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Simulation of Shoulder Dystocia for Skill Acquisition andCompetency AssessmentA Systematic Review and Gap Analysis
Edith D. Gurewitsch Allen, MD, MBA Summary Statement:Mastery of shoulder dystocia management skills acquired viasimulation training can reduce neonatal brachial plexus injury by 66% to 90%. However,the correlation between simulation drills and reduction in clinical injuries has been incon-sistently replicated, and establishing a causal relationship between simulation trainingand reduction of adverse clinical events from shoulder dystocia is infeasible due to ethicallimitations. Nevertheless, professional liability insurance carriers increasingly are mandatingsimulation-based rehearsal and competency assessment of their covered obstetric providers’shoulder dystocia management skills—a high-stakes demand that will require rapid scalingup of access to quality shoulder dystocia simulation. However, questions remain about differ-ing simulation training schemes and instructional content used among clinically effectiveand ineffective educational interventions. This reviewof original research compares curric-ular content of shoulder dystocia simulation and reveals several critical gaps: (1) prescrip-tive instruction prioritizing maneuvers shown to decrease strain on the brachial plexus isinconsistently used. (2) Proscriptive instruction to avoid placing excessive and laterallydirected traction on the head or to observe a brief hands-off period before attemptingtraction is infrequently explicit. (3) Neither relative effectiveness nor potential interactionbetween prescriptive and proscriptive elements of instruction has been examined directly.(4) Reliability of high-fidelity mannequins capable of objective measurement of clinician-applied traction force as compared with subjective assessment of provider competenceis unknown. Further study is needed to address these gaps and inform efficient and effectiveimplementation of clinically translatable shoulder dystocia simulation.(Sim Healthcare 13:268–283, 2018)
Key Words:Prescriptive instruction, proscriptive instruction, virtual reality simulation, hapticsimulation, high-fidelity mannequins, brachial plexus injury, risk management.
Shoulder dystocia, the obstructed delivery of an infant'sshoulders and body after emergence of the head in the finalmoments of birth (Fig. 1), occurs unpredictably as an obstetricemergency in 1 in 20 to 30 term vaginal deliveries.1–3 Promptrecognition and expeditious, skillful performance of specializeddelivery maneuvers (Fig. 2) are required to mitigate againstinjury to the newborn's brachial plexus nerves that controlmovement and sensation of the upper extremity. Brachialplexus injuries complicate up to 40% of deliveries affectedby shoulder dystocia.4 Permanent neonatal brachial plexusinjury related to shoulder dystocia is a leading cause of litigationagainst obstetric providers in the United States, with 60% oflawsuits resulting in median payouts up to four times that ofall other malpractice claims.5
The largest prospective study of clinician-applied tractionat more than 30,000 consecutive vaginal deliveries in Sweden
demonstrates an increased likelihood of obstetric brachialplexus palsy with increasing levels of self-reported traction6
and a positive correlation between higher levels of tractionand the number of nerve roots affected.7 Despite a near-universal association between permanent brachial plexus palsyand antecedent shoulder dystocia,8–11 the clinician's role inmitigating the risk of injury continues to be debated—mostvigorously in countries where litigation against providers iscommonplace.4 The Agency for Healthcare Research andQuality recognizes a link between malpractice liability risk andthe resistance of providers to examine root causes of patientharm.12 For maternity care specifically, exposure to liability riskhas been linked to a 5.3% annual reduction in obstetric providerworkforce.13,14 These sobering facts threaten continued trainingin and delivery of quality obstetric care unless reliable methodsto reduce adverse outcomes from shoulder dystocia can bedemonstrated and widely disseminated. Any objective assess-ment of provider competence in managing shoulder dystociawill depend on scientifically sound evidence of an inverse rela-tionship between technical skill and the occurrence of injury.
Even before competency in management of shoulderdystocia can be assessed, there must be dependable processesfor acquiring necessary skills. The unpredictable and emer-gent nature of shoulder dystocia challenges educators' ability
From the Departments of Gynecology/Obstetrics and Biomedical Engineering, JohnsHopkins University School of Medicine, Baltimore, MD.
Reprints: Edith D. Gurewitsch Allen, MD, MBA, Division of Maternal Fetal Medicine,Johns Hopkins Hospital, 600 North Wolfe St, Phipps 207, Baltimore, Maryland 21287(e‐mail: egurewi@jhmi.edu).
The author declares no conflict of interest.
Copyright © 2018 Society for Simulation in HealthcareDOI: 10.1097/SIH.0000000000000292
Review Article
268 Shoulder Dystocia Simulation Training: Status Update Simulation in HealthcareCopyright © 2018 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
to consistently train and credential obstetric providers inshoulder dystocia management if they rely solely on thisemergency's actual occurrence during routine care. As a result,shoulder dystocia management has become a commonly usedscenario for simulation-based instruction within obstetricseducation. Simulation allows trainees to be exposed to realis-tic challenges and consequences of shoulder dystocia in asafe, controlled teaching environment.15
The greatest validation of any simulation-based medicaleducation is to demonstrate a significant clinical impact16 onquality metrics, such as reduced rates of actual birth injury.For management of shoulder dystocia specifically, severalinvestigators have achieved success in transferring skillsmastered with simulation training to clinical practice.17–21
Not only have rates of brachial plexus injury been reducedby 66%18,20 to 90%17; permanent neonatal brachial plexusinjuries have even been eliminated altogether when trainingis repeated annually.22 Professional liability insurance carriersincreasingly are mandating simulation-based rehearsal andcompetency assessment of their covered obstetric providers'shoulder dystocia management skills,23,24 no doubt spurredby these impressive results, which include reductions in mal-practice claims filed.25 Nonetheless, other investigators havenot demonstrated these benefits of simulation training forshoulder dystocia management,26,27 which raises questionsabout the comparative effectiveness of differing simulationtraining schemes and instructional content used amongsuccessful and unsuccessful interventions.28
Whether the impetus for mandating simulation-basedskills acquisition and competency assessment for managementof shoulder dystocia is to examine and respond to presumedroot causes of sentinel events such as permanent brachial plexusinjury or is externally incentivized by malpractice insurers,meeting the demand for quality shoulder dystocia simulationwill require rapid scaling up of access with considerable invest-ment of time and resources.29,30 Thus, it is crucial that evidencefor shoulder dystocia simulation training's effectiveness—whether educational, clinical, or cost—is evaluated and itslimitations and gaps identified. Many previous reviews of theliterature on simulation-based training for shoulder dystocia
management skills acquisition and competency assessmentare ad hoc rather than systematic.29,31,32 Smith31 concluded thatteam training and institutional protocols for shoulder dystociashould be an integral part of safety initiatives to improve techni-cal skills and team performance. Others consider the evidenceas part of several obstetric emergencies that can be effectivelysimulated.33–40 There are three systematic reviews of generalobstetric simulation; all focus on multiple complications. A re-view by Cooper et al41 includes shoulder dystocia within its tableof previous simulation studies; they conclude that simulation isa critical component of obstetric curricula because it enhancesclinical practice and reduces the time to gain competence.Merién et al42 and Lapkin et al43 conclude that simulation isuseful for reducing errors, improving behavior, and increasingknowledge and critical thinking skills.
