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ORIGINAL RESEARCH |
From *Georgetown University Hospital, Washington, DC; National Naval Medical Center, Bethesda, Maryland; and Uniformed Services University of the Health Sciences, Bethesda, Maryland.
Address reprint requests to: Shad Deering, MD, Department of Obstetrics and Gynecology, Georgetown University Hospital, 3-PHC, 3800 Reservoir Road, NW, Washington, DC 20007; e-mail: deering95{at}hotmail.com.
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ABSTRACT |
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 ABSTRACT MATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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METHODS: Residents from 2 training programs participated in this study. The residents were block-randomized by year-group to a training session on shoulder dystocia management that used an obstetric birthing simulator or to a control group with no specific training. Trained residents and control subjects were subsequently tested on a standardized shoulder dystocia scenario, and the encounters were digitally recorded. A physician grader from an external institution then graded and rated the resident's performance with a standardized evaluation sheet. Statistical analysis included the Student t test, 
2, and regression analysis, as appropriate.
RESULTS: Trained residents had significantly higher scores in all evaluation categories, including timelines of their interventions, performance of maneuvers, and overall performance. They also performed the delivery in a shorter time than control subjects (61 versus 146 seconds, P = .003).
CONCLUSION: Training with a simulation-training scenario improved resident performance in the management of shoulder dystocia.
LEVEL OF EVIDENCE: I
Medical simulation is a relatively new field and is well suited to emergencies such as shoulder dystocia. While several articles have endorsed the use of simulation in obstetrics and gynecology for a variety of procedures, there is little objective evidence documenting an improvement in resident performance.3 The primary objective of this current report was to assess whether training incorporating an obstetric birthing simulator improved resident competency in the management of shoulder dystocia.
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MATERIALS AND METHODS |
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ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Residents randomly assigned to training were given instruction according to the following protocol: small group sessions were conducted, with a maximum of 9 residents in each group, during which 1) residents received a brief lecture about risk factors for shoulder dystocia, 2) maneuvers and a basic algorithm for management were discussed and then demonstrated on the obstetric birthing simulator, and 3) each resident performed a delivery on the model, which was complicated by a shoulder dystocia, and then practiced the various maneuvers, as well as other important tasks, such as calling for assistance and asking for a pediatrician to be present at delivery. Residents who were not randomly assigned to training attended their regularly scheduled academic meetings during the days training was done. No specific instructions were given to the trained residents about discussing the simulation training they received.
Two weeks after the training session, and without prior notice, all residents were tested with a standardized shoulder dystocia scenario. The encounters were digitally recorded for evaluation. Before entering the room for testing, residents were given a clinical history to review. It described a 35-year-old multiparous patient who had been pushing for approximately 90 minutes and whose only prenatal complications included advanced maternal age and an abnormal 1-hour glucose challenge test, with a normal 3-hour glucose tolerance test. The residents were instructed to treat the simulation as a real situation and to use instruments, gloves, and whatever else would be needed in a real labor and delivery room. The human actors had been trained not to break character during the simulation. A standard delivery table was present in the room, which included, among other common instruments, clamps, scissors, and 2 sets of forceps. When the resident entered the room, an assistant playing the role of the nurse told the resident that the patient was pushing well, and then the fetal head was made to deliver in the right occiput anterior position. When the resident applied downward traction to the fetal head for delivery, a harness around the fetus, which was not visible to the resident because it was located inside the abdomen, was used by the testing staff to prevent the fetal shoulder from delivering. Additional assistants, who were acting as a second nurse and a pediatrician, were available in the room and would come to help if the resident asked for their assistance. The resident's actions were then monitored by the testing staff, and the fetus was allowed to deliver if the resident successfully delivered the posterior arm. If the resident could not or did not attempt to deliver the posterior arm, then the scenario was stopped when either a cephalic replacement was performed or when the resident was unable to perform any other maneuvers. After delivery, the resident, in a structured self-critique, was asked to describe all maneuvers used, as well as any other maneuvers that could have been used if needed. Residents were also asked to estimate the head-to-body delivery time. The scenario and simulation events were held confidential by the residents and evaluation staff.
