Original Research Improving Neonatal Outcome Through Practical Shoulder Dystocia Training Timothy J. Draycott, MD, Joanna F. Crofts, BMBS, Jonathan P. Ash, MBBS, Louise V. Wilson, MBChB, Elaine Yard, RM, Thabani Sibanda, MSc, and Andrew Whitelaw, MD OBJECTIVE: To compare the management of and neo- natal injury associated with shoulder dystocia before and after introduction of mandatory shoulder dystocia simu- lation training. METHODS: This was a retrospective, observational study comparing the management and neonatal outcome of births complicated by shoulder dystocia before (January 1996 to December 1999) and after (January 2001 to Decem- ber 2004) the introduction of shoulder dystocia training at Southmead Hospital, Bristol, United Kingdom. The manage- ment of shoulder dystocia and associated neonatal injuries were compared pretraining and posttraining through a review of intrapartum and postpartum records of term, cephalic, singleton births in which difficulty with the shoul- ders was recorded during the two study periods. RESULTS: There were 15,908 and 13,117 eligible births pretraining and posttraining, respectively. The shoulder dystocia rates were similar: pretraining 324 (2.04%) and posttraining 262 (2.00%) (P.813). After training was introduced, clinical management improved: McRoberts’ position, pretraining 95/324 (29.3%) to 229/262 (87.4%) posttraining (P<.001); suprapubic pressure 90/324 (27.8%) to 119/262 (45.4%) (P<.001); internal rotational maneuver 22/324 (6.8%) to 29/262 (11.1%) (P.020); delivery of posterior arm 24/324 (7.4%) to 52/262 (19.8%) (P<.001); no recognized maneuvers performed 174/324 (50.9%) to 21/262 (8.0%) (P<.001); documented excessive traction 54/324 (16.7%) to 24/262 (9.2%) (P.010). There was a significant reduction in neonatal injury at birth after shoulder dystocia: 30/324 (9.3%) to 6/262 (2.3%) (relative risk 0.25 [confidence interval 0.11– 0.57]). CONCLUSION: The introduction of shoulder dystocia training for all maternity staff was associated with im- proved management and neonatal outcomes of births complicated by shoulder dystocia. (Obstet Gynecol 2008;112:14–20) LEVEL OF EVIDENCE: II S houlder dystocia is an uncommon and largely unpredictable event 1,2 with serious potential mor- bidity for both mother and baby, particularly obstetric brachial plexus injury, 3–6 which may be exacerbated by inappropriate management. 7–9 Training for shoul- der dystocia has been shown to improve the manage- ment of simulated shoulder dystocia. 10 –12 Shoulder dystocia training is now mandated by the Clinical Negligence Scheme for Trusts in the United King- dom 13 and recommended by the Joint Commission on Accreditation of Healthcare Organizations in the United States, 14 but there is currently no evidence of any associated improvement in neonatal outcome. 6 Indeed, a recent study from a U.K. hospital reports a significant increase in the rate of brachial plexus injuries associated with shoulder dystocia between 1991 and 2005 despite the introduction of training. 15 The aim of this study was to compare the man- agement of shoulder dystocia and neonatal injury associated with shoulder dystocia before and after the introduction of shoulder dystocia training for all staff in a single maternity unit. METHOD This retrospective, observational study compares the management and neonatal outcome of births compli- cated by shoulder dystocia before and after the intro- From the Department of Obstetrics and Gynaecology, North Bristol NHS Trust, Southmead Hospital, Bristol, United Kingdom; the Department of Obstetrics and Gynaecology, United Bristol NHS Trust, St. Michael’s Hospital, Bristol, United Kingdom; and the University of Bristol, Bristol, United Kingdom. Presented at the Institute of Healthcare Improvement Conference, December 9 –12, 2007, Orlando, Florida. The authors thank Denise Ellis (Registered Midwife) and Cathy Winter (Registered Midwife), who aided the research by searching the STORK maternity database. Corresponding author: Dr. Timothy Draycott, Consultant Obstetrician, Depart- ment of Obstetrics and Gynaecology, North Bristol NHS Trust, Southmead Hospital, Bristol, BS10 5NB, UK; e-mail: tdraycott@gmail.com. Financial Disclosure Dr. Draycott has been a consultant to Limbs and Things Ltd (Bristol, UK), manufacturers of the PROMPT Birthing Simulator. The other authors have no potential conflicts of interest to disclose. © 2008 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/08 14 VOL. 112, NO. 1, JULY 2008 OBSTETRICS & GYNECOLOGY