Only one study devoted specifically to shoulder dystociaincludes a systematic review, but it focuses exclusively on therole of episiotomy in shoulder dystocia management.44 Nostudy to date has performed a systematic review of the role ofsimulation specifically for shoulder dystocia management. Theother ad hoc reviews specifically on shoulder dystocia simula-tion training cite evidence for its variable clinical impact,33–40
but none differentiate curricular elements between effectiveand ineffective simulation-based training content.
Thus, the objectives of this systematic review are two-fold:(1) to assess critically the current evidence for simulation ofshoulder dystocia as an efficient and effective tool for providerskill acquisition and competency assessment and (2) to iden-tify gaps in current knowledge about the comparative effec-tiveness of varied simulation-based educational content. Theavailable research is appraised for its differentiation of cur-ricular emphasis on use of rotational maneuvers, limitingclinician-applied force and assessment of time to relieve theobstruction, because these three elements of training arehypothesized—based on the effect of traction, technique,and head-to-body interval on injury45–49—to correlate withsuccessful translation of simulation effectiveness to actual pa-tient outcomes. Herein, the status of shoulder dystocia simula-tion as a training method is evaluated and lingering questionsare identified. The latter is intended to set the research agenda
FIGURE 1. Impaction of the fetal shoulder against the maternal pubic symphysis obstructs delivery of the body; if unrecognized,forceful attempts at delivery can stretch and injure the brachial plexus nerves that control arm movement. Retrieved from: http://l450v.alamy.com/450v/adtwj4/shoulder-dystocia-adtwj4.jpg.
Vol. 13, Number 4, August 2018 © 2018 Society for Simulation in Healthcare 269Copyright © 2018 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
needed to inform widespread evidence-based implementationof shoulder dystocia simulation for obstetric providers' skillacquisition and competency assessment.
METHODSPubMed, Scopus, and CINAHL Plus databases were searchedusing the following terms: “simulation AND shoulder dys-tocia,” “obstetric simulation training,” “shoulder dystociatraining,” and “‘shoulder dystocia’AND ‘systematic review’.”Snowball sampling was performed to identify additionalrelevant literature from the bibliographies of relevant articlesyielded from the initial search. Articles were included forabstract review if they were published between 2003 and2017 (within the last 15 years) and their full-length text
was available online in English. Each abstract was then re-viewed, and final articles were selected for in-depth analysisif they presented original research on simulation-based train-ing specifically for shoulder dystocia, involved trainee partici-pants, and included identified metrics subjected to statisticalanalysis. Where studies included simulation of multiple ob-stetric emergencies, articles were included if the results of theshoulder dystocia simulation were evaluated separately. Thosearticles describing interprofessional training were retainedif clinicians who perform deliveries (ie, midwives and/orphysicians, either practicing or in training) were among theparticipants. Conference abstracts, ad hoc reviews, letters,commentaries, and narrative-only descriptions of simulationwithout data collection or analysis were excluded.
FIGURE2. Maneuvers to alleviate shoulder dystocia can be categorized as indirect—where the locus of manipulation is maternal(eg, McRoberts and suprapubic pressure)—or direct—where the locus of manipulation is fetal (eg, Rubin, modified Woods screwor delivery of the posterior arm). Direct manipulation avoids placing traction on the fetal head, an action that increases the risk ofinjury to the brachial plexus. Retrieved from: https://static1.squarespace.com/static/536a936ae4b09724c1063b54/t/55170a22e4b0d6bbb54c0398/1427573283363/dystocia.JPG.
270 Shoulder Dystocia Simulation Training: Status Update Simulation in HealthcareCopyright © 2018 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
The selected articles were analyzed for study design, typesand number of participants, outcomes of interest, primarymetrics used, and whether specific instructional elements suchas emphasis on limiting delivery force, prioritization of ro-tational maneuvers, and evaluation of time were described.Several national guidelines on management of shoulderdystocia50–54 and published educational objectives for simu-lation training55 also were consulted if they were designatedwithin the selected studies as the curricular basis for thespecific training provided during the study. The educationalparadigms of prescriptive and proscriptive instruction servedas the theoretical framework for the analysis; “prescriptive”and “proscriptive” were defined respectively as positive ordirected teaching of “what to do” and negative teaching ordeliberate demonstration of common errors in techniquethat would increase the risk of injury (ie, specific instructionin “what NOT to do”).
RESULTSOf 794 initial search returns, 190 non-overlapping titles metinitial search criteria for abstract review. A secondary searchof the OVID Medline and Google Scholar databases did notyield any titles not already identified, and only one additionalarticle was identified from bibliographies. From the 190 ab-stracts reviewed, a total of 45 separate articles describingoriginal research on simulation of shoulder dystocia fortraining purposes met inclusion criteria for in-depth quali-tative systematic review. Three foci of educational researchon this topic were classifiable as follows: evaluation of learnerperformance (LE) by trainers (Table 1, 23 articles), evaluationof the simulation program (SE) by participants (Table 2, 8articles), and the clinical impact (CI) of systematic simulation-based training on actual outcomes of shoulder dystocia(Table 3, 14 articles). Thirty-eight articles were primaryanalyses; another seven were secondary analyses of parentstudies. Specific prescriptive instruction was described far morecommonly (30/38 primary articles, 79%) than was proscriptiveinstruction (16/38 primary articles, 42%). In the CI-focusedarticles (6/12 primary articles, 50%), description of specificelements of proscriptive instruction occurred more commonlythan it did among SE-focused (3/8 primary articles, 38%) andLE-focused (7/18 primary articles, 39%) articles.
Although not the first publication on the matter,15,56 themost extensive knowledge on shoulder dystocia simulationtraining to date derives from the Simulation and Fire-drillEvaluation (SaFE) Study, a large randomized controlled trialof obstetric simulation training commissioned by the Depart-ment of Health of England and Wales.58 Although the scopeand success of this comprehensive simulation trainingprogram are undeniable, it also dominates the literature34—accounting for 11 (24%) of the 45 articles reviewed here. In-deed, these authors collectively have published most of theoriginal research evaluating multiple aspects of simulation-based training specifically for shoulder dystocia management,including study design and randomization,58 development ofassessment instruments,57,59,88 training of trainers,59,65 di-dactic content described,58,89 learner evaluation metrics (eg,force measurement, documentation, communication, skillretention),58,60,63,89 evaluation of instructional elements
(eg, simulator type, setting, teamwork),58,59 lessons learned,63
and translational clinical results.17,22 Only recently have othernational-level efforts at simulation-based training been repli-cated,69,72,87 which included additional analyses of clinicalimpact,86 skill retention,87 and cost-effectiveness.30
SYNTHESISWhich Maneuvers to Use? A Prescriptive Approach
Self-reported confidence in the technical performance ofmaneuvers improves when learners are exposed to simulationtraining.77,80Most studies of simulation training employ a pre-scriptive approach, directing participants through a specifiedsequence of maneuvers; however, they vary in their emphasison specific techniques. Nine (39%) of 23 studies that evaluatedlearner performance (Table 1) between participants who did ordid not receive training15,66,67,69,74 or in the same participantsbefore and after training58,59,64,72 did not specify a distinctprotocol or algorithm to be used; yet the use of specific ma-neuvers was scored by raters, and use of posterior arm deliv-ery demarcated the successful resolution of shoulderdystocia in all studies of learner performance. By contrast,among eight studies where the quality and utility of simulationwere evaluated by the participants (Table 2), only three (38%)specified the sequence of maneuvers to be followed,73,76,78
whereas the remainder involved systematic review and rehearsalof all maneuvers without predetermined expectations aboutsequence or independent recollection.