A maternal–fetal medicine staff physician, who was from an outside institution and blinded to both the resident's year-level and prior training, graded and rated the resident's performance using a standardized evaluation sheet. The evaluation included a checklist of all maneuvers performed, demonstrated, and/or explained and a 9-point Likert scale to grade performance and preparation. For evaluation purposes, the following actions were considered "critical" tasks: recognizing shoulder dystocia, asking for additional help, calling for pediatrics to be present, applying gentle downward traction on the fetal head, placing the patient in McRobert's position, and applying suprapubic pressure. One point was awarded for each of these components and a total critical objectives score was calculated for each resident that ranged from 1 to 6. Critical objective scores were compared between both trained and untrained residents. Other maneuvers and actions that were considered "important" tasks included the following: attempt to perform rotational maneuver (Rubin's or Woodscrew), episiotomy, delivery of the posterior arm, fracture of clavicle, symphysiotomy, all-fours maneuver, a cephalic replacement (Zavenelli) maneuver if other maneuvers were not successful, and collection of blood for cord gases (Table 1). Four questions used a 9-point Likert scale to evaluate these aspects of the resident's performance: the timeliness of their interventions, whether maneuvers were performed correctly, overall performance, and overall preparedness. The results from these 4 questions were analyzed individually and added to produce a total overall score, which could range from 4 to 36. Scores were then compared between the groups. Another checklist was provided for the evaluators to enable them to record whether or not the resident performed or described the listed maneuvers during their testing, and whether they performed or described the maneuver correctly. The total number of maneuvers described or performed and the total number of maneuvers described or performed correctly were then calculated for each resident and compared between the trained and untrained groups.
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The actual head-to-body delivery intervals were obtained from the digital recordings and entered into the data sheet. These data were then compared between the trained and untrained groups. Statistical analyses included the Student t test for continuous variables, the Mann–Whitney U test for ordinal data, linear regression, and 2 analysis, as appropriate. P < .05 was considered significant.
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RESULTS |
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Analysis of "critical" components revealed that trained residents were more likely to call for additional help (94% [15 of 16] versus 35% [6 of 17], P = .001) and for a pediatrician to be present for the delivery (75% [12 of 16] versus 18% [3 of 17], P = .002) than untrained residents. There were no significant differences in the other 4 critical components (Table 4). The overall critical component score was also significantly higher in the trained group (5.37 ± 0.62 versus 4.24 ± 1.25, P = .003; 95% confidence interval [CI] –1.85, –0.43).
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The total number of maneuvers that each resident was able to perform and describe was not different between the 2 groups (6.75 ± 1.6 versus 5.94 ± 1.6, P = .15; 95% CI –1.95, 0.33; Table 5). Regression analysis failed to demonstrate a significant association between the residents’ year-levels and their overall scores (P = .327; 95% CI –1.47, –4.29).
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DISCUSSION |
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Training residents in the management of shoulder dystocia is usually done in a lecture or as an informal, impromptu teaching session after one has occurred. Although this is necessary and beneficial, medical simulation offers educators the ability to evaluate how well residents actually perform during the situation and not just whether or not they can recite the list of actions they should take. Shoulder dystocia lends itself well to simulation because it is relatively rare, yet encountered by all practicing obstetricians, and when it does occur, the situation may be too medically risky to permit significant participation by trainees. Furthermore, shoulder dystocia tends to occur in the absence of risk factors and rapid and correct interventions can decrease both maternal and neonatal morbidity, and it can be simulated with minimal difficulty with existing technology.
Because nearly 60% of shoulder dystocias will be resolved with only the McRobert's maneuver and suprapubic pressure, we chose to include these maneuvers, as well as the recognition of the problem and calling for assistance, in our list of critical tasks.4 However, because a significant number of shoulder dystocias will require additional maneuvers and we wanted to evaluate how these residents would perform with a more complicated situation, we chose to not allow the fetus to deliver unless either the posterior arm delivered or a cephalic replacement maneuver was performed.
We theorize that the reason the head-to-body delivery time was shorter in the trained resident group was that members of this group had practiced performing different maneuvers and were more willing and ready to go on to another maneuver when their initial interventions had failed.
Because we did not specifically instruct trained residents to not discuss their training with the other residents, it is possible that some of the untrained residents may have read more about the management of shoulder dystocia before their testing. If this was the case, then it serves to strengthen the conclusions of our study because the trained residents performed better regardless of whether the untrained residents had prepared on their own.
