Download PDF
Am J Perinatol 2017; 34(11): 1088-1096
DOI: 10.1055/s-0037-1603819
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Improving Shoulder Dystocia Management and Outcomes with a Targeted Quality Assurance Program

Edith D. Gurewitsch Allen
1   Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
2   Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland
,
Susan E. Brown Will
1   Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
,
Robert H. Allen
1   Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
2   Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland
,
Andrew J. Satin
1   Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
› Author Affiliations
Further Information

Publication History

08 May 2017

11 May 2017

Publication Date:
12 June 2017 (online)

    Permissions and Reprints

Abstract

Background Several investigators have achieved remarkable success in transferring shoulder dystocia management skills mastered with simulation training to clinical practice. However, other investigators have not demonstrated similar benefits, raising questions about the comparative effectiveness of specific simulation schemes, instructional content, and additional quality assurance measures between successful and unsuccessful interventions. After our initial review revealed gaps in following shoulder dystocia management algorithms, documentation and timely follow-up of injured neonates, we developed and implemented five interventions, three educational and two systems-level, aimed at improving shoulder dystocia management.

Objective To describe the clinical impact of a systematic program of quality improvement on outcomes of vaginal births complicated by shoulder dystocia.

Setting An urban tertiary academic medical center that trains 36 obstetrics/gynecology residents (9 per year) and provides comprehensive obstetrical services for approximately 2,000 deliveries annually.

Study Design We use SQUIRE 2.0 (Standards for Quality Improvement Reporting Excellence) to (1) describe our core instructional content and simulation-based practice, emphasizing specific proscriptive and prescriptive recommendations and their evidence basis, and (2) to report an interrupted time series assessment of the clinical impact of our systematic quality improvement program targeting shoulder dystocia-associated brachial plexus injury.

Results Compared with baseline (June 1993 to December 2004), the incidence of shoulder dystocia among vaginally delivered infants with birth weight ≥ 2,500 g at Johns Hopkins Hospital (January 2014 to December 2015) increased from 2.6 to 4.6% (X 2 = 29.8; df = 1; p < 0.0001); in addition, documentation improved, direct fetal manipulation increased, while use of episiotomy for the management of shoulder dystocia decreased. While preintervention only 65% of brachial plexus injury were associated with shoulder dystocia, 100% of neonatal brachial plexus injuries were associated with shoulder dystocia postintervention (80/122 [65%] vs. 7/7 [100%], X 2 = 3.66; df = 1; p = 0.055), a trend reflecting simultaneous increased recognition of impacted shoulders and improved overall management of shoulder dystocia. Most importantly, the incidence of brachial plexus injury among shoulder-dystocia-complicated vaginal deliveries has decreased from a baseline of 31.6 to 6.3% (X 2 = 27.9; df = 1; p < 0.0001), and the absolute brachial plexus injury rate declined from 8.2 to 2.9 per 1,000 vaginal births ≥ 2,500 g, a reduction of 64.5% (X 2 = 7.3; df = 1; p = 0.007).

Conclusion A systematic program of quality assurance with specific proscriptive and prescriptive instructional content and management recommendations is associated with improved recognition, management, and clinical outcomes of shoulder dystocia.

Keywords

simulation - practice-based learning - proscriptive instruction - prescriptive management - maneuvers - brachial plexus injury - risk reduction

Note

The study was presented at the 37th Annual Pregnancy Meeting of the Society for Maternal-Fetal Medicine, Las Vegas, NV, January 28, 2017 (Abstract #906).


 