Ethical concerns limit the feasibility of testing in vivo therelative efficacy of differentmaneuvers for their impact on fetalinjury. Experimental findings in the biomedical engineeringlaboratory48 and biomechanical analysis90 suggest that shoul-der dystocia maneuvers that involve direct manipulation ofthe fetal trunk by the birth attendant (eg, Rubin maneuverand delivery of the posterior arm) have a mechanical advan-tage over indirect maneuvers where the mother is acted uponby nondelivering members of the team or by laypersons (eg,application of suprapubic pressure and McRoberts position-ing). The latter achieves delivery of the fetal body by tractionon the fetal head; the former eschews pulling on the head(Fig. 2). Furthermore, determining the alignment of the fetalshoulders by direct palpation and then manually adjustingthe fetus' shoulder span to an oblique orientation within thepelvis before application of traction to the fetal head (Rubinmaneuver)48 and delivery of the posterior arm,91 each reducesstrain on the brachial plexus compared with McRoberts orlaterally applied traction. Prioritizing a rotational maneuverearly in a management algorithm for shoulder dystocia duringsimulation-based drills decreases the incidence of brachialplexus injury in the clinical setting,18 whereas emphasis onuse of McRoberts maneuver is associated with an increase inactual brachial plexus injuries.27
A Question of Clinician-Applied Traction ForceDespite controversy about its role in every type of neona-
tal brachial plexus palsy,4 it is considered axiomatic andprudent to limit the traction applied to the fetus' head dur-ing attempts to relieve shoulder dystocia.52,54 Nevertheless,the extent to which application of traction is emphasizedor addressed at all in shoulder dystocia simulation training
Vol. 13, Number 4, August 2018 © 2018 Society for Simulation in Healthcare 271Copyright © 2018 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
TABLE
1.Summ
aryofOriginalResearcho
fSimulation-B
asedTrainingforShoulderDystocia—
LearnerEvaluation
*Autho
r,Year
Cou
ntry
Stud
yDesign
Participants
Outcomeof
Interest
PrimaryMetrics
Used
PrescriptiveInstruction
ProscriptiveInstruction
Deering
etal,20041
5UnitedStates
Rando
mized
controlledtrial
Simulationtraining
vs.n
osimulation
training
Ob/Gyn
residents;
n=33
Performance
scores
onsimulated
shou
lder
dystocia
Performance
score(9-point
Likertscale)
on“critical”
tasksand“impo
rtant”tasks;
head
tobody
deliverytim
einterval;n
umberof
maneuversattempted
Trained:d
idactic
lectureon
shou
lder
dystociarisk
factors,
maneuvers,and
algorithm
followed
bydemon
stratio
nandrehearsalo
nsimulator
“Critical”tasks:recognizes
shou
lder
dystocia;callsfor
assistance
andpediatrics;
McRobertsandsuprapub
icpressure;
“Impo
rtant”tasks:
Episiotomy;rotatio
nal
maneuver;deliveryof
the
posteriorarm;cleidotom
y;Gaskin;
Zavanelli;obtains
cord
gases;symph
isiotomy
Untrained:n
oinstructiongiven
“Critical”task
includ
eduseof
gentletractio
n(m
agnitude
not
measured)
Deering
etal,20045
6UnitedStates
Second
aryanalysis
Sameas
parent
stud
yQualityof
documentatio
ncomparedwith
videotaped
simulation
15“key
compo
nents”
ofdo
cumentatio
nSameas
parent
stud
ySameas
parent
stud
y
Croftsetal,20055
7UnitedKingdom
Observatio
nal
Pretrainingand
posttraining
performance
Junior
andsenior
obstetriciansand
midwives
n=38
Peak
forceapplied;
timeto
deliveryand
improvem
ent
inassessmentscores
Assessm
entscore
based
onuseof
specific
maneuversin
specific
sequ
ence;tim
eto
delivery;peak
force
(onlyin
10subjects)
Specificmanagem
ent
techniqu
es:assessm
ent,
callforhelp,episiotom
y,McR
oberts;m
aneuver,
suprapub
icpressure,
deliveryof
posterior
shou
lder,W
oods'
screwmaneuver
App
liedforcewas
not
disclosedto
participantsbefore
oraftertraining
Croftsetal,20065
8
SaFE
Stud
yUnitedKingdom
Rando
mized
controlledtrial
Low-vs.h
igh-fid
elity
mannequ
in§
Junior
andsenior
physicians;jun
iorand
senior
midwives;
n=140
Pretrainingand
posttraining
performance
Abilityto
completedelivery;
head-to-body
deliverytim
e;performance
ofmaneuvers;
forceapplied;
andqu
ality
ofcommun
ication
Discussionof
shou
lder
dystociamanagem
ent
anddemon
stratio
nof
maneuvers
App
liedforceprovided
toparticipants
retrospectively
*Croftsetal,20075
9
SaFE
Stud
yUnitedKingdom
Second
aryanalysis
Localvs.simulationcenter;
each
with
andwith
out
team
worktraining
Sameas
parent
stud
yKno
wledgescores
pretraining
andpo
sttraining
Changein
scoreon
repeated
MCQatbaselin
eand3wk
aftertraining
Didactic
contentviawritten
andaudiovisualm
edia,
followed
bysimulation
rehearsalo
fmaneuvers
Not
specified
Croftsetal,20073
7
SaFE
Stud
yUnitedKingdom
Second
aryanalysis
Sameas
parent
stud
yPatternanddegree
offorceapplied
during
simulated
shou
lder
dystocia
Maxim
um,average
totaland
appliedforcegradients
Non
e(analysislim
itedto
baselin
epretraining
simulation)
Non
e(analysislim
ited
tobaselin
epretraining
simulation)
Croftsetal,20076
0
SaFE
Stud
yUnitedKingdom
Follow-upat6and12
mo
n=122of
original140
Long-term
skillretention
Abilityto
completedelivery;
head-to-body
deliverytim
e;performance
ofmaneuvers;
forceapplied;
andqu
ality
ofcommun
icationat6-
and
12-m
opo
sttraining
Perparent
stud
ytraining
was
notrepeated
Perparent
stud
ytraining
was
notrepeated
272 Shoulder Dystocia Simulation Training: Status Update Simulation in HealthcareCopyright © 2018 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
*Maslovitzetal,20076
1Israel
Observatio
nal
Team-based
simulation
training
n=42
team
s60
residentsand
88midwives
Identifiablemistakes
andadequacy
ofdo
cumentatio
n
Checklistand
review
ofvideotaped
sessions;
documentatio
n
“full-scaleshou
lder
dystociadrill”
Not
specified
Croftsetal,20086
2
SaFE
Stud
yUnitedKingdom
Second
aryanalysis
n=110of
original140
Accuracyand
completenessof
documentatio
ncomparedwith
videotaped
simulation
Deliverymaneuvers;
head-to-body
deliverytim
e;fetalh
eadpo
sitio
n;andforceapplied
Perparent
stud
yPerparent
stud
y
Croftsetal,20086
3UnitedKingdom
Qualitativereview
ofvideotaped
simulations
n=450simulations
performed
by45
doctorsand
95midwives
Specificdifficulties
revealed
during
simulation
Com
mun
ication,
abilityto
deliver,inabilityto
gain
internalaccess,
applicationof
fund
alpressure
anduseof
excessiveforce
Perparent
stud
yPerparent
stud
y
*Croftsetal,20086
2UnitedKingdom
Second
aryanalysis
Pretrainingandpo
sttraining
perceptio
nof
patient
actorsof
traineeskills
n=132individu
altrainees
performing
shou
lder
dystocia
simulation
3do
mains
ofperceived
traineeperformance:
commun
ication;
respect;safety
Three
5-po
intL
ikertscales,
1foreach
domain:
feltwell-inform
ed;
feltrespected;
feltsafe
Perparent
stud
yPerparent
stud
y
Goffm
anetal,20086
4UnitedStates
Observatio
nal
Pretrainingandpo
sttraining
performance
with
interveningeducational
debrief
Ob/Gyn
residentsand
attend
ingph
ysicians;
n=71
Skilland
commun
ication
performance
Performance
scores
presim
ulationand
postsimulationtraining,
with
intervening
debrief/educationalsession
Didactic
lectureon
shou
lder
dystocia;reviewof
“basic
maneuvers”and
managem
entalgorithm;
discussion
ofop
timized
team
performance;
keycompo
nentsof
documentatio
n
Not
specified;h
owever,
videotaped
simulations
were
review
eddu
ring
debrief
Goffm
anetal,20086
4UnitedStates
Second
aryanalysis
Sameas
inparent
stud
yCon
tent
ofdo
cumentatio
nbetweenbaselin
eand
posttraining
simulations
16“key
compo
nents”
ofdo
cumentatio
n;didno
tinclud
eestim
ationof
deliverytractio
n
Perparent
stud
yPerparent
stud
y
Siassakosetal,20106
5UnitedKingdom
Rando
mized
controlledtrial
Small-grou
ptutorialvs.
