Objective
We sought to determine whether implementation of shoulder dystocia training reduces the incidence of obstetric brachial plexus injury (OBPI).
Study Design
After implementing training for maternity staff, the incidence of OBPI was compared between pretraining and posttraining periods using both univariate and multivariate analyses in deliveries complicated by shoulder dystocia.
Results
The overall incidence of OBPI in vaginal deliveries decreased from 0.40% pretraining to 0.14% posttraining ( P < .01). OBPI after shoulder dystocia dropped from 30% to 10.67% posttraining ( P < .01). Maternal body mass index ( P < .01) and neonatal weight ( P = .02) decreased and head-to-body delivery interval increased in the posttraining period ( P = .03). Only shoulder dystocia training remained associated with reduced OBPI ( P = .02) after logistic regression analysis. OBPI remained less in the posttraining period ( P = .01), even after excluding all neonates with birthweights >2 SD above the mean.
Conclusion
Shoulder dystocia training was associated with a lower incidence of OBPI and the incidence of OBPI in births complicated by shoulder dystocia.
Shoulder dystocia is an uncommon complication of childbirth that is often associated with adverse perinatal outcomes for both mother and baby, including obstetric brachial plexus injury (OBPI). Rates of shoulder dystocia have escalated over the past few decades, which has intensified the importance of understanding how to handle these emergencies and lessen the risk for infant morbidity. Even given this importance, there has been remarkably little progress toward developing a standardized, systematic approach for managing shoulder dystocia emergencies. Predicting shoulder dystocia in clinical practice has proven to be nearly impossible, thus improved management is the only avenue for reducing risk of morbidity.
Despite numerous efforts to ascertain which maneuvers most effectively resolve shoulder dystocia emergencies, controversy remains about which are the most effective and safe approaches for managing these cases. Although there are few clinical data to support their recommendations, shoulder dystocia training is now recommended by the Joint Commission on Accreditation of Healthcare Organizations in the United States and mandated by the Clinical Negligence Scheme for Trusts in the United Kingdom to reduce complications.
Numerous studies have reported improved management of shoulder dystocia following training and practice using simulation models. However, few have examined the incidence of serious complications in neonates from shoulder dystocia in clinical practice following such training. Further, none have published a stepwise, detailed, and simple protocol to follow in cases of shoulder dystocia. The aim of the current study is to compare the rates of OBPI occurring in shoulder dystocia emergencies prior to and after the introduction of a simple shoulder dystocia protocol. By providing a standardized approach for all labor and delivery staff to follow during these emergencies, we hypothesized a significant reduction in the incidence of OBPI would result.
Materials and Methods
A retrospective cohort study was conducted using information gathered from electronic medical records of mothers and their infants born from Aug. 1, 2003, through Dec. 31, 2009. The start date was selected as being the day on which our electronic medical records in labor and delivery began. Figure 1 summarizes the process of patient selection for the current study. Medical records of all patients with suspected shoulder dystocia and/or OBPI were identified by International Classification of Diseases, Ninth Revision , 6th edition code (660.4; 767.6; 767.7; 767.2). Shoulder dystocia was confirmed in all cases by review of the maternal intrapartum notes for evidence of shoulder dystocia (shoulder dystocia, tight/difficult shoulders, or turtle sign that required additional maneuvers to accomplish delivery) by an obstetrician (S.R.I., N.F., J.B.C.). Exclusion criteria included cesarean delivery, vaginal breech deliveries, multiple gestations, and/or non-live births. Some births were excluded for >1 of the above reasons.
As per hospital protocol, all neonates with shoulder dystocia during birth are assessed by a neonatologist after delivery. Details of any neonatal injury (eg, decreased arm movement, suspected fracture) were recorded in the neonatal notes. Since shoulder dystocia management training was instituted during July and August 2006, all shoulder dystocia cases before July 1, 2006, were considered to be pretraining cases and all shoulder dystocia cases after Aug. 31, 2006, were considered to be posttraining cases (intent to treat). During the 2-month training period (July and August 2006), cases of shoulder dystocia in which standardized management was not activated ( n = 5) were included in the pretraining group; those in which standardized management was activated ( n = 2) were included in the posttraining group.
The goal of implementing the shoulder dystocia training protocol was to simplify and standardize the management of shoulder dystocia emergencies. The training covered risk factors, early recognition, management, and documentation of shoulder dystocia.
The training was conducted by maternal-fetal medicine specialists, the director of midwifery, and the clinical nurse manager of labor and delivery. The standardized shoulder dystocia training course was attended by all hospital labor and delivery staff (attending physicians, resident physicians, midwives, and nurses) and proficiency with the protocol was tested with a practical examination. Individual hands-on simulated shoulder dystocia training scenarios were mandatory and unsatisfactory proficiency warranted repeat training sessions and practical examination. All new staff were trained and certified upon hire; everyone underwent recertification in 2008. The practical training was performed on a prototype shoulder dystocia training mannequin (Obstetrical Manikin, part no. 110-180; Simulaids Inc, Woodstock, NY).
The standardized shoulder dystocia training was designed to be a simple, systematic set of procedures. It is activated by the labor and delivery staff upon first recognizing the signs of shoulder dystocia. Once shoulder dystocia has been called, a “hands-off” procedure (no hands and no traction on the fetal head) is implemented. The operator first assesses the position of the anterior shoulder, announces this finding to the team, and begins to employ the maneuvers and/or position changes outlined in the protocol ( Figure 2 ). Once the shoulder is oblique or the posterior arm has been delivered, maternal pushing is encouraged to complete the delivery. Quiet (conversational level) communication, a calm environment, and a deliberate response (no panic) to this emergency are emphasized.
Results
Differences in characteristics of all deliveries between pretraining ( n = 6269) and posttraining ( n = 5593) study periods are outlined in Table 1 . There was no difference in the incidence of shoulder dystocia ( P = .93) coupled with an overall decreased incidence of OBPI ( P < .01) during the study ( Table 1 ). The proportion of infants born by cesarean delivery was higher in the posttraining period ( P < .05) ( Figure 1 ).
| Characteristic | Pretraining n = 6269 a | Posttraining n = 5593 a | P value b |
|---|---|---|---|
| Shoulder dystocia | 83 (1.32%) | 75 (1.34%) | .93 |
| OBPI | 25 (0.40%) | 8 (0.14%) | < .01 |
| Maternal age, y, mean | 26.27 | 26.08 | NS c |
| Maternal diabetes mellitus | 239 (3.81%) | 199 (3.56%) | .82 |
| Spontaneous onset of labor | 3124 (49.83%) | 3765 (67.32%) | .00 |
| Instrumental delivery | 122 (1.95%) | 157 (2.81%) | .11 |
| Gestational age, d, mean | 275.73 | 271.25 | NS |
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