Simulator Teaches Force Modulation for Shoulder Dystocia


From the Annual Research Meeting of Academyhealth

Major Finding: Following training on a birth simulator, the percentage of clinicians pulling with more than 150 N during simulated shoulder dystocia deliveries fell from 75% to 43%.

Data Source: A nonrandomized educational intervention involving 40 clinicians.

Disclosures: Dr. Guise said she had no relevant financial disclosures. The project was funded by the Agency for Healthcare Research and Quality (AHRQ).

SEATTLE – Use of a birth force simulator taught clinicians better how to modulate how much force they use when handling a case of shoulder dystocia to avoid brachial plexus and other injuries.

The pull should be no more than 100 newtons (N), a gentle but firm traction, according to Dr. Jeanne-Marie Guise, an obstetrician and gynecologist at Oregon Health and Science University, Portland. It's hard to know, however, exactly how much that is. Shoulder dystocia occurs in only 0.2%-3.0% of births, so training opportunities are rare, and shoulder dystocia emergencies are not very teachable moments. Dr. Guise and her colleagues wanted to see if training on a birth simulator would help clinicians get a feel for how much force to use.

Twenty-eight obstetricians, six family physicians, and six certified midwives, with experience ranging from 6 months to 34 years, were trained on a PROMPT birthing simulator with force monitoring, made by Limbs & Things Ltd. (Bristol, England). Initially, they were blinded to the force-monitoring screen; 38 (95%) pulled with more than 100 N, 30 (75%) with more than 150 N, and 21 (53%) with more than 200 N. Greater force was used as time wore on.

Then, while watching the screen and then from memory, participants pulled with 50 N and then 100 N several times, to get a feel for what those levels of force felt like. At 100 N, Dr. Guise told them, “this is the most you should ever feel, so pay attention” to what it feels like: “If you're starting to shake, how your facial muscles feel,” and so on.

To see if the training took, participants went through surprise simulations. During their shifts, a nurse came running up saying, “I need a doctor, I need a doctor!” Trainees were pulled into a triage room, “but didn't exactly know why,” Dr. Guise said. In the room, they faced the PROMPT simulator again, but this time with an actress playing the part of a frantic mother during a shoulder dystocia delivery. Participants couldn't see the force-monitoring screen. “We plummeted the heart rate and tried to get everything as realistic as it could be. The actress was really acting it up,” she said.

Even under pressure, training made a significant difference. Although 33 (82%) of the participants used more than 100 N, only 17 (43%) used more than 150 N, and 11 (28%) used more than 200 N. “There was a reduction in overall forces applied after simulation training. Participants were able to gauge forces applied after training,” Dr. Guise and her colleagues concluded in the study abstract.

“It's nice to find a way to teach providers to modulate the amount of force in a moment that's not as critical,” she said.

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