hybrid
task
trainer-patient
actor
Medicalstud
entson
obstetrics
rotatio
n;n=24
Deliveryand
commun
ication
skills
Kno
wledgeassessment;
forceapplied;
commun
icationscore
(asratedby
patient
actor
orpreceptor)
“Con
sistentwith
natio
nal
guidelines”(RCOG2005)
Not
specified
*Danielsetal,20106
6UnitedStates
Rando
mized
controltrial
Simulationvs.d
idactic
teaching‡
L&Dnu
rses
andobstetric
residents;
n=32
Team
performance
Scoreon
checklist,with
points
lostforinapprop
riateactio
ns;
documentatio
nof
head
tobody
deliverytim
e
McR
oberts'position
;suprapub
icpressure;
episiotomy;delivery
ofthepo
steriorarm;
internalrotatio
n
Excessiveforce;
fund
alpressure
Reyno
ldsetal,20106
7Po
rtugal
Rando
mized
control
Simulationvs.d
idactic
lecture
n=50
midwives
intraining
Kno
wledgeof
managem
entof
norm
aldeliveryand
shou
lder
dystocia
Scores
onMCQtestpretraining
andpo
sttraining;L
ikertscale
ofself-repo
rted
confidence
Not
specified
Not
specified
Contin
uednextpage
Vol. 13, Number 4, August 2018 © 2018 Society for Simulation in Healthcare 273Copyright © 2018 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
TABLE
1.(Continued)
*Autho
r,Year
Cou
ntry
Stud
yDesign
Participants
Outcomeof
Interest
PrimaryMetrics
Used
PrescriptiveInstruction
ProscriptiveInstruction
Deering
etal,20116
8UnitedStates
Observatio
nal
Measurementof
participant
applieddeliveryforce
during
SDsimulation
Ob/Gyn
andfamily
practiceresidentsand
attend
ingph
ysicians;
n=47
Peak
levelo
fforce
applieddu
ring
simulated
shou
lder
dystocia
Magnitude
ofpeak
forceapplied(sum
mative)
during
4scenarios:
norm
alvaginald
elivery;
todiagno
seshou
lder
dystocia;d
uringmaneuvers∥;
andatabando
nmentof
vaginald
eliveryfor
cesarean
section
Non
eFeedback
onapplied
forceprovided
retrospectively
*Fransen
etal,20126
9The
Netherlands
Cluster
rand
omized
controlledtrial
n=74
Teamsof
1Ob/Gyn,
1midwife,1
resident
and
2–3nu
rses
Teamworkscoreand
useof
all-fours
maneuverto
deliver
thefetus
Clin
icalTeamworkScaleand
yes/no
useof
thespecific
all-foursmaneuver
All-foursmaneuver;
MOET
curriculum
Not
specified
*Vadnaisetal,20127
0UnitedStates
Observatio
nal
Kno
wledgeand
self-assessmentat
baselin
eand1yr
Residentsandattend
ing
physicians;
n=63
Long-term
know
ledge
retention†
and
self-assessment
Scorechange
betweenbaselin
eand1yr
on(1)kn
owledge
MCQ;and
(2)Likert-scale
self-assessmentof
confidence
“Stand
ardmaneuvers”
with
coaching
asneeded
Not
discussed
Stoh
letal,2012
71UnitedStates
Observatio
nal
Accuracyof
documentatio
nof
shou
lder
dystocia
managem
entandou
tcom
e
n=7
Inclusionof
15elem
ents
ofdo
cumentatio
naftersimulated
shou
lder
dystocia
Percentof
midwives
documentin
geach
specificelem
ent
2maternalm
aneuversand
atleast2fetalrotational
maneuversbefore
deliveringthe
posteriorarm
Not
specified
Noblotetal,20157
2France
Observatio
nal
Pretrainingand
posttraining
performance
n=131team
sof
2–3participants
(midwife
orOb/Gyn
with
anu
rse)
Techn
ique,kno
w-how
,commun
icationwith
team
;com
mun
ication
with
patient;safety
Scores
onpreselectedgrids;
completionof
extractio
nandtim
eto
delivery
McR
oberts'position
and
suprapub
icpressure;
patient
positio
ning;
“directeddelivery”;
hyperrestitutionof
chin
beneaththe
pubicsymph
ysis
Cessatio
nof
pushing
Mannella
etal,20167
3Italy
Quasi-experim
ental
case-con
trol
Simulationvs.n
osimulation
Ob/Gyn
residents;
n=32
Performance
ofshou
lder
dystocia
maneuvers
Scores
forperformance
metrics
atbaselin
eand
at8wk
McR
oberts'position
;suprapub
icpressure;
episiotomy;Rub
inmaneuver;Wood
maneuver;Po
sterior
arm
delivery;Zavanelli
Not
discussed
Kordi
etal,20177
4Iran
Rando
mized
clinicaltrial
Simulationvs.d
idactic
lecture/presentatio
n
n=51
midwives
Performance
ofshou
lder
dystociamaneuvers;
commun
icationskills
Scores
onOSC
Echecklist
Not
specified
Not
discussed
*Sho
ulderdystociasimulationwas
embedd
edwith
inlarger
simulationexercise
focusedon
obstetricem
ergencies.
†Sim
ulationtraining
was
repeated
atthelong-term
follow-up;
pretrainingandpo
sttraining
performance
was
assessed
atboth
short-andlong-term
stud
yvisits.
