What do accoucheurs really know about the management of Shoulder Dystocia ?

What do accoucheurs really know about the

management of Shoulder Dystocia ?

Tim Draycott, Consultant Obstetrician & Gynaecologist

Declaration of Interest

• Limbs & Things collaboration

• Erbs Palsy Group

BBC Shoulder Dystocia

Shoulder Dystocia

• Unpredictable → Unpreventable• Rare• Some fetal morbidity may be due

to inappropriate/inadequate management

• OBPI complicates 4-16% SD deliveries

• UK Incidence 1/2300 live birth

• Approx 252 per year in UK– No change over last 40 years

Evans Jones et al. Arch Dis Child Fetal: 2003

Res ipsa loquitur

• “…all brachial plexus injuries are the fault of the accoucheur, who must have applied excessive traction during difficult delivery of the shoulders…”

• Incompetence by Incompetents !

• Refuted by medical practitioners

But ……….

• In 66% of neonatal deaths after SD, different management may have altered the outcome

CESDI 5th Annual Report - Focus Group Shoulder Dystocia, London

• 42% Staff did not feel confident to manage SDNeil et al, Shoulder dystocia: room for improvement? J Obs Gynae 1999

What do we really know ?

SaFE Study

• 6 Hospitals

• 141 Staff

– 96 Midwives

– 45 Doctors

The SaFE Study

Simulation and Fire drill

Evaluation

Training Intervention

Post-training Assessments3 weeks, 6 months and 12 months

Pre-training Assessment

SaFE Study Design

Local HospitalNo team training

One day

Simulation CentreNo team training

One day

Local HospitalTeam training

Two days

Simulation CentreTeam training

Two days

MCQClinical Scenarios

MCQClinical Scenarios

Evaluation of training

• Knowledge - MCQ• Clinical skill - simulation

– Shoulder Dystocia– Eclampsia– PPH

• Team work - Teamwork Assessment tool (Weller)

• Pre & Post training with follow up at 6 months and 1 year

Shoulder Dystocia

Evaluation scenario

Knowledge

Correct answers Pre training

(n=140)

Risk factors 115 (82.2)

Basic manoeuvres 105 (75.3)

Advanced manoeuvres 74 (52.8)

Fundal pressure 93 (66.4)

Force 89 (63.6)

Neonatal complications 68 (48.3)

Maternal complications 84 (59.8)

Pre - Basic Manoeuvres

0

10

20

30

4050

60

70

80

90

100

J r Midwif e Sr Midwif e J r Doctor Sr Doctor

% p

erfo

rmed

bas

ic m

anoe

uvre

s

Pre-training 81.4% could perform all basic manoeuvres

Pre - Achieved Delivery

0

20

40

60

80

100

J r Midwif e Sr Midwif e J r Doctor Sr Doctor

% a

chie

ved

deliv

ery

Pre-training 42.9% could deliver the baby

Applied Delivery Forces

Errors and Omissions

Not Stating Problem 33 %

Not Calling Paediatrician 63 %

Stated Fundal Pressure 11 %

Performed Fundal Pressure

4 %

Pulled over 100 N 66 %

Observed Difficulties

450 consecutive simulated deliveries

• Inability to gain vaginal access to perform internal manoeuvres

• Confusion over internal rotational manoeuvres

• Attempting to deliver the posterior shoulder NOT the posterior arm

• Requesting fundal pressure and applying supra-pubic pressure

Vaginal Access

Vaginal access

What we don’t know ?

Knowledge• 46 % unaware fundal pressure could

cause uterine rupture

Skills• 16% could not perform basic actions

• 57 % could not do more than McRoberts & SPP

• 66% pulled above 100 N

• 4% performed fundal pressure

Why deficiencies ?

• Not bad practitioners, but poor training

• Difficult to train

• Accurate models

• Syllabus

• How best to train

Training ?

Experential Learning

Syllabus: RCOG Flowchart

Accurate Models ?

• “The most bio-fidelic model available.”

R. Allen. Johns Hopkins University, Baltimore. 2002

Noelle

Compared with no training (n=17)

• Timeliness of intervention• Overall performance• Decreased head-to-body time

Deering et al, Improving resident competency in the management of shoulder dystocia with simulation training. AJOG 2004 6

p1224-8

Noelle

SaFE Study Results

• Increase in delivery rate– 43.9% v 83.3% (p<0.001)

• Reduction in total force– 2,030Ns v 2,916Ns (p=0.009)

• Number of participants with good communication (score ≥ 4) increased – 56.8% to 82.6% (p<0.001)

Conclusions

• High Fidelity mannequin – L&T

– Improved delivery rate (72% vs 89%)

– Improved performance of int. manoeuvres

– Reduction in peak force of 10N

– Significantly less called for PaedCrofts, Draycott et al. Obstet Gynecol. 2006

SD at Southmead

• New Training – Training on high fidelity mannequin

– Introduced 2000

– 100% staff annual updates

– 70% reduction of neonatal injury post training (p<0.001)

Injuries after SD

0

5

10

Pre training Post training

%

Shoulder dystocia (% of totaldels)

Neonatal injury (% of SD dels)

*RR=0.27*p<0.0001 (Chi-squared test)

Management Errors

0

4

8

12

16

Pre- Training Post Training

% o

f in

juri

es

Evidence XS Traction

InappropriateManouevres

New Problem ?

“The course no sooner finished, [these] young surgeons and women, rushing to benefit from a profession they know only superficially. But when difficulties arise they are absolutely unskilled, and until long experience instructs them they are the witness or the cause of many misfortunes, of which the least terrible is the death of the mother or the child and even both..”

Madame du Coudray to Louis XV 1756

M du Coudray 1756

• Obstetric Machine

Conclusion

• Verified a training need– Pre-training knowledge and skills

deficiencies– Possibly upto 70% of injuries may be

avoidable

• Training improves performance

• High fidelity trainer offers some advantages

• Error reduction can directly improve perinatal outcome

Thankyou

• All staff in SW

• SaFE Study Team

• PROMPT training programme

• tdraycott@gmail.com

• safestudy@hotmail.com