Improving Neonatal Outcome Through Practical Shoulder Dystocia Training

Abstract

Shoulder dystocia is an uncommon event that is largely unpredictable, and that may cause serious morbidity in both the mother and infant. Brachial plexus injury may be worsened by inappropriate treatment. This retrospective observational study compared the management and outcome of births complicated by shoulder dystocia before and after introducing 1 day of training that utilized a prototype shoulder dystocia training mannequin. Training included risk factors, recognition, documentation, helpful maneuvers, and a simulated shoulder dystocia scenario. A total of 15,908 pretraining births were compared with 13,117 taking place after the introduction of training. Rates of shoulder dystocia were similar: 2.04% in the pretraining group and 2.00% in the posttraining group. Before training, none of the several maneuvers recommended for the resolution of shoulder dystocia (including McRoberts’ position, suprapubic pressure, internal rotation, delivery of the posterior arm, and the All-Fours-Maneuvers) were utilized in half or more of the affected infants. After training, in contrast, at least 1 of the recommended maneuvers was utilized in more than 90% of the cases of shoulder dystocia. In addition, the proportion of dystocias in which excessive traction was documented was significantly reduced. The risk of neonatal injury in cases of shoulder dystocia decreased significantly from 9.3% to 2.3% after training became available (relative risk, 0.25; 95% confidence interval, 0.11–0.57). Brachial plexus injuries that persisted at ages 6 and 12 months were less common after training, but not significantly. The posttraining reduction in neonatal fractures was not statistically significant. The investigators conclude that because shoulder dystocia is, in the main, unpredictable and nonpreventable, training of all maternity staff may be the best means of optimizing the neonatal outcome.