as of good quality (Supplemental Table 1). 22,23,32 The study by Fransen et al 16 was a randomized clinical trial and was, therefore, not assessed using the NOS. Funnel plots did not indicate evidence of publication bias (Supplemental Figures 1e6).…”

“…Although 9 (56.3%) of the studies were conducted in the United States, 12,13,21,22,31,32,25e27 the remainder were done in other countries. 15,16,23,24,26,29,30 Shoulder dystocia was identified either by International Classification of Diseases (ICD)-9 or ICD-10 codes (6 studies), 13,21,22,27,30,32 medical record review (4 studies), 15,23e25 or the identification method was not disclosed (6 studies). 12,16,26,28,29,31 The interventional exercises varied among the trials Systematic Reviews ajog.org with 8 of the 16 reporting the use of either the PROMPT or NOELLE highfidelity trainers.…”

“…12,16,26,28,29,31 The interventional exercises varied among the trials Systematic Reviews ajog.org with 8 of the 16 reporting the use of either the PROMPT or NOELLE highfidelity trainers. 21e26, 28,32 All studies had multidisciplinary attendance for the exercises. There was diverse simulation leadership among the trials.…”

“…12,13,22e25,27e32 There was significant heterogeneity among the study effects for the outcome of shoulder dystocia (I 2 ¼68%), primarily among USbased studies. 12,13,22,25,27,31,32 The increased diagnosis of shoulder dystocia postintervention was more pronounced in the studies using NOELLE or PROMPT simulators compared with other training methods (Supplemental Figure 7).…”

“…25,30 The proportion of clavicle or humerus fractures (RR, 0.56; 95% Cr, 0.27e1.18; probability of reduction 94%) in 6 studies with 2275 cases of shoulder dystocia showed some evidence of reduction following the implementation of a shoulder dystocia simulation exercise (Supplemental Figure 11). 23,24,28,29,30,32 Moreover, there was less evidence of a change in the incidence of obstetrical anal sphincter injuries (RR, 0.79; 95% Cr, 0.49e1.29; probability of reduction 84%) in 4 studies with 1071 cases of shoulder dystocia reported, irrespective of the delivery route (Supplemental Figure 12). 12,28,30,32 ajog.org…”