Evaluation of multidisciplinary shoulder dystocia simulation training on knowledge, performance, and documentation

BACKGROUND

Research has shown the utility of simulations involving individuals, yet little data exist on whether communication and documentation are impacted by the integration of all team members into a scenario. In 2018, the obstetrics department at this tertiary hospital began a multidisciplinary team-training simulation for shoulder dystocia. An educational portion was included, teaching a new practice where the provider announces delivery events (head, shoulder, body) to be marked on the delivery record, a standardized approach was introduced, and a pre- and post-simulation test was administered.

OBJECTIVE

In this study, we sought to evaluate the lasting impact of this team-based tool on the outcomes and documentation of shoulder dystocia cases, specifically the recording of the exact shoulder dystocia duration in seconds. Secondary outcomes included evaluation of the documentation of shoulder dystocia maneuvers and a pre- and post-simulation knowledge test. Included in this test were questions from the validated survey, the Safety Attitudes Questionnaire, a tool focused on evaluating team dynamics and communication. It was hypothesized that this simulation would improve communication as shown by sustained improvement in documentation, competence in shoulder dystocia care, and confidence among members of the team as shown by improved scores on the Safety Attitudes Questionnaire.

STUDY DESIGN

This was a retrospective cohort study of shoulder dystocia cases from 2017 and 2019 at a safety-net tertiary care hospital, 1 full year before and after the implementation of a multidisciplinary shoulder dystocia simulation in 2018. Delivery outcomes were compared, documentation of delivery event times was recorded and analyzed, and the delivery note was evaluated using the American College of Obstetricians and Gynecologists guidelines for shoulder dystocia. The surveys from participants were assessed for postsimulation improvement. Categorical variables were analyzed using chi-square tests and continuous variables were compared using Student t tests. Because shoulder dystocia duration is a nonparametric variable, this was compared using a Kruskal-Wallis test.

RESULTS

There were 28 cases in the 2017 cohort and 25 in the 2019 cohort. In the 2017 cohort, 25% of delivery documentation (7 of 25) included the exact shoulder dystocia duration, which increased to 96% (24 of 25) in the 2019 cohort (P<.001). There was no significant impact on the shoulder dystocia duration (P=.163). On average, 2.7 maneuvers were required in the 2017 cohort, which increased to 3.4 maneuvers used in the 2019 cohort, showing a significant increase in the use of shoulder dystocia maneuvers (P=.030). The posttests showed no impact on shoulder dystocia background knowledge (P=.142) or knowledge of risk factors (P=.171) but did show an increased understanding of the definition and performance of shoulder dystocia maneuvers (P=.008). The Safety Attitudes Questionnaire revealed that simulation participants would feel safe being treated by their colleagues with a score of 4.7/5. On the paired responses after the simulation, nurses reported feeling that their input was more highly valued (P=.045), and participants of all disciplines felt they received adequate feedback on their performances (P=.041).

CONCLUSION

A multidisciplinary simulation on shoulder dystocia led to sustained improvement in documentation and shoulder dystocia maneuvers used, suggesting increased comfort with advanced maneuvers. Future studies should evaluate whether multidisciplinary simulations, mimicking the normal delivery team, may lead to other sustained improvements in maternal care.

Simulation of Shoulder Dystocia for Skill Acquisition and Competency Assessment: A Systematic Review and Gap Analysis

STATEMENT

Mastery of shoulder dystocia management skills acquired via simulation training can reduce neonatal brachial plexus injury by 66% to 90%. However, the correlation between simulation drills and reduction in clinical injuries has been inconsistently replicated, and establishing a causal relationship between simulation training and reduction of adverse clinical events from shoulder dystocia is infeasible due to ethical limitations. Nevertheless, professional liability insurance carriers increasingly are mandating simulation-based rehearsal and competency assessment of their covered obstetric providers' shoulder dystocia management skills-a high-stakes demand that will require rapid scaling up of access to quality shoulder dystocia simulation. However, questions remain about differing simulation training schemes and instructional content used among clinically effective and ineffective educational interventions. This review of original research compares curricular content of shoulder dystocia simulation and reveals several critical gaps: (1) prescriptive instruction prioritizing maneuvers shown to decrease strain on the brachial plexus is inconsistently used. (2) Proscriptive instruction to avoid placing excessive and laterally directed traction on the head or to observe a brief hands-off period before attempting traction is infrequently explicit. (3) Neither relative effectiveness nor potential interaction between prescriptive and proscriptive elements of instruction has been examined directly. (4) Reliability of high-fidelity mannequins capable of objective measurement of clinician-applied traction force as compared with subjective assessment of provider competence is unknown. Further study is needed to address these gaps and inform efficient and effective implementation of clinically translatable shoulder dystocia simulation.