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MS WordPerinatologist Corner - C.E.U/C.M.E. Modules
Shoulder Dystocia
Sponsored by The Indian Health Service Clinical Support Center
10. Documentation and Drills
Documentation
Well, I guess you’re tired now! Hopefully you have someone available to help you stabilize the infant. Explain to the parents in detail what happened, and what you did to accomplish the delivery, and keep them updated about the baby. Don’t forget to write or dictate a detailed note in the chart, and be sure the whole team, nursing staff, and pediatric staff, all concur on the final account.
The sequelae of shoulder dystocia can be a major cause of litigation if the infant is damaged, despite having done your best. Careful documentation of everything you did, and the time course, is critical.
You may want to consider using the HELPERR mnemonic as a template to structure your procedure note. Documentation of the management of shoulder dystocia should concentrate on the maneuvers performed and the duration of the event. Also document if you preformed any preventive measures, e.g., the ‘C C C Deliver Through maneuver.
Terms such as mild, moderate, or severe shoulder dystocia offer little information about the situation or care encountered. Other team members assisting the delivery should be listed, as well as cord pH, if obtained.
Specific notation regarding which arm was impacted against the pubis should be made in the event that subsequent nerve palsy develops. The delivery should be reviewed with the parents, and the management and prognosis for any infant palsy should be explained.
This is unfortunately part of the reality of attending births, and if you document in detail what you did to deal with this very difficult situation, it will be your best defense in case of a problem later.
It’s also important to practice these maneuvers with a manikin, so that, like CPR, and ACLS, you have familiarity with the procedures you never know when you will need! You may want to consider attending an ALSO Provider Course in your vicinity and /or taking a refresher Course every 5 years.
Drills
A.)
Your facility should perform regular emergency delivery drills. Please perform the actual drill, don’t just talk your way through it. It is when you actually try to move the patient quickly down the hall and the fetal monitor and IV get displaced that you can learn. Or why is the Bicitra locked in the Pyxis at a time like this?
Here is an excellent resource from the national Indian MCH and Women’s Health meeting
Emergency Delivery Simulations: How to Develop Teamwork,
by Michele Lauria (PowerPoint 728 k)
B.)
Simulation training scenario improves competency in the management of shoulder dystocia.
The Level I study below raises an important point and begs the question of another. Shoulder dystocia is a rare and potentially devastating problem that often presents without warning, even in low risk settings. This study shows the value of individual provider training. Another excellent example is the Advanced Life Support in Obstetrics (ALSO) Provider Course
OBJECTIVE: To determine whether a simulation training scenario improves resident competency in the management of shoulder dystocia.
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, chi(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 performance in the management of shoulder dystocia.
LEVEL OF EVIDENCE: I
Deering S, Improving resident competency in the management of shoulder dystocia with simulation training. Obstet Gynecol. 2004 Jun;103(6):1224-8.
