Dr LEE Man Hin Menelik – Associate Consultant Ms CHAN CN – APN Dr MA TWL – Consultant

Typical gentle downward traction on the fetal head, which is used to deliver the anterior shoulder, is not sufficient to deliver the anterior shoulder Basically – shoulder impact against symphysis pubis

0.2-3% of all vaginal deliveries Complications:

Fetal injury Erb’s palsy (2.3-16%) fracture (radius, humerus, clavical)

Birth asphysia Fetal death Maternal morbidity such as PPH

Provides opportunities to rehearse and learn from mistakes without risk to patients (Ennen et al 2010)

Improve management and perinatal outcomes. Draycott et al 2008

More likely to utilize maneuvers in a timely and correct fashion (Deering et al 2004)

Improve communications, leadership skills and team work (Smith 2016, Grobman et al 2014)

Clinical Negligence Scheme of Trusts (CNST) – UK mandated annual drilling of all obstetrics and midwifery staff in obstetrics emergencies including shoulder dystocia.

RCOG - All maternity staff should participate in shoulder dystocia training at least annually. Grade D evidence

Suggested decline in knowledge at early as 4 months (Vadnais et al) and 6 months (Crofts et al 2007)

Regular training is not mandatory

6-12 months training in shoulder dystocia amongst midwives In form of lectures only

12-18 months training for doctors Simulation training only started in recent years

First prospective study on simulation training in Hong Kong

Whether the skill of shoulder dystocia improves after simulation training

investigate the level of skill retention at 6 and 12 months training after simulation shoulder dystocia training

so as a department, one can schedule on the regularity required for shoulder dystocia skills training

between August 2014 to September 2015 All midwives and doctors from the department of

Obstetrics and Gynaecology at Queen Elizabeth Hospital, Hong Kong were invited to participate

Excluded Those who had training (in-house or national training

e.g. ALSO) Staff due to leave our department within 12 months e.g.

houseman Those involved in the study

Select participants

Divided into doctors and midwives

Random allocate to 6 months retesting (group 1) and 12 months retesting (group 2)

Training 1 hour training – lecture and simulation training Using mannequins baby and pelvis

Testings: Pretest – 1 week before training At test – immediately after training Post test – either 6 or 12 months after training

15 mark – self generated marking scheme Based on

RCOG guideline on shoulder dystocia – no. 42 ALSO examination marking scheme PROMPT (Practical Obstetrics Multi – Professional Training) Local settings

Month 0 Month 6 Month 12 Group 2 start training Group 1 start training Group 1 and 2 Pretest and test after training Pretest and test after training retested together

Post testing – unwarned, unprepared – e.g. test participant during break hours or lunch hours at work Aim: 1) To test every participant at the same time 2) Reduce the chance of preparation before the retesting 3) Avoid (maximum) participants inter communication affecting results However: 1) Cannot complete all retraining within one day 2) Intercommunications is unavoidable

Shoulder Dystocia Clinical Checklist

Name: Position: Doctor [ ] Midwife [ ]

Date: Phase: Pre [ ] Test [ ]

Post [ ] months: _________________

Recent training in Shoulder dystocia? Yes [ ] No [ ] if yes when:

Call for help

• Emergency bell activated or recognise to be a state of emergency • Ask for senior obstetrician, senior midwife and neonatologist

Evaluate for episiotomy

• Able to gain access to the sacral hollow

Legs – McRobert’s Position

• Bed Flat • Legs hyperflexed • Pillows behind mother’s back removed

Pressure – Suprapubic pressure

• Correct position and directed from the side of the fetal back

Enter – Internal rotational manoeuvres

• Pressure on the posterior aspect of the anterior shoulder (Rubin’s II) • Pressure on the anterior aspect of the posterior shoulder (Wood’s screw) • Pressure on the posterior aspect of the posterior shoulder

(Reverse Wood’s screw) • Delivery of posterior arm – flex the posterior arm at the elbow, hold the baby’s

hand and delivery arm across baby’s chest

Other manoeuvres:

• Turn mother to all 4s and try again • Zavenelli, Fracture Clavicle, Symphysiotomy

Post:

• Documentation • Patient and partner briefing

Total Score (1 mark each out of 15): HEAD to BODY delivery time (minutes):

By a single doctor – FHKCOG, ALSO instructor

Reduce discrepencies

2 parts recorded –

Marking out of 15

Time taken to complete drill

Markings - Verbal and demonstration components

Verbal –

1 mark given when all parts answered or demonstrated correctly

½ mark given if partially answered or attempted but incorrectly demonstrated

None if no parts answered

Time taken

Total time to complete drill will be taken

Delivery is deemed when all 4 internal manoevres demonstrated –

Rubin II, Woodscrew, reverse woodscrew and posterior arm delivery

Drill complete when baby delivered and all post delivery management were mentioned