Although we trained residents from 2 separate programs, who had different experiences and teaching before this testing, both the training and testing scenarios were standardized by using the same equipment and the same instructor to decrease the chances for different experiences in training or testing. Graders were chosen for their expertise in the field and because they did not know any of the residents they were evaluating. The blinding of the graders to the training status of residents, ie, whether they were trained with the simulator before testing, and the fact that the graders did not know what year-group the residents were in as they graded them, were aspects of the study designed to prevent any bias from preconceived notions about residents’ expected levels of performance. In addition, stratification of the data by institution and grader demonstrated similar differences between trained and untrained residents in the overall performance scores at both sites.
These results support our belief that simulation training improves resident competency in the management of shoulder dystocia. Simulation laboratories have huge potential to enhance and monitor training, but new initiatives should be evaluated and not just assumed to be beneficial. Changes in residency training requirements, curricula, and evaluation techniques are sometimes introduced based only on expert opinion without data or subsequent evaluation, and although simulation training in obstetrics intuitively seems beneficial, it is imperative to validate its use rather than simply endorsing it as effective.3,5
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Footnotes |
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Received January 8, 2004. Received in revised form March 2, 2004. Accepted March 11, 2004.
10.1097/01.AOG.0000126816.98387.1c
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REFERENCES |
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2. Gherman RB, Ouzounian JG, Goodwin TM. Obstetric maneuvers for shoulder dystocia and associated fetal morbidity. Am J Obstet Gynecol 1998;178:1126–30.[Medline]
3. Letterie GS. Medical education as a science: the quality of evidence for computer-assisted instruction. Am J Obstet Gynecol 2003;188:849–53.[Medline]
4. McFarland MD, Langer O, Piper JM, Berkus MD. Perinatal outcome and the type and number of maneuvers in shoulder dystocia. Int J Gynaecol Obstet 1996;55:219–24.[Medline]
5. Macedonia CR, Gherman RB, Satin AJ. Simulation laboratories for training in obstetrics and gynecology. Obstet Gynecol 2003;102:388–92.
This article has been cited by other articles:
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 T. Draycott, C. Sanders, J. Crofts, and J. Lloyd A template for reviewing the strength of evidence for obstetric brachial plexus injury in clinical negligence claims Clin Risk, May 1, 2008; 14(3): 96 - 100. [Abstract] [Full Text] [PDF]
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 J F Crofts, C Bartlett, D Ellis, C Winter, F Donald, L P Hunt, and T J Draycott Patient-actor perception of care: a comparison of obstetric emergency training using manikins and patient-actors Qual. Saf. Health Care, February 1, 2008; 17(1): 20 - 24. [Abstract] [Full Text] [PDF]
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J. F. Crofts, C. Bartlett, D. Ellis, L. P. Hunt, R. Fox, and T. J. Draycott Management of Shoulder Dystocia: Skill Retention 6 and 12 Months After Training Obstet. Gynecol., November 1, 2007; 110(5): 1069 - 1074. [Abstract] [Full Text] [PDF]
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J. F. Crofts, C. Bartlett, D. Ellis, L. P. Hunt, R. Fox, and T. J. Draycott Training for Shoulder Dystocia: A Trial of Simulation Using Low-Fidelity and High-Fidelity Mannequins Obstet. Gynecol., December 1, 2006; 108(6): 1477 - 1485. [Abstract] [Full Text] [PDF]
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S. Deering, J. Brown, J. Hodor, and A. J. Satin Simulation Training and Resident Performance of Singleton Vaginal Breech Delivery Obstet. Gynecol., January 1, 2006; 107(1): 86 - 89. [Abstract] [Full Text] [PDF]
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S. Deering and A. J. Satin Evaluation of Residents' Delivery Notes After a Simulated Shoulder Dystocia Obstet. Gynecol., February 1, 2005; 105(2): 448 - 449. [Full Text] [PDF]
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S. Deering, S. Poggi, J. Hodor, C. Macedonia, and A. J. Satin Evaluation of Residents' Delivery Notes After a Simulated Shoulder Dystocia Obstet. Gynecol., October 1, 2004; 104(4): 667 - 670. [Abstract] [Full Text] [PDF]
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R. M. Cyr Improving Resident Competency in the Management of Shoulder Dystocia With Simulation Training Obstet. Gynecol., September 1, 2004; 104(3): 633 - 634. [Full Text] [PDF]
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