  • References

  • 1 Deering S, Poggi S, Macedonia C, Gherman R, Satin AJ. Improving resident competency in the management of shoulder dystocia with simulation training. Obstet Gynecol 2004; 103 (06) 1224-1228
    CrossrefPubMedGoogle Scholar
  • 2 Draycott TJ, Crofts JF, Ash JP. , et al. Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol 2008; 112 (01) 14-20
    CrossrefPubMedGoogle Scholar
  • 3 Inglis SR, Feier N, Chetiyaar JB. , et al. Effects of shoulder dystocia training on the incidence of brachial plexus injury. Am J Obstet Gynecol 2011; 204 (04) 322.e1-322.e6
    CrossrefPubMedGoogle Scholar
  • 4 Grobman WA, Miller D, Burke C, Hornbogen A, Tam K, Costello R. Outcomes associated with introduction of a shoulder dystocia protocol. Am J Obstet Gynecol 2011; 205 (06) 513-517
    CrossrefPubMedGoogle Scholar
  • 5 Crofts JF, Lenguerrand E, Bentham GL. , et al. Prevention of brachial plexus injury-12 years of shoulder dystocia training: an interrupted time-series study. BJOG 2016; 123 (01) 111-118
    CrossrefPubMedGoogle Scholar
  • 6 Walsh JM, Kandamany N, Ni Shuibhne N, Power H, Murphy JF, O'Herlihy C. Neonatal brachial plexus injury: comparison of incidence and antecedents between 2 decades. Am J Obstet Gynecol 2011; 204 (04) 324.e1-324.e6
    CrossrefPubMedGoogle Scholar
  • 7 MacKenzie IZ, Shah M, Lean K, Dutton S, Newdick H, Tucker DE. Management of shoulder dystocia: trends in incidence and maternal and neonatal morbidity. Obstet Gynecol 2007; 110 (05) 1059-1068
    CrossrefPubMedGoogle Scholar
  • 8 Gurewitsch ED, Johnson E, Hamzehzadeh S, Allen RH. Risk factors for brachial plexus injury with and without shoulder dystocia. Am J Obstet Gynecol 2006; 194 (02) 486-492
    CrossrefPubMedGoogle Scholar
  • 9 Kim EJ, Theprungsirikul P, McDonald MK, Gurewitsch ED, Allen RH. A biofidelic birthing simulator. Models for research and training in complicated human births. IEEE Eng Med Biol Mag 2005; 24 (06) 34-39
    PubMedGoogle Scholar
  • 10 Gurewitsch ED, Kim EJ, Yang JH, Outland KE, McDonald MK, Allen RH. Comparing McRoberts' and Rubin's maneuvers for initial management of shoulder dystocia: an objective evaluation. Am J Obstet Gynecol 2005; 192 (01) 153-160
    CrossrefPubMedGoogle Scholar
  • 11 Crofts JF, Bartlett C, Ellis D, Hunt LP, Fox R, Draycott TJ. Training for shoulder dystocia: a trial of simulation using low-fidelity and high-fidelity mannequins. Obstet Gynecol 2006; 108 (06) 1477-1485
    CrossrefPubMedGoogle Scholar
  • 12 Goodman D, Ogrinc G, Davies L. , et al. Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: examples of SQUIRE elements in the healthcare improvement literature. BMJ Qual Saf 2016; 25 (12) e7 . Doi: 10.1136/bmjqs-2015-004480
    CrossrefPubMedGoogle Scholar
  • 13 Acker DB. A shoulder dystocia intervention form. Obstet Gynecol 1991; 78 (01) 150-151
    PubMedGoogle Scholar
  • 14 ACOG. Patient safety checklist No. 6: documenting shoulder dystocia. Obstet Gynecol 2012; 120 (2 Pt 1): 430-431
    CrossrefPubMedGoogle Scholar
  • 15 Gherman R. Task Force on Neonatal Brachial Plexus Palsy. Washington, DC: American Congress of Obstetricians and Gynecologists; 2014
    Google Scholar
  • 16 Belzberg AJ, Dorsi MJ, Storm PB, Moriarity JL. Surgical repair of brachial plexus injury: a multinational survey of experienced peripheral nerve surgeons. J Neurosurg 2004; 101 (03) 365-376
    CrossrefPubMedGoogle Scholar
  • 17 Brauer CA, Waters PM. An economic analysis of the timing of microsurgical reconstruction in brachial plexus birth palsy. J Bone Joint Surg Am 2007; 89 (05) 970-978
    CrossrefPubMedGoogle Scholar
  • 18 Crofts JF, Fox R, Ellis D, Winter C, Hinshaw K, Draycott TJ. Observations from 450 shoulder dystocia simulations: lessons for skills training. Obstet Gynecol 2008; 112 (04) 906-912
    CrossrefPubMedGoogle Scholar
  • 19 Mollberg M, Wennergren M, Bager B, Ladfors L, Hagberg H. Obstetric brachial plexus palsy: a prospective study on risk factors related to manual assistance during the second stage of labor. Acta Obstet Gynecol Scand 2007; 86 (02) 198-204
    CrossrefPubMedGoogle Scholar