Stop at max 8 minutes

30 secs to prompt the participants

30 secs for each component

At 6 months retesting (group 1)

total of 27 participants (6 doctors and 21 midwives) able to participate in the retest 5 midwives resigned

At 12 months retesting (group 2)

27 participants (6 doctors and 21 midwives) able to participate in the retest. 1 doctor 4 midwives have either got pregnant or resigned

Group 1 (retest at 6 months) Group 2 (retest at 6 months) P value

Total number of participants 27 27 1.00

Total number of doctors 6 6 1.00 Total number of midwives 21 21 1.00 Average years of working experience

14.29 ± 7.03 14.89 ± 5.61 0.734

Number of participants regularly working in the labour ward settings (i.e. exclude those only work in antenatal or postnatal wards)

15 17 0.585

Data comparison within individual group

Mean Time or Score ± (Standard Deviation)

P value Mean Time or Score ± (Standard Deviation)

P value

Group 1 (retest at 6 months) N=27 Group 2 (retest at 12 months) N=27

Overall score (Out of 15)

Pre-training vs At-training

8.26 (± 3.49) 14.26 (±1.53)

All participants Group 1 (n=27) Group 2 (n=27) P values (between group1 and 2)

Score Pre-training 8.26 (±3.49) 9.46 (±3.34) 0.201

At-training 14.26 (±1.53) 14.69 (±0.56) 0.179

Post-training 11.54 (±2.53) 11.70 (±2.75) 0.818

Pre- vs At- training 5.81 (±3.19) 4.96 (±3.25) 0.335

At- vs post-training -2.63 (±2.29) -2.81 (±2.76) 0.790

Pre- vs Post- training 3.19 (±3.25) 2.15 (±2.61) 0.202

Time Pre-training 273.63 (±82.27) 320.30 (±96.68) 0.062

At-training 145.11 (±47.91) 176.26 (±36.28) 0.01

Post-training 209.89 (±61.81) 196.52 (±45.84) 0.371

Pre- vs At- training -124.81 (±69.82) -129.15 (±97.23) 0.852

At- vs Post-training 64.63 (±56.94) 20.22 (±47.38) 0.033

Pre- vs Post training -63.81 (±69.38) -120.07 (±85.73) 0.011

Data comparison within individual group Doctors only – N = 12 Mean Time or Score ± (Standard

Deviation) P value Mean Time or Score ± (Standard

Deviation) P value

Group 1 (retest at 6 months) N=6 Group 2 (retest at 12 months) N=6

Overall score (Out of 15)

Pre-training vs At-training

10.92 (±2.46) 14.75 (±0.42)

0.013 10.92 (±2.31) 15.00 (±0)

0.05

At-training vs Post-training

14.75 (±0.42) 12.67 (±1.25)

0.015 15.00 (±0) 13.92 (±0.97)

0.041

Pre-training vs Post-training

10.92 (±2.46) 12.67 (±1.25)

0.153 10.92 (±2.31) 13.92 (±0.97)

0.009

Time (Seconds)

Pre-training vs At-training

202.67 (±66.83) 122.17 (±32.17)

0.06 241.17 (±87.69) 166.83 (±53.80)

0.160

At-training vs Post-training

122.17 (±32.17) 182.33 (±10.13)

0.011 166.83 (±53.80) 160.50 (±30.09)

0.717

Pre-training vs Post-training

202.67 (±66.83) 182.33 (±10.13)

0.485 241.17 (±87.69) 160.50 (±30.09)

0.101

Compare between group 1 and group 2 Group 1 Group 2 P values (between

group1 and 2)

Score (Out of 15)

Pre-training 10.92 (±2.46) 10.92 (±2.31) 1.000 At-training 14.75 (±0.481) 15.00 (±0) 0.174 Post-training 12.67 (±1.25) 13.92 (±0.97) 0.082 Pre- vs At- training 3.83 (±2.48) 3.83 (±2.14) 1.00 At- vs post-training -2 (±1.10) -0.83 (±0.75) 0.057 Pre- vs Post- training 1.83 (±2.71) 2.83 (±1.47) 0.446

Time (Seconds) Pre-training 202.67 (±66.83) 241.17 (±87.69) 0.412 At-training 122.17 (±32.17) 166.83 (±53.86) 0.111 Post-training 182.33 (±10.13) 160.50 (±30.09) 0.123 Pre- vs At- training -80.50 (±81.46) -74.33 (±110.42) 0.915 At- vs Post-training 60.17 (±37.46) -6.33 (±40.51) 0.014 Pre- vs Post training -20.33 (±66.11) -80.67 (±98.28) 0.241

Data comparison within individual group Midwives only – N = 42 Mean Time or Score ±

(Standard Deviation) P value Mean Time or Score ±

(Standard Deviation) P value

Group 1 (retest at 6 months) N=42 Group 2 (retest at 12 months) N=42

Overall score (Out of 15)