‡Didactic
sessions
includ
ed30
minutes
ofhand
s-on
demon
stratio
nandpractice;simulationhadno
lectures,but
1.5ho
ursof
simulationwith
contentd
elivered
during
debrief.
§High-fid
elity
mannequ
inhadem
bedd
edstrain
gaugeto
measure
appliedforce;low-fidelity
mannequ
inhadno
force-measuring
capability.
∥Maneuversweresuprapub
icpressure
andMcR
oberts'position
,which
involvetractio
non
thefetalh
ead.
¶Intervention(“high-fidelity”)
grou
phad“psychological”fid
elity
byhaving
participantsrole-playrespon
seto
emergencyrather
than
simplyrehearse
maneuvers.
L&D
indicateslabo
r&
delivery;
MCQ,multiple-choice
question
;MOET
,managingob
stetricem
ergenciesandtrauma;
Ob/Gyn,ob
stetrics/gynecology;
OSC
E,Objective
Structured
Clin
ical
Exam
ination;
RCOG,Royal
College
ofObstetricians
and
Gynaecologists;RCT,rando
mized
controlledtrial;SaFE
,Sim
ulationandFire-drillEvaluation
;SD,sho
ulderdystocia.
274 Shoulder Dystocia Simulation Training: Status Update Simulation in HealthcareCopyright © 2018 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
TABLE
2.Summ
aryofOriginalResearcho
fSimulation-B
asedTrainingforShoulderDystocia—
SimulationEvaluation
*Autho
r,Year
Cou
ntry
Stud
yDesign
Participants
Outcomeof
Interest
PrimaryMetrics
Used
PrescriptiveInstruction
ProscriptiveInstruction
Lathropetal,20077
5UnitedStates
Pilotstudy
Stud
entn
urse
midwives;
n=4
Program
evaluatio
nPresim
ulationand
postsimulationtraining
self-assessmentof
preparednessforshou
lder
dystociamanagem
entin
3do
mains:cognitive;
psycho
motor;and
affective;
stud
entfeedb
ack
Didactic
self-stud
ymod
uleand
2-H
simulationworksho
pof
4successivelymoredifficult
iteratio
nsof
shou
lder
dystocia
simulationrequ
iringincreasing
numbersof
maneuvers
Not
discussed
*Pliego
etal,20087
6UnitedStates
Qualitative
Evaluatio
nof
simulation
“bootcamp”
Ob/Gyn
andfamily
practiceresidents;
n=23
Program
evaluatio
nSelf-assessment(Likertscore)
oftechnicalcom
petence,
leadership
confidence
and
stress“hardiness”
Didactic
contentabou
tantepartum
andintrapartum
risk
factors;
recognition
ofshou
lder
dystocia
aftermod
eratetractio
n;McR
oberts,sup
rapu
bicpressure,
episiotomy,internalrotatio
n,deliveryof
thepo
steriorarm
andZavanelli
Use
of“steady”
tractio
nwith
outtorqu
e
*Sørensenetal,20097
7Denmark
Observatio
nal
Physicians,m
idwives
andL&
Dnu
rses
n=220
Program
evaluatio
nPretrainingandpo
sttraining
andlong-term
(9–15-mo)
self-assessmentof
confidence
andstress;self-repo
rtof
impacton
workenvironm
ent
Mandatory
training
program
requ
ired
ofalld
epartm
ent
person
nel
Lectures
andtraining
worksho
ps(con
tent
notspecified)
Not
specified
Curtis
andGuillien,20097
8UnitedStates
Survey
Physicians,m
idwives
andL&
Dnu
rses
Program
evaluatio
nPo
stim
plem
entatio
nof
team
-based
shou
lder
dystocia
drillssurvey
(Likertscale)
ofsatisfactionwith
program
Didacticsandreview
ofteam
-mem
berroles;
prop
erexecutionof
McR
obertsandsuprapub
icpressure;H
ELPE
RRmnemon
ic
Not
specified
*And
righettietal,20127
9UnitedStates
Quasi-experim
ental
case-con
trol
Low-fidelity
vs.
high-fidelity
simulation
Nurse
midwifery
stud
ents;
n=28
Presim
ulationand
postsimulation
self-assessed
stud
entcon
fidence
Presim
ulationand
postsimulationconfidence
scores
(Likertscale)
andkn
owledgetestscores
Didactic
instructionvialectureand
videoand“low
-fidelity”
demon
stratio
nandrehearsalo
nstaticmannequ
in
Not
discussed
*Mon
odetal,20148
0Sw
itzerland
Survey
Midwives;jun
iorand
senior
physicians;
n=168
Program
evaluatio
nSelf-assessmentscores
(Likertscale)
ofconfidence;
technicalskills;kno
wledge
ofalgorithmsandteam
commun
ication;
impression
sof
simulation
Not
specified
Videotapesreview
eddu
ring
debriefin
g
*Miller
etal,20158
1UnitedStates
Pilotstudy
Nurse
midwifery
stud
ents;
n=4
Program
evaluatio
nStud
entevaluatio
nsafter
2simulationsessions
cond
ucted5moapart
Noadditio
naltrainingbefore
simulations;intervening
educationald
ebriefing
Not
discussed
*Kom
orow
skietal,2017
82UnitedStates
Qualitative
Evaluatio
nof
simulation
experience
Certifiedprofession
almidwives
inactive
home-birthpractice;
n=12
Fidelityof
homebirth
simulation;
participant
satisfactionand
self-confidence
Simulationdesign
scalescore;
participantself-repo
rted
Likert-scalesatisfactionand
self-confidence
scores
“app
ropriatemidwifery
interventio
n”:specified
as2maneuversbeyond
McR
obertsandsuprapub
icpressure;including
Zavanelli
ifun
successful
Nouseof
excessive
tractio
n;no
useof
fund
alpressure;
abando
nmentof
homedelivery
*Sho
ulderdystociasimulationwas
embedd
edwith
inlarger
simulationexercise
focusedon
obstetricem
ergencies.
