Does Shoulder Simulation Training Decrease the Incidence of Brachial Plexus Injury?
December 1, 2022
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By Ahizechukwu C. Eke, MD, PhD, MPH
Associate Professor in Maternal Fetal Medicine, Division of Maternal Fetal Medicine, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore
SYNOPSIS: This study demonstrated that improved team and individual performance can result from systematic simulation-based shoulder dystocia training, which can considerably lower the incidence of permanent brachial plexus injuries.
SOURCE: Kaijomaa M, Gissler M, Ayras O, et al. Impact of simulation training on the management of shoulder dystocia and incidence of permanent brachial plexus birth injury: An observational study. BJOG 2022; Aug 10. doi: 10.1111/1471-0528.17278. [Online ahead of print].
Shoulder dystocia is a complication of vaginal delivery in which the shoulder(s) of the fetus get stuck above the maternal pubic bone at the time of delivery despite gentle downward traction (usually with prolonged head-to-body delivery interval of > 1 minute), requiring additional maneuvers to dislodge the fetus.1,2 It occurs in 0.15% to 2% of all deliveries, and is an obstetric emergency that results in traumatic experiences to the patient, caregivers, and healthcare providers.³ Shoulder dystocia is hard to predict, even though researchers have studied ways to do so.3
Although shoulder dystocia can be complicated by injuries involving neonatal cervical nerve 5 through thoracic nerve 1 (C5-T1), namely Erb’s (C5-C7) and Klumpke’s (C8-T1) brachial plexus palsies, Erb’s palsy constitutes by far the majority of injuries that result from continued stretch of the nerves.4 Brachial plexus injuries occur in approximately 2.3% to 16% of deliveries complicated by shoulder dystocia.5,6 While approximately 80% to 96% of cases recover within three months of delivery, in 4% to 20% of cases, brachial nerve injuries become permanent and can result in severe morbidity for the affected child.7 Therefore, prevention of shoulder dystocia should be a top priority in obstetric delivery units.
Simulation has been recommended as a way to reduce the incidence of shoulder dystocia, including its potential complications of nerve plexopathies.8 Simulator-based training has been endorsed by many healthcare organizations, although investigations on its effects have produced conflicting findings. Therefore, Kaijomaa and colleagues conducted this study to analyze the effect of simulation-based training on the management of shoulder dystocia and the incidence of permanent brachial plexus injuries.9
This study was a retrospective cohort study conducted at the Helsinki University Women’s Hospital between 2010-2019 (2010-2015 was the pre-intervention and 2015-2019 was the post-intervention).9
In 2015, regular three-hour, multi-professional shoulder dystocia simulation trainings were started and conducted on a weekly basis, with a focus on midwives, residents, and attending physicians. Midwives and doctors with limited work experience were given priority, and participation was mandatory for all providers. The practice of non-technical skills, namely teamwork, reporting (identification, situation, background, assessment, recommendation), communication (closed-loop), and crisis resource management, also were taught and included in every simulation training session.9 All training was conducted by a team of certified simulation trainers from the hospital that included a specialist in obstetrics and gynecology and two or three midwives.
For this study, all vaginal deliveries (of fetuses in vertex position) met the inclusion criteria. Cases were excluded if they were delivered via assisted breech or by cesarean. All cases with permanent brachial plexus injuries were identified from the hospital database with International Classification of Diseases, 10th revision (ICD-10) codes. A permanent brachial plexus injury was defined as clinically evident limited active or passive range of motion or decreased strength of the affected limb detectable at the age of 1 year.9 Pregnancy and postpartum outcomes included the incidence of shoulder dystocia, presence of risk factors for shoulder dystocia (fetal weight, mean maternal weight, gestational diabetes in current pregnancy), maternal age, percentage of fetuses delivered by induction of labor, and percentage of fetuses delivered by vacuum extraction. Other neonatal outcomes included umbilical cord pH and Apgar scores at one minute and five minutes.
A total of 113,785 vaginal deliveries during the study period met the inclusion criteria. Among women who delivered vaginally, 248 cases (0.22%) of shoulder dystocia were identified between 2010-2019. After the implementation of systematic simulation training, the risk for permanent brachial plexus injuries among cases of shoulder dystocia was significantly lower (43.5% vs. 6.0%, P < 0.001). Up to 67% of annual shoulder dystocia cases resulted in permanent brachial plexus injury during the pre-training period, but the percentage rapidly decreased to < 12% after the implementation of simulation training. Maternal age (31.2 ± 5.2 years vs. 31.7 ± 5.1 years, P < 0.001), maternal weight (65.11 ± 12.91 kg vs. 65.88 ± 13.50 kg, P < 0.001), and the incidence of gestational diabetes (12.3% vs. 18.5%, P < 0.001) also were higher during the post-training period.
