Shoulder dystocia drills can improve response

Shoulder dystocia drills should become a routine part of risk reduction in any hospital delivering babies, according to experts who say the drills can greatly improve how clinicians respond to this emergency.

The American College of Obstetricians and Gynecologists (ACOG) in Washington, DC, and other resources generally report the incidence of shoulder dystocia to be between 0.5% and 1.5%, but the true incidence of shoulder dystocia is unclear because the rate is dependent upon how this condition is defined and how accurately it is reported. Many obstetricians may be reluctant to document shoulder dystocia for fear that this will be a red flag attracting a malpractice suit if it turns out later that the baby has suffered an injury. Most sources estimate that about 20% of shoulder dystocia cases result in injury, such as brachial plexus impairments and Erb's palsy, and the resulting malpractice cases often result in multimillion-dollar payouts. (Editor's note: For more information about shoulder dystocia and the consequences, see www.shoulderdystociainfo.com.)

A major risk management challenge

The relatively infrequent occurrence of shoulder dystocia and the potentially terrible consequences for all involved create a major risk management challenge, says Sean Blackwell, MD, associate professor of maternal fetal medicine at the University of Texas Health Science Center at Houston. When obstetrical teams don't see the condition often, they don't get much chance to practice a response, he says. Yet they must be able to respond quickly and correctly to avoid disaster. That is why shoulder dystocia drills should be as common as infant abduction drills and disaster drills, he says.

Unfortunately, they're not. Even at Blackwell's own hospital, shoulder dystocia drills are not performed regularly. A primary hurdle usually involves getting physicians to come to the hospital and participate, he says.

"Even for hospitals with a high volume of deliveries, most hospitals don't do the drills on a formal basis," Blackwell says. "There will be all sorts of informal training where physicians instruct residents and the obstetrics teams discuss it when they have a chance, but most do not do formal drills with instruction, observation, and a means to measure the performance."

Drills improve communication

Blackwell notes that there is not much evidence in the medical literature to prove that shoulder dystocia drills will reduce adverse outcomes. But he suggests the evidence is lacking simply because too few hospitals have implemented regular drills and even fewer have studied the results. The idea of drilling to practice a critical emergency response, however, makes sense no matter what the particular emergency is, he says. Hospitals more often perform drills to rehearse responses to emergency cesarean drills and hemorrhage.

The purpose of a shoulder dystocia drill is not necessarily to teach clinicians how to care for the condition, but rather the drill is designed to help them improve communication and coordinate their response, Blackwell says.

"One of the issues that comes up in medical/ legal events is often communication — who said what, when they said it, and whether everyone communicated clearly and effectively," he says. "This is what the shoulder dystocia drill can improve. The team needs to know not just what to do in a didactic sense but how to communicate and work with the other team members."

Blackwell also points out that shoulder dystocia drills can be a real asset for the defense when litigating an injury resulting from dystocia.

"It's a question that comes up very often in malpractice cases: Have you ever done a shoulder dystocia drill? How recently? Have you ever seen the ACOG video on shoulder dystocia?" he says. "Hospitals certainly have a self-interest in documenting the efforts to provide continuing training in this skill, and risk managers can champion this cause in the hospital just as they are doing for fetal heart rate monitoring."

Underwriter endorses dystocia drills

The value of shoulder dystocia drills should not be underestimated, says Susan R. Chmieleski, APRN, FASHRM, JD, vice president, Risk Man-agement and Client Services, Darwin Professional Underwriters in Farmington, CT. Her company recently introduced a new risk reduction program for obstetrical departments and policyholders receive a premium reduction for completing the educational modules. One element of the education involves the importance of shoulder dystocia drills.

"We developed these resources with an eye toward best practices and common issues," she says. "We determined that shoulder dystocia drills represent an excellent opportunity to improve patient safety and reduce the potential liability from this event."

Use mannequins, simulators

A good shoulder dystocia drill should involve the use of medical mannequins and patient simulators that allow the obstetrics team to physically go through the different maneuvers necessary to alleviate dystocia, Chmieleski says.

"The purpose of the drill is to give the obstetrics team some experience, both for the individual and as they work as a team, in this emergency situation that they will not encounter with great frequency," she says. "The risk manager is an ideal position to understand the potential consequences of not being able to respond effectively, and to convey the need for formal drills."

(Editor's note: Blackwell recommends a DVD on how to conduct shoulder dystocia drills that is available from ACOG. The ACOG DVD on shoulder dystocia drills is available at www.acog.org/bookstore/DVDs_Obstetrics_ C70.cfm. The price is $75 for nonmembers and $49 for ACOG members.)

Sources

For more information on shoulder dystocia drills, contact:

  • Sean Blackwell, MD, Associate Professor, Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Science Center at Houston (TX). Telephone: (713) 500-6293. E-mail: Sean.Blackwell@uth.tmc.edu.
  • Susan R. Chmieleski, APRN, FASHRM, JD, vice president, Risk Management and Client Services, Darwin Professional Underwriters, Farmington, CT. Telephone: (860) 284-1954. E-mail: schmieleski@darwinpro.com.