Simulation of Shoulder Dystocia for Skill Acquisition and ...€¦ · shoulder dystocia management skills,23,24 no doubt spurred by these impressive results, which include reductionsin

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: [email protected]).

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.


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


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


*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


TABLE

1.(Continued)

*Autho

r,Year

Cou

ntry

Stud

yDesign

Participants

Outcomeof

Interest

PrimaryMetrics

Used



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.


TABLE

2.Summ


fSimulation-B


SimulationEvaluation

*Autho

r,Year

Cou

ntry

Stud

yDesign

Participants

Outcomeof

Interest

PrimaryMetrics

Used



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.


TABLE

3.Summ


fSimulation-B


ClinicalImpact

*Autho

r,Year

Cou

ntry

Stud

yDesign

Participants

Outcomeof

Interest

PrimaryMetrics

Used



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


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


TABLE

3.(Continued)

*Autho

r,Year

Cou

ntry

Stud

yDesign

Participants

Outcomeof

Interest

PrimaryMetrics

Used



*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

.


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


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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Simulation of Shoulder Dystocia for Skill Acquisition and ...€¦ · shoulder dystocia management skills,23,24 no doubt spurred by these impressive results, which include reductionsin