  • 20 Gurewitsch E, Cha S, Johnson T. , et al. Traction training for routine and shoulder dystocia deliveries: an experimental study. Am J Obstet Gynecol 2005; 193 (06) S41 . Doi: 10.1016/j.ajog.2005.10.115
    PubMedGoogle Scholar
  • 21 Gurewitsch ED, Allen RH. Fetal manipulation for management of shoulder dystocia. Fetal Matern Med Rev 2006; 17 (03) 239-280
    CrossrefPubMedGoogle Scholar
  • 22 Allen RH, Gurewitsch ED. Shoulder dystocia. Available at http://emedicine.medscape.com/article/1602970 . Updated August 22, 2016. Accessed February 26, 2017
    PubMedGoogle Scholar
  • 23 Grimm MJ, Costello RE, Gonik B. Effect of clinician-applied maneuvers on brachial plexus stretch during a shoulder dystocia event: investigation using a computer simulation model. Am J Obstet Gynecol 2010; 203 (04) 339.e1-339.e5
    CrossrefPubMedGoogle Scholar
  • 24 Gurewitsch ED, Donithan M, Stallings SP. , et al. Episiotomy versus fetal manipulation in managing severe shoulder dystocia: a comparison of outcomes. Am J Obstet Gynecol 2004; 191 (03) 911-916
    CrossrefPubMedGoogle Scholar
  • 25 Locatelli A, Incerti M, Ghidini A. , et al. Head-to-body delivery interval using ‘two-step’ approach in vaginal deliveries: effect on umbilical artery pH. J Matern Fetal Neonatal Med 2011; 24 (06) 799-803
    CrossrefPubMedGoogle Scholar
  • 26 Gurewitsch E, Stallings S, Tam W, Allen R. Does maneuver rate affect shoulder dystocia outcome?. Am J Obstet Gynecol 2004; 191 (06) S66 . Doi: 10.1016/j.ajog.2004.10.107
    PubMedGoogle Scholar
  • 27 Gurewitsch ED, Allen RH. Reducing the risk of shoulder dystocia and associated brachial plexus injury. Obstet Gynecol Clin North Am 2011; 38 (02) 247-269 , x
    CrossrefPubMedGoogle Scholar
  • 28 Allen R, Sorab J, Gonik B. Risk factors for shoulder dystocia: an engineering study of clinician-applied forces. Obstet Gynecol 1991; 77 (03) 352-355
    PubMedGoogle Scholar
  • 29 Allen RH. On the mechanical aspects of shoulder dystocia and birth injury. Clin Obstet Gynecol 2007; 50 (03) 607-623
    CrossrefPubMedGoogle Scholar
  • 30 Leung TY, Stuart O, Suen SS, Sahota DS, Lau TK, Lao TT. Comparison of perinatal outcomes of shoulder dystocia alleviated by different type and sequence of manoeuvres: a retrospective review. BJOG 2011; 118 (08) 985-990
    CrossrefPubMedGoogle Scholar
  • 31 Barbieri RL. Intractable shoulder dystocia: a posterior axilla maneuver may save the day. OBG Management. 2016; 28 (04) 17-21
    PubMedGoogle Scholar
  • 32 Menticoglou SM. A modified technique to deliver the posterior arm in severe shoulder dystocia. Obstet Gynecol 2006; 108 (3 Pt 2): 755-757
    CrossrefPubMedGoogle Scholar
  • 33 Sokol RJ, Blackwell SC. ; American College of Obstetricians and Gynecologists. Committee on Practice Bulletins-Gynecology. ACOG practice bulletin: shoulder dystocia. Number 40, November 2002. (Replaces practice pattern number 7, October 1997). Int J Gynaecol Obstet 2003; 80 (01) 87-92
    CrossrefPubMedGoogle Scholar
  • 34 Crofts JF, Ellis D, James M, Hunt LP, Fox R, Draycott TJ. Pattern and degree of forces applied during simulation of shoulder dystocia. Am J Obstet Gynecol 2007; 197 (02) 156.e1-156.e6
    CrossrefPubMedGoogle Scholar
  • 35 Moragianni VA, Hacker MR, Craparo FJ. Improved overall delivery documentation following implementation of a standardized shoulder dystocia delivery form. J Perinat Med 2011; 40 (01) 97-100
    PubMedGoogle Scholar
  • 36 Draycott TJ, Collins KJ, Crofts JF. , et al. Myths and realities of training in obstetric emergencies. Best Pract Res Clin Obstet Gynaecol 2015; 29 (08) 1067-1076
    CrossrefPubMedGoogle Scholar
  • 37 Beall MH, Spong C, McKay J, Ross MG. Objective definition of shoulder dystocia: a prospective evaluation. Am J Obstet Gynecol 1998; 179 (04) 934-937
    CrossrefPubMedGoogle Scholar
  • 38 Poggi SH, Allen RH, Patel CR, Ghidini A, Pezzullo JC, Spong CY. Randomized trial of McRoberts versus lithotomy positioning to decrease the force that is applied to the fetus during delivery. Am J Obstet Gynecol 2004; 191 (03) 874-878
    CrossrefPubMedGoogle Scholar