Vol. 13, Number 4, August 2018 © 2018 Society for Simulation in Healthcare 275Copyright © 2018 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
TABLE
3.Summ
aryofOriginalResearcho
fSimulation-B
asedTrainingforShoulderDystocia—
ClinicalImpact
*Autho
r,Year
Cou
ntry
Stud
yDesign
Participants
Outcomeof
Interest
PrimaryMetrics
Used
PrescriptiveInstruction
ProscriptiveInstruction
MacKenzieetal,20072
7UnitedKingdom
Observational
Com
parisonof
managem
ent
ofshoulderdystociaand
incidenceof
brachial
plexus
injury
beforeand
afterintroductionof
regulartraining
oflabor
anddeliverystaff
Hospitalleveldataon
514casesof
shoulder
dystociaand44
cases
ofneonatalbrachial
plexus
injuriesover15
yr
Changein
managem
ent
techniquesovertim
e,encompassing10
yrbeforeand5yr
after
training
introduced;
rateof
neonatalinjury
Diagnosisof
shoulder
dystocia;ratesof
different
maneuversused
including
traction;occurrence
ofbrachialplexus
injury,
fracturesor
neonatalasphyxia;
Emphasison
useof
McRobertsas
first-line
response
Not
discussed
Draycottetal,20081
7UnitedKingdom
Observational
Com
parisonof
managem
ent
andoutcom
esof
births
complicated
byshoulder
dystociapretraining
andposttraining
Hospitalleveldataon
all
deliveriescovering
5-yr
periodsbeforeand
aftertraining,
3yr
intervening;includes
586casesof
shoulderdystocia
Maneuversused;rateof
neonatalinjury
Diagnosisof
shoulder
dystocia;ratesof
each
type
ofmaneuverused;
occurrence
ofbrachial
plexus
injury
orfractures;and
assessmento
ftraction
indocumentation
Emphasison
mechanical
conceptsfocusedon
rotatin
gthefetalshoulders
outo
fanterior-posterior
orientationto
oblique
positionin
thepelvis;
algorithm:M
cRoberts;
suprapubicpressure;
deliveryof
theposterior
arm;internalrotation
Not
discussed;
noforcemeasurement
onoriginalprototype
simulator
used
Grobm
anetal,20111
9UnitedStates
Observatio
nal
3continuo
us6-moperiods
before,d
uringandafter
simulation-basedtraining
Hospitalleveldataon
254shou
lder
dystociabirths
Docum
entatio
nand
maternaland
neon
atal
adverseou
tcom
es
Con
sistency
between
physicianandnu
rsing
documentatio
n;maternaltraum
aor
hemorrhage;
neon
atalbrachial
plexus
palsy
After
developm
entof
aprotocol,sim
ulation
training
was
specifically
focusedon
team
respon
se,
andNOTon
technical
skillperformance
Not
discussed
Inglisetal,20111
8UnitedStates
Retrospectivecoho
rtCom
parisonof
pretraining
andpo
sttraining
period
outcom
esof
shou
lder
dystociadeliveries
Hospitalleveldataon
11,862
deliveriesover
5.5yr;includes
158casesof
shou
lder
dystocia
Incidenceof
brachial
plexus
injury
Brachialp
lexusinjury;
maneuversused;
head-to-body
deliverytim
e
Protocol
requ
ires
assessmento
fsho
ulder
positio
nandrotatio
nto
oblique
orientation
before
initiationof
othermaneuvers
(McR
oberts);
suprapub
icpressure;
corkscrew;all-fours;
deliveryof
the
posteriorarm;
Zavanelli,
symph
ysiotomy
orcleido
tomy
Nofund
alpressure,
nopu
shing,no
head
tractio
ndu
ring
mandatory
“hands-off”
procedure
Walsh
etal2011
26Ireland
Retrospectivecoho
rtAllinfantswith
brachial
plexus
injury
intwo
5-yr
period
sbefore
and
aftertraining
(10-yr
interventio
n)
Hospitalleveldataon
brachialplexus
injury
rates
among41,828
deliveries;
includes72
brachialplexus
injuries(9
perm
anent);
reported
shoulderdystocia
rate:7.2/1000
Brachialp
lexusinjury
rate
before
andaftertraining
inshou
lder
dystocia
managem
ent
Brachialp
lexusinjury
rate
(including
perm
anence);
occurrence
ofshou
lder
dystocia;cesarean
deliveryrate
Protocol
emph
asizes
McR
obertsand
suprapub
icpressure
asfirst-linerespon
se,
followed
byinternal
rotatio
nanddelivery
ofthepo
sterior
afterfirstattempt
attractio
n
Not
discussed
276 Shoulder Dystocia Simulation Training: Status Update Simulation in HealthcareCopyright © 2018 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
Nguyenetal,20118
3UnitedStates
Observatio
nal
Impactof
sequ
ential
introd
uctio
nof
compu
terizeddelivery
chartin
gthen
simulationdrills
Hospitalleveldataon
180casesof
actual
shou
lder
dystocia
Team
drillsinclud
edattend
ingph
ysicians;
residentsand
L&Dnu
rsing
Docum
entatio
ncompleteness
in3tim
eperiod
s:before
interventio
n;afterintrod
uctio
nof
compu
terizedchartin
g;afterintrod
uctio
nof
shou
lder
dystocia
simulationdrills
Com
pliancewith
25elem
ents
ofdo
cumentatio
n
Team
simulation
drillbasedon
AHRQTeamST
EPPS
model
Recognitionof
shoulder
dystocia;patient
commun
ication;
staffcom
mun
ication;
notin
gpositionof
the
head;M
cRoberts';
suprapubicpressure;
rotationalm
aneuvers;
deliveryof
theposterior
arm;episio
tomy;
cord
gases
Ceasing
tractio
non
thefetalh
ead
Corneau
andCraig,
2014
84Canada
Observatio
nal
Impactof
documentation
training
onactual
documentation
Ob/Gyn
resid
ents
n=17
Exam
inationof
documentationin
1beforeand1after
training
participation
inactualshoulder
dystociaby
sameresid
ent
Docum
entation
completeness
andaccuracy
inreallife
shoulderdystocia
deliverychartin
g
Inclusionof
21elem
ents
ofdocumentationin
dictated
notesof
actual
shoulderdystocia
eventsoccurring
pre-andpostsim
ulation
training
(based
onRCOG2005)
Onlyretrospectivefeedback
ofperformance
provided
after“surprise”shoulder
dystociadrillon
hybrid†
model(content
notspecified)
Not
specified
Van
deVen
etal,20168
5The
Netherlands
Retrospectivecoho
rt38-m
ointervalcomparison
before
andafterteam
training
inshou
lder
dystocia
Hospitallevelou
tcom
edata
on3492
and3496
ceph
alic
vaginald
eliveriesbefore
and
afterim
plem
entatio
nof
team
training
Diagnosisof
shou
lder
dystocia;m
aneuvers
used;fetalinjury
Com
binedfetalinjury
outcom
e:perinatal
asph
yxiaandtrauma
Techn
icaland
commun
ication
skills;algorithm
ofMcR
oberts;sup
rapu
bic
pressure;rotational
maneuver;deliveryof
the
posteriorarm;all-fours
(Gaskin)
maneuver
Mentio
nsobjectiveof
usingmaneuversthat
minim
izeforce;used
forcemeasurements
insimulations
Croftsetal,20162
2UnitedKingdom
Interrup
tedtim
eseries
Com
parisonof
managem
ent
andneon
atalou
tcom
esof
births
complicated
byshou
lder
dystocia
Hospitallevelou
tcom
edata
on1148
casesof
shou
lder
dystociain
3tim
eperiod
scovering
pretraining;early
training
(2001–2004)and
latetraining
(2009–2012)
Managem
ento
fsho
ulder
dystociaaccordingto
guidelines
andincidence
ofbrachialplexus
injury,
includ
ingperm
anence;
assessmentof
continuance
ordecayof
original
improvem
entsover
time
Diagnosisof
shou
lder
dystocia;frequ
ency
ofuseof
recommended
maneuvers;incidence
ofbrachial
plexus
injury
Didactic
sessionfollowed
byrehearsalo
fmaneuverson
simulator
andthen
team
training
simulation
session;
repeated
annu
ally—contractually
mandatedof
all
hospitalp
ersonn
el
Emph
asison
impo
rtance
ofroutinetractio
non
ly:
“dono
tpullh
ard,
dono
tpullq
uickly,
dono
tpulld
own”;
incorporatelesson
sfrom
previous
simulationstud
ies
Kallianidisetal,20162
1The
Netherlands
Observatio
nal
Self-repo
rtof
actual
clinicalmanagem
entof
shou
lder
dystociaafter
attend
ingsimulation
training
n=64
actualcasesof
shou
lder
dystociarepo
rted
from
amon
gatotalo
f198em
ergenciesmanaged
by337midwives
