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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 - PowerPoint PPT Presentation
Citation preview
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