Pre-training vs At-training

7.50 (±3.41) 14.12 (±17.0)

Single centre

Limited amount of participants

Participants may encounter real life event of shoulder dystocia

Unable to test all participants in one day or at same time Intercommunication between participants

May affect results

simulation training results in immediate, short-term and contribute to long-term improvement in shoulder dystocia management

however knowledge degrades over time Knowledge significantly decrease at 6 months but maintain at

a similar level at 12 months 12 monthly training improves knowledge significantly over

those who had not had training in last 12 months Annual training has benefits though 6 monthly or even more

frequent maybe preferred Applies to doctors and midwives Strike a balance between training and daily work

commitments

1. Shoulder dystocia. ACOG Practice Bulletin No. 40. American College of Obstetrician and Gynaecologists. Obstet Gynecol. 2002; 100:1045-50

2. Dracott T, Sibanda T, Owen L et al. Does training in obstetrics emergencies improve neonatal outcomes? BJOG. 2006. 113: 177-182.

3. Cass GKS, Crofts JF, Dracott TJ. The use of simulation to teach clinical skills in obstetrics. Seminars in Perinatology. 2011; 35: 68-73.

4. Draycott TF, Crofts JF, Ash JP et al. Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol. 2008; 112(1): 14-20.

5. Deering S, Poggi S, Macedonia C et al. Improving resident competency in the management of shoulder dystocia with simulation training. Obstet Gynecol. 2004; 103: 1224-1228.

6. Croft JF, Bartlett C, Ellis D et al. Training for shoulder dystocia; a trial of simulation using low-fidelity and high-fidelity mannequins. Obstet Gynecol. 2006; 108 (6): 1477-85.

7. Smith S. Team training and institutional protocols to prevent shoulder dystocia complications. Clin Obstet Gynecol. 2016; 59(4): 830-840.

8. Goffman D, Heo H, Pardanani S et al. Improving shoulder dystocia management among resident and attending physicians using simulations. Am J Obstet Gynecol. 2008; 199(3): 294.

9. Vadnais MA, Dodge LE, Awtrey CS et al. Assessment of long-term knowledge retention following single-day simulation training for uncommon but critical obstetrical events. J Matern Fetal Neonatal Med. 2012; 25(9) 1640-5.

10. Buerkle B, Pueth J, Hefler et al. Objective structured assessment of technical skills evaluation of theoretical compared with hands-on training of shoulder dystocia management: a randomized controlled trial. Obstet Gynecol. 2012; 120(4): 809-14.

11. Madani A, Watanabe Y, Vassiliou MC et al. Long-term knowledge retention following simulation-based training for electrosurgical safety: 1-year follow-up of a randomized controlled trial. Surg Endosc. 2016; 30(3): 1156-63.

12. Lewis G. CEMACH, Why Mothers Die 2000-2002. The Sixth report of the confidential enquiries into maternal deaths in the United Kingdom. RCOG Press. 2004.

13. Siassakos D, Crofts J, Winter C and SaFE study group. Education Multiprofessional ‘fire-drill ’training in the labour ward. The Obstetrician and Gynaecologist. 2009; 11: 55-60.

14. Crofts JF, Bartlett C, Ellis D et al. Management of Shoulder Dystocia. Skill retention 6 and 12 months after training. Obstet and Gynecol. 2007; 110(5) 1069-1074.

15. ALSO Advanced Life Support in Obstetrics – 2016. 16. Cornthwaite K, Crofts JF, Draycott T et al. Training for Obstetrics emergencies: PROMPT and shoulder dystocia. PROMPT.

March 2015. 17. RCOG. Shoulder Dystocia. Green Top Guideline no. 42. 2012. 18. Ennen CS, Satin AJ. Training and assessment in obstetrics: the role of simulation. Best Practice & research clinical obstetrics

and gynaecology. 2010; 24(747-758). 19. Gregg SC, Heffernan DS, Connolly MD et al. Teaching leadership in trauma resuscitation: Immediate feedback from a real-time,

competency-based evaluation tool shows long-term improvement in resident performance. J Trauma Acute Care Surg. 2016; 81(4): 729-34. 20. Grobman WA. Shoulder dystocia: simulation and a team centered protocol. Semin Perinatol. 2014; 38(4) 205-9.

Special thanks to:

Dr KY Leung, Dr T Ma

QEH MDSSC

QEH medical and midwivery staff

Randomized Controlled Study to assess Skill Retention at 6 versus 12 Months After Simulation Training in Shoulder DystociaWhat is shoulder dystocia Why Simulation training in obstetrics International recommendations Currently at QEHAim of study Inclusion and exclusion criteria MethodsTesting and trainingTimelineMarking schememarkingResultsAll StaffAll Staff – comparing differences Doctors only Slide Number 17LimitationsConclusionReferences:�Thank you