Improved shoulder dystocia management and outcomes after training

1. Evidence-based maneuvers for management of shoulder dystocia were increasingly employed after implementation of the training program.

2. Fewer brachial plexus injuries were temporally associated with initiation of the training program.

Evidence Rating Level: 2 (Good)       

Study Rundown: Shoulder dystocia is an obstetric emergency that arises when fetal shoulders are not positioned optimally for passage through the pelvic inlet and a shoulder becomes trapped under the pubic symphysis. It occurs in up to 3% of births and can result in brachial plexus injuries, which may result in permanent neurological deficits. The primary risk factor for shoulder dystocia is high birth weight. Since shoulder dystocia cannot be accurately predicted, obstetric providers have to be prepared in all vaginal deliveries. Special maneuvers, including the McRoberts’ maneuver, delivery of the posterior arm and internal rotation, can be performed to disimpact the shoulder. Prior studies have yielded mixed results of the impact of shoulder dystocia training on neonatal outcomes and it is unclear what method of training, if any, is most effective. In the present work, authors explored the long-term effects of a mandatory, annual obstetric emergencies training in the United Kingdom and found that appropriate management of shoulder dystocia was more common and also that brachial plexus injuries decreased over time.

Strengths of the study include the use of national birth registry data and evaluation of outcomes over time. Limitations include dependence on chart documentation, which may vary in quality across providers and facilities, and a higher Cesarean section rate after implementation of the training, which may affect the observed results. Exploration of the feasibility and impact of similar training outside of a universal healthcare system is needed.

Click to read the study in BJOG

Relevant Reading: Improving neonatal outcome through practical shoulder dystocia training

In-Depth [cross-sectional study]: This study evaluated the impact of a mandatory annual shoulder dystocia training on intrapartum management of shoulder dystocia and subsequent neonatal outcomes in 1,148 cases of shoulder dystocia in term, singleton pregnancies. Outcomes of interest included use of appropriate and inappropriate maneuvers, brachial plexus injury, fractured clavicle or humerus and Apgar score at 5 minutes.

After implementation of the training in 2000, by 2009-2012 the number of shoulder dystocia cases in which no recommended maneuvers were performed decreased from 53.7% to 0.2% (p<0.001). Correspondingly, the use of inappropriate maneuvers such as excessive traction also declined (p<0.001). The incidence of brachial plexus injury also decreased from 1.51 to 0.41 per 1000 vaginal births (p<0.01).

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