1. What do accoucheurs really know about the management of Shoulder Dystocia ? Tim Draycott, Consultant Obstetrician & Gynaecologist

2. Declaration of Interest Limbs & Things collaboration Erbs Palsy Group

3. BBC Shoulder Dystocia

4. 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

5. 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

6. 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 SD Neil et al, Shoulder dystocia: room for improvement? J Obs Gynae 1999

7. What do we really know ? SaFE Study 6 Hospitals 141 Staff –96 Midwives –45 Doctors

8. Training Intervention Post-training Assessments 3 weeks, 6 months and 12 months Pre-training Assessment SaFE Study Design MCQ Clinical Scenarios MCQ Clinical Scenarios

9. 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

10. Shoulder Dystocia

11. Evaluation scenario

12. Knowledge Correct answers Pre training (n=140) Risk factors115 (82.2) Basic manoeuvres105 (75.3) Advanced manoeuvres74 (52.8) Fundal pressure93 (66.4) Force89 (63.6) Neonatal complications68 (48.3) Maternal complications84 (59.8)

13. Pre - Basic Manoeuvres Pre-training 81.4% could perform all basic manoeuvres

14. Pre - Achieved Delivery Pre-training 42.9% could deliver the baby

15. Applied Delivery Forces

16. Errors and Omissions Not Stating Problem33 % Not Calling Paediatrician63 % Stated Fundal Pressure11 % Performed Fundal Pressure 4 % Pulled over 100 N66 %

17. 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

18. Vaginal Access

19. Vaginal access

20. 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

21. Why deficiencies ? Not bad practitioners, but poor training Difficult to train Accurate models Syllabus How best to train

22. Training ?

23. Experential Learning

24. Syllabus: RCOG Flowchart

25. Accurate Models ? “The most bio-fidelic model available.” R. Allen. Johns Hopkins University, Baltimore. 2002

26. 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

27. Noelle

28. 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)

29. 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 Paed Crofts, Draycott et al. Obstet Gynecol. 2006

30. 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)

31. Injuries after SD *RR=0.27 *p<0.0001 (Chi-squared test)

32. Management Errors

33. 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

34. M du Coudray 1756 Obstetric Machine

35. 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

36. Thankyou All staff in SW SaFE Study Team PROMPT training programme tdraycott@gmail.com safestudy@hotmail.com