Maneuversused,sequence,
head-to-body
delivery
interval,and
occurrence
ofbrachialplexus
injury,
fracture
and/or
hypo
xic-ischem
icenceph
alop
athy
Frequencyof
useof
specific
maneuvers,h
ead-to-bod
ydeliveryintervaland
occurrence
oftrauma
orasph
yxia
CAVEsimulationcourse
Not
specified
Contin
uednextpage
Vol. 13, Number 4, August 2018 © 2018 Society for Simulation in Healthcare 277Copyright © 2018 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
TABLE
3.(Continued)
*Autho
r,Year
Cou
ntry
Stud
yDesign
Participants
Outcomeof
Interest
PrimaryMetrics
Used
PrescriptiveInstruction
ProscriptiveInstruction
*Fransen
etal,20178
6The
Netherlands
Randomized
controlledtrial
Com
parison
ofcomposite
outcom
esmeasure
betweentrained
anduntrained
hospitalunits
Multicenterhospitallevel
outcom
esdataon
low
Apgarscores;severe
postpartum
hemorrhage;
traumaaftershoulder
dystocia;eclam
psiaand
hypoxic-ischemic
encephalopathy
Effectivenessof
team
training
with
simulation
Com
positeoutcom
eof
adverseobstetric
events
betweentrainedand
untrainedun
its
Didactic
sessionreview
ing
RCOG2005
algorithm
followed
bysim
ulation
session.Retrospective
debriefingof
performance
only
Reviewofvideotapes
fordeeperdiscussio
ns
*Van
deVen
etal,20178
7The
Netherlands
Secondaryanalysis
Retentionofclinical
impactaftertraining
asassessed
at3-mointervals
posttraining
Multicenterhospital
leveldataof
low
Apgarscore,severe
postpartum
hemorrhage,trauma
dueto
shoulder
dystocia;eclam
psia,
andhypoxic-ischemic
encephalopathy
Effectivenessof
team
training
with
simulation
Com
positeou
tcom
eof
adverseobstetricevents
betweentrainedand
untrainedun
ites
Sameas
parent
stud
ySameasparent
study
Van
deVen
etal,20173
0The
Netherlands
Mod
el-based
cost-effectivenessanalysis
Sameasparent
study
Cost-effectivenessof
simulationtraining
topreventadverse
from
shou
lder
dystocia
ICER
Sameas
parent
stud
ySameas
parent
stud
y
Gurew
itsch
Allen
etal,20172
0UnitedStates
Observational
Presim
ulationand
postsim
ulation
training
intervention
comparison
ofadverseneonatal
outcom
esafter
shoulderdystocia
n=72
traineesover8yr;
Aggregatehospitallevel
dataon
shoulder
dystociamanagem
ent
andoutcom
es
Effectivenessof
simulationtraining
aspartof
amultifaceted
quality
assuranceprogram
Incidenceof
brachial
plexus
injury
after
actualcasesof
shou
lder
dystocia
Emphasison
rotational
andinternalmaneuvers
torelieve
shoulder
dystocia;debriefing
aftereveryactualcase
ofshoulderdystocia
Emphasison
avoiding
excessivelateralforce;
insertingahands-off
(donothing)
perio
dto
awaitspontaneous
restitution.
*Ind
icates
shou
lder
dystociasimulationwas
embedd
edwith
inlarger
simulationexercise
focusedon
obstetricem
ergencies.
†Hybridmod
elconsistsof
partialtasktrainercombinedwith
patient
actor.
AHRQindicatesAgencyforHealth
care
ResearchandQuality;CAVE,
CursusAcuteVerloskun
de;ICER
,incrementalcost-effectivenessratio
.
278 Shoulder Dystocia Simulation Training: Status Update Simulation in HealthcareCopyright © 2018 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
varies considerably among the different studies, and its spe-cific inclusion in guidelines and educational objectives hasevolved over time.50–52,54 A comparison of the original na-tional guidelines50,51 reveals significant differences in man-agement recommendations between the United States andthe United Kingdom,92 which persist even after revision.The updated American national guidelines downplay therelationship of clinician-applied traction to brachial plexusinjury.4,54 In contrast, British national guidelines for man-agement of shoulder dystocia have been updated to includea joint recommendation by the Royal College of Midwivesand the Royal College of Obstetricians and Gynaecologistsfor annual skill drills for all birth attendants. In addition, theoriginal statement that “routine traction in an axial directionmay be employed to diagnose shoulder dystocia”51 wasredacted to add the following caveat: “but any other tractionshould be avoided.”52 The recent American Congress ofObstetricians and Gynecologists Simulations Consortium'sLearning Objectives for Shoulder Dystocia only mentions useof “appropriate” traction in the recognition and diagnosis ofshoulder dystocia;55 limiting of concomitant traction appliedduring other maneuvers is not addressed.
The difference in emphasis on clinician-applied tractionlikely is attributable to the varying assessment of its signifi-cance that has emerged from simulation training research.Among the five studies where applied traction force wasassessed, studies using a subjective assessment by the evaluatorfound no difference in applied force15 or did not specify whetherforce patterns differed64,66 between trained and untrainedparticipants. However, marked differences in level of forceused before and after training57,89 and in patterns of forceused during different maneuvers68 were found in those studieswhere applied force was measured objectively by a strain gaugeembedded within the mannequin. It is noteworthy that severalstudies showing a positive impact of simulation training onrate of actual fetal injury after shoulder dystocia used theobjective force measurement during training,17,22,85 whereasthose showing no difference in outcomes of actual shoulderdystocia did not include an assessment of clinician-appliedtraction during training.26,27 Only one study evaluating thevalue of simulation to learners makes specific mention of themagnitude and direction of traction force to be applied, butthis was assessed by participants only subjectively (ie, no forcemeasurements were taken).76 In those studies where force wasmeasured, the amount of force exerted was only provided toparticipants retrospectively during debriefing.57,58,68 To date,there has not been a direct comparison of objective andsubjective assessments of simulation-trained clinicians' appliedtraction nor between real-time and after-the-fact disclosure offorce measurements to trainees.
Time as a FactorShoulder dystocia is considered an emergency because
failure to timely resolve the obstructed delivery of the infantcan result in neonatal asphyxia or even death. The preciseamount of time that can safely elapse before asphyxial insultoccurs is unknown, but it is estimated to be at least 6 minutesfor an otherwise healthy fetus.93 Because nearly every maneuverfor shoulder dystocia can be executed in a matter of seconds,
time to resolution of shoulder dystocia is another objective met-ric for provider competence15,58,60,66 and considered a criticalelement for documentation.56,62,71,94 Only the SaFE study usedan a priori limit of 5 minutes to complete delivery58; otherstudies of learners' performance of simulated shoulder dysto-cia maneuvers15,58,72 allowed participants to continue untileither posterior arm delivery was performed or no furthermaneuvers were attempted. In all these studies, a shorterhead-to-body delivery interval time was considered evidenceof learners' skill acquisition.