There was no difference in the incidence of primiparity (44.2% vs. 44.2%, P = 0.964) and mean gestational age at delivery (39.9 ± 1.77 weeks of gestation vs. 39.9 ± 1.80 weeks of gestation, P = 0.766). The incidence of induction of labor (21.4% vs. 25.2%, P < 0.001) and vacuum-assisted deliveries (12.5% vs. 13.3%, P > 0.001) was higher during the post-training period. Although the mean birthweight (3,493.9 ± 529.7 g vs. 3,481.4 ± 527.4 g, P = 0.043) and the incidence of birthweight > 4,000 g (15.4% vs. 14.6%, P < 0.001) and > 4,500 g (2.0% vs. 1.7%, P < 0.001) was lower during the post-training period among all neonates, there was no difference in the mean birthweight (4,221.3 g vs. 4,125.2 g, P = 0.171) and incidence of birthweight > 4,000 g (71.0% vs. 61.4%, P = 0.176) and > 4,500 g (25.8% vs. 23.9%, P = 0.764) among newborns whose deliveries were complicated by shoulder dystocia.
This study by Kaijomaa and colleagues demonstrated that the frequency of persistent brachial plexus injuries dropped dramatically after the adoption of routine, multi-professional simulation-based training, thus emphasizing the need for simulation-based shoulder dystocia training to reduce the incidence of brachial plexus injuries.9
The immediate management of shoulder dystocia at the time of delivery is critical. After shoulder dystocia is recognized, maternal pushing should be discouraged and additional help should be sought immediately. This should include more nurses, obstetricians, neonatologists, and anesthesiologists. The HELPERR mnemonic has been promoted as an acronym for first- and second-line management steps in cases of shoulder dystocia:10,11
• H: Call for help;
• E: Consider early episiotomy;
• L: Leg positioning for McRoberts maneuver;
• P: Pressure over the suprapubic region;
• E: Enter maneuvers (Rubins, Woods corkscrew, or reverse corkscrew maneuvers);
• R: Removal of the posterior arm;
• R: Roll over to all fours (Gaskin’s maneuver).
Although the HELPERR maneuvers can be executed in the order described here, they also can be executed in any other fashion, depending on the skill and comfort level of the provider(s). Third-line maneuvers, including cleidotomy, symphysiotomy, and the Zavanelli maneuver (vaginal replacement of the fetal head followed by emergent cesarean delivery) should only be attempted after first- and second-line maneuvers have failed to deliver the fetus. In the management of shoulder dystocia, fundal pressure to expedite fetal delivery should be strongly discouraged, since it can worsen the already affected shoulder and can result in uterine rupture.
Shoulder dystocia has multiple known risk factors. Diabetes, fetal macrosomia, a previous history of shoulder dystocia, assisted vaginal delivery (vacuum), maternal obesity, and protracted labor are a few known risk factors for shoulder dystocia, albeit fetal macrosomia is the most important. Therefore, prediction and prevention of shoulder dystocia risk factors potentially could decrease the future risk of shoulder dystocia. However, only two measures, management of gestational diabetes to optimize blood sugars and early induction of labor in cases of suspected fetal macrosomia in the setting of gestational diabetes, have been demonstrated to have a potential effect on the prevention of shoulder dystocia.12,13 Nevertheless, it must be emphasized that, despite attempts at preventing shoulder dystocia, it cannot be accurately predicted and prevented.
Shoulder dystocia is a condition that all obstetricians are expected to know about and be able to manage. Similar to the findings from this study, prior studies have demonstrated that the overall incidence of shoulder dystocia and other obstetric-related complications has decreased as a result of simulation-based training.9,14,15 It has been demonstrated that hands-on shoulder dystocia training enhances patients’ perceptions of their care during simulated shoulder dystocia as well as healthcare provider knowledge, competence, and handling of shoulder dystocia cases.16 Simulation provides a safe environment for teams to practice communication, teamwork, and skills in the event of a real-world emergency. The Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives advocate for yearly participation in shoulder dystocia training.17 Communication and teamwork skills acquired during these shoulder dystocia training sessions have been demonstrated to help in mitigating future shoulder dystocia occurrences.
