The objective of this study was to assess outcomes that are associated with the implementation of a shoulder dystocia protocol that is focused on team response. We identified women who had a shoulder dystocia during 3 time periods: 6 months before (period A), 6 months during (period B), and 6 months after (period C) the institution of a shoulder dystocia protocol. Documentation and health outcomes were compared among the time periods. During the study period, 254 women (77, 100, and 77 in periods A, B, and C, respectively) had a shoulder dystocia. There were no differences among study periods in patient characteristics. However, complete and consistent documentation increased (14% to 50% to 92%; P < .001), and brachial plexus palsy that was diagnosed at delivery (10.1% to 4.0% to 2.6%; P = .03) and at neonatal discharge (7.6% to 3.0% to 1.3%; P = .04) declined.
Shoulder dystocia is an obstetric emergency and occurs with a reported frequency of approximately 1%. This event is associated with an increased risk of both maternal morbidity, such as perineal trauma and postpartum hemorrhage, and perinatal morbidity, such as brachial plexus palsy. Although there are known risk factors for its occurrence, these risk factors are not good predictors, and as such, no system has been shown to reliably allow its efficient prevention.
Because shoulder dystocia cannot be prevented reliably, its management depends on prompt recognition and treatment at the time of occurrence. Yet, because of its unpredictable, relatively uncommon, and emergent nature, this management must be enacted by a team of healthcare providers who rarely, if ever, may have encountered the complication as a team. Simulation and protocols have been suggested as techniques that could enhance management of events with such characteristics.
Despite the theoretic benefits of these techniques, there has been little actual evidence in support of their efficacy with regard to clinical outcomes of shoulder dystocia, and the studies that do exist have provided inconsistent results. We recently described the development and introduction of a team-based protocol for the management of shoulder dystocia. The purpose of the present study was to assess whether documentation and health outcomes would be improved after the introduction of this protocol.
Methods
Between March 1, 2006, and May 30, 2006, a new shoulder dystocia protocol was introduced to all care providers on the labor delivery unit of a large urban tertiary care hospital. This protocol had been developed on the basis of information that was provided by existing clinical guidelines and key informant interviews and was refined operationally through the use of iterative practice drills. The final protocol was introduced to all obstetric care providers through the use of low-fidelity multidisciplinary training sessions, during which the focus was on the team-level response during and after a shoulder dystocia and not on the practice or evaluation of manual skills that are used during the maneuvers ( Figure ). These sessions included a didactic component that reviewed the general and protocol-specific response to shoulder dystocia, which was followed by repeated simulations and a debriefing. Key components of the protocol include (1) an overt and unequivocal announcement by the obstetrician or midwife when a shoulder dystocia is recognized, (2) a simplified approach to summoning additional personnel (ie, nurses, additional attending obstetrician, anesthesiologist, pediatrician, and obstetric residents) to the shoulder dystocia through both overhead notification and a paging tree, (3) the declaration of duration since delivery of the fetal head at 30-second intervals, (4) the establishment of role clarity for different providers at the shoulder dystocia, and (5) a structured documentation tool that was available in every room. A full description of protocol development and the training sessions has been described previously.
Three continuous 6-month time periods were defined in relation to the introduction of the shoulder dystocia protocol. Time period A was the 6-month period immediately before the occurrence of any training; time period B was immediately after time period A and included the 3-month period during which the protocol had been introduced to all staff and the 3 months immediately after all staff had been trained and were becoming familiar with the drill during actual clinical operations; time period C was the 6-month period immediately after time period B.
All women who experienced a shoulder dystocia were identified during the 18 months of the study, and their outcomes were abstracted from the chart. These outcomes were then stratified and compared by the time period in which the shoulder dystocia occurred. One outcome of interest was the adequacy of documentation. Documentation was judged according to 2 criteria: completeness and consistency. Charts were considered complete if there was documentation anywhere within the chart of 3 key pieces of information that are specific to the occurrence of a shoulder dystocia: the length of time of the dystocia, which arm was anterior (either by noting the side to which the fetal occiput restituted or the side of the arm itself), and the presence or absence of maneuvers (and if present, which ones were used). Charts were considered consistent if the attending physician, resident physician, and nurse all related similar information. Thus, there were 4 categories of documentation: complete and consistent, complete and inconsistent (ie, all key information was present, but only by piecing together information in different notes), incomplete and consistent (ie, all notes contained similar information, but not all key information was present), and incomplete and inconsistent.
Both maternal and neonatal health outcomes also were evaluated. Maternal outcomes that were assessed were adverse events that were associated with shoulder dystocia (such as perineal trauma and postpartum hemorrhage). Similarly, neonatal outcomes compared were those outcomes that were relevant to the occurrence of shoulder dystocia, which included Apgar score, umbilical arterial cord gas, and the presence of brachial plexus palsy at birth and discharge. Brachial plexus palsy was based on the diagnosis of an attending pediatrician.
Continuous data were evaluated with analysis of variance or Kruskal Wallis test, as appropriate, based on normality; categoric data were analyzed by χ 2 test and the test for trend for ordered groups. All tests were 2-tailed, and a probability value of < .05 was considered to be significant. Analyses were performed with Minitab 13 (Minitab Inc, State College, PA) and Stata 11 software (Stata Corporation, College Station, TX). The Northwestern University Institutional Review Board approved this study.
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