The deliberate insertion of a hands-off period in which noaction is taken until the next uterine contraction occurs afterdelivery of the head has been advocated as a method to reducethe incidence of shoulder dystocia95,96 and has been shown tohave no significant clinical effect on neonatal Apgar scores orcord blood pH level.97,98 Inglis et al18 incorporated this intoan algorithm along with adjustment of the shoulder positionto oblique orientation before application of traction. Theynoted only a 30-second increase in recorded head-to-body inter-val during actual shoulder dystocia after the introduction ofsimulation-based drills using these principles, while simul-taneously increasing the use of Rubin's maneuver from17% to 32% and reducing the incidence of brachial plexusinjury from 30% to 10.7%.18 Gurewitsch Allen et al20 recentlyreported similar results using the same principles.
The Value of Team-Based and Repeated TrainingEvidence for the value of simulation training for develop-
ment of individual participants' technical and nontechnicalskills, confidence, and competence is more positive comparedwith evidence of its value for team-based responses to shoulderdystocia. Neither the SaFE study59 nor the randomizedcontrolled trial of team training by Fransen et al86 founda difference in either team-member knowledge59 or clinicalimpact69 between simulations that included teamwork andthose that did not. Similarly, Walsh et al26 did not observe achange in clinical outcomes with the introduction of team-based training. On the other hand, Grobman et al19 found thatteam training was associated with positive clinical outcomes,and improved work environment was demonstrated by Sørensenet al.77 Recent secondary analyses of team-based simulationtraining for obstetric emergencies, including shoulder dystocia,have also shownpositive clinical impact on adverse outcomes.86,87
Paradoxically, it is noteworthy that the assessment tools usedfor evaluation of teamwork have been validated and standard-ized to a far greater extent than have those used to assessprovider skill, either for obstetric emergencies in general orfor shoulder dystocia management in particular. The latterrepresents an important gap in knowledge about reliabilityand validity of simulation-based competency assessment.
Those few studies that assess long-term skills reten-tion22,60,70,73,77,81,87 also have yielded mixed results; however,repetition of training before reassessment and length of timebetween training sessions varied widely. Where studied, theoverall impact of repeat simulation training on skills acqui-sition and retention by novices tended to be greater than byexperienced personnel who already demonstrated greatercompetence at initial training.60
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Learning From ErrorThe Role of Proscriptive InstructionMedical simulation is touted for its ability to uncover
systematic error, which in turn can be used to improve sub-sequent performance—either at the individual or at theteam level—during training99 and in actual clinical practice.19
Only four studies have addressed directly the types of errorsspecifically identified during simulation training for shoulderdystocia.18,61,63,100 Protocols for team management of shoul-der dystocia have been developed using quantitative methodssuch as targeted interviews with providers and iterative re-hearsals100; unit-wide dissemination of the protocol to alllabor and delivery personnel was achieved with simulationon site.18,63,100 Deficiencies in communication63,100 anddocumentation,61,100 as well as errors in performing maneu-vers61,63 were reported commonly.However, onlyCrofts et al63
specifically cited use of excessive traction as an error and onlyInglis et al18 included a deliberate “hands-off” procedure uponinitial recognition of shoulder dystocia. From an educationalstandpoint, a corollary to proscriptive instruction NOT toapply too much traction is NOT to apply any traction too soon.Thus, the conscious limiting of traction applied to the headand purposely awaiting a brief period of time in which no ac-tion should be taken (eg, manually assisting external rotationof the fetal head) are proscriptive instructions, requiring thepreceptor to specify what not to do. This differs from identify-ing errors of omission, which are corrected with prescriptiveinstruction demonstrating each technique. Errors of commis-sion, such as using improper technique or applying traction inexcess of that normally used, may or may not materialize dur-ing a given shoulder dystocia simulation; thus, correction oremphasis on specific avoidance of such errors will occur onlyintermittently during simulation training unless purposely in-cluded in the instructional content.65,70 To date, the effective-ness of prescriptive versus proscriptive elements of instructionhas not been compared directly.
Feedback to LearnersIn 8 (21%) of 37 primary-analysis original reports on
shoulder dystocia simulation for training and competency as-sessment, evaluation of participant performance, documenta-tion accuracy, and detection of errors was made retroactively,using careful analysis of videotaped sessions,15,56,58,61–63,66,72
whereas only six (16%) simultaneously included a checklistthat was completed by the preceptor in real time during simu-lation.15,61,62,64,65,87 Goffman et al64 relied on real-time scoring,referring to the videotapes only to adjudicate between incongru-ous scores by independent observers. The SaFE study used onlyreal-time recording of objective time points (eg, performanceof specific maneuvers, head-to-body interval) to assist withtime-based analysis of objective force measurement data.58,63,89
Viewing of videotapes as part of debriefing immediately aftersimulation training was used in only two studies.64,73 However,a direct comparison of real-time versus retroactive assessmentfor validity and interrater reliability has not been made.
COMMENTARYThis review analyzes simulation of shoulder dystocia specifi-cally and reveals significant differences in simulation curricula
andmetrics, as well as several critical gaps in current knowledge:(1) prescriptive instruction prioritizing maneuvers shown todecrease strain on the brachial plexus is inconsistently used.(2) Proscriptive instruction to avoid placing excessive andlaterally directed traction on the head or to observe a briefhands-off period before attempting traction is infrequentlyexplicit. (3) Neither relative effectiveness nor potential inter-action between prescriptive and proscriptive elements ofinstruction has been examined directly. (4) Reliability andvalidity of costly high-fidelity mannequins capable of objectivemeasurement of clinician-applied traction force as comparedwith subjective assessment of provider competence are unknown.
Several limitations of this systematic review must be ac-knowledged. As is true of most qualitative research methods,the chosen theoretical framework as the basis for this analysisreflects the perspective and expertise of the single author;interaction between the research findings and the researchers—whether singular or multiple—cannot be avoided. Most of theoriginal research on simulation for shoulder dystocia manage-ment predates the relatively recent emphasis on standardizedsimulation-based research reporting. Thus, it is possible, ifnot likely, that a simulation-based curriculum may have in-cluded such topics as limiting traction and effective timemanagement, but these may not have been explicitly statedin the article. Furthermore, in every CI-focused study, themethods for calculating actual clinical rates of brachialplexus injury and the periods over which this relatively un-common complication was observed were not standardized;thus, the reasons for inconsistent translation of simulationresults to actual clinical results cannot be directly attributedto the differences in curricular content systematically reviewedherein. This would require formal experimentation withexplicit reporting standards.
Finally, the most glaring deficiency in simulation-basedtraining is the lack of standardization and validation of specificcurricular content. Development of cognitive aids in this areawill require iterative steps, and evaluation of several key re-search questions before use of simulation for skills acquisitionand competency assessment can be considered valid, reliable,sufficiently standardized, and high quality to be used forcertification purposes: How does the deliberate inclusionof specific demonstrations of applying excessive tractionor using improper technique impact learners' skills acquisitionand competency assessment? Is there an interaction betweenprescriptive and proscriptive instructional methods? Is therea difference in skills acquisition and/or competency assessmentwhen simulation-based training uses real-time versus retroac-tive evaluation metrics? Is subjective assessment of providerperformance comparable with objective metrics such as forcemeasurement? These questions will require further study toinform widespread evidence-based implementation of shoulderdystocia simulation for clinically translatable skill acquisitionand competency assessment.
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