In summary, shoulder dystocia is an obstetric emergency, and simulations geared toward reducing its incidence should be encouraged in every obstetric unit to prevent the complications of shoulder dystocia, notably permanent brachial plexus injuries. The American College of Obstetricians and Gynecologists (ACOG) recommends systematic approaches to simulation training aimed at reducing shoulder dystocia and its sequelae.18 ACOG also recommends that women with a history of shoulder dystocia in prior pregnancies should be offered elective cesarean delivery in future pregnancies. In women with fetuses with estimated fetal weight > 4,500 g (diabetic) or > 5,000 g (nondiabetic), ACOG recommends cesarean delivery to prevent shoulder dystocia and its sequalae.18
- Politi S, D’emidio L, Cignini P, et al. Shoulder dystocia: An evidence-based approach. J Prenat Med 2010;4:35-42.
- Chauhan SP, Gherman R, Hendrix NW, et al. Shoulder dystocia: Comparison of the ACOG practice bulletin with another national guideline. Am J Perinatol 2010;27:129-136.
- Hill MG, Cohen WR. Shoulder dystocia: Prediction and management. Womens Health (Lond) 2016;12:251-261.
- Andersen J, Watt J, Olson J, Van Aerde J. Perinatal brachial plexus palsy. Paediatr Child Health 2006;11:93-100.
- Gherman RB, Ouzounian JG, Goodwin TM. Obstetric maneuvers for shoulder dystocia and associated fetal morbidity. Am J Obstet Gynecol 1998;178:1126-1130.
- Mazouni C, Menard J-P, Porcu G, et al. Maternal morbidity associated with obstetrical maneuvers in shoulder dystocia. Eur J Obstet Gynecol Reprod Biol 2006;129:15-18.
- Chater M, Camfield P, Camfield C. Erb’s palsy – Who is to blame and what will happen? Paediatr Child Health 2004;9:556-560.
- Kim T, Vogel RI, Das K. Simulation in shoulder dystocia: Does it change outcomes? BMJ Simul Technol Enhanc Learn 2019;5:91-95.
- Kaijomaa M, Gissler M, Äyräs O, et al. Impact of simulation training on the management of shoulder dystocia and incidence of permanent brachial plexus birth injury: An observational study. BJOG 2022; Aug 10. doi:10.1111/1471-0528.17278. [Online ahead of print].
- Baxley EG, Gobbo RW. Shoulder dystocia. Am Fam Physician 2004;69:1707-1714.
- Bothou A, Apostolidi D-M, Tsikouras P, et al. Overview of techniques to manage shoulder dystocia during vaginal birth. Eur J Midwifery 2021;5:48.
- Schmitz T. [Delivery management for the prevention of shoulder dystocia in case of identified risk factors]. J Gynecol Obstet Biol Reprod (Paris) 2015;44:1261-1271.
- Horvath K, Koch K, Jeitler K, et al. Effects of treatment in women with gestational diabetes mellitus: Systematic review and meta-analysis. BMJ 2010;340:c1395.
- Sørensen JL, Løkkegaard E, Johansen M, et al. The implementation and evaluation of a mandatory multi-professional obstetric skills training program. Acta Obstet Gynecol Scand 2009;88:1107-1117.
- Shaw-Battista J, Belew C, Anderson D, van Schaik S. Successes and challenges of interprofessional physiologic birth and obstetric emergency simulations in a nurse-midwifery education program. J Midwifery Womens Health 2015;60:735-743.
- Dahlberg J, Nelson M, Abrandt Dahlgren M, Blomberg M. Ten years of simulation-based shoulder dystocia training — impact on obstetric outcome, clinical management, staff confidence, and the pedagogical practice — a time series study. BMC Pregnancy Childbirth 2018;18:361.
- Crofts JF, Bartlett C, Ellis D, et al. Management of shoulder dystocia: Skill retention 6 and 12 months after training. Obstet Gynecol 2007;110:1069-1074.
- [No authors listed]. Practice Bulletin No 178: Shoulder dystocia. Obstet Gynecol 2017;129:e123-e133.
This study demonstrated that improved team and individual performance can result from systematic simulation-based shoulder dystocia training, which can considerably lower the incidence of permanent brachial plexus injuries.
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