Simulation-based training of midwives and doctors significantly reduces permanent brachial plexus birth injury
Brachial plexus birth injury (BPBI) is usually a complication of a difficult delivery and is caused by traction to the cervical and thoracic nerve roots (C5–T1). Most mild injuries recover spontaneously and a permanent BPBI is defined as a clinically evident limited active or passive range of motion or decreased strength of the affected limb at the age of 1 year.
The most significant risk factor for BPBI is shoulder dystocia (SD). It is a highly unpredictable obstetric emergency that is defined by the American College of Obstetricians and Gynaecologists (ACOG) and the Royal College of Obstetricians and Gynaecologists (RCOG) as a delivery that 'requires additional obstetric maneuvers when gentle downward traction has failed to affect the delivery of shoulders'. Maternal diabetes, obesity, fetal macrosomia and operative vaginal delivery are known to increase the risk for SD and thus for BPBI, but a reliable prediction of SD is difficult.
As SD and the risk for BPBI are difficult to control and predict, high-quality management and training of midwives and doctors is important. Various healthcare institutions have recommended simulation-based training, but studies on the impact of training have shown contradictory results.
Marja Kaijoma et al studied the impact of shoulder dystocia (SD) simulation training on the management of SD and the incidence of permanent brachial plexus birth injury (BPBI) in a retrospective observational study conducted at Helsinki University Women's Hospital, Finland included deliveries with SD. The incidence of permanent BPBI decreased significantly after the implementation of regular and multi-professional simulation-based training at clinic. The most significant change in the management of SD was the increased rate of successful posterior arm delivery post-training.
Multi-professional, regular and systematic simulation training for obstetric emergencies began in 2015, and SD was one of the main themes. A study was conducted to assess changes in SD management and the incidence of permanent BPBI. The study period was from 2010 to 2019; years 2010–2014 were considered the pre-training period and years 2015–2019 were considered the post-training period.
The primary outcome measure was the incidence of permanent BPBI after the implementation of systematic simulation training. Changes in the management of SD were also analysed.
During the study period, 1,13,085 vertex deliveries were recorded. The incidence of major SD risk factors (gestational diabetes, induction of labour, vacuum extraction) increased and was significantly higher for each of these factors during the post-training period (p<0.001). The incidence of SD also increased significantly (0.01% vs 0.3%, p><0.001) during the study period, but the number of children with permanent BPBI decreased by 55% after the implementation of systematic simulation training (0.05% vs 0.02%, p><0.001). The most significant change in the management of SD was the increased incidence of successful delivery of the posterior arm.><0.001). The incidence of SD also increased significantly (0.01% vs 0.3%, p<0.001) during the study period, but the number of children with permanent BPBI decreased by 55% after the implementation of systematic simulation training (0.05% vs 0.02%, p<0.001). The most significant change in the management of SD was the increased incidence of successful delivery of the posterior arm.
Despite the increase in risk factors and SD cases, the incidence of permanent BPBI decreased significantly after the implementation of regular and multi-professional simulation-based training at clinic. The most significant change in the management of SD was the increased rate of successful posterior arm delivery post-training. The results of our study provide strong evidence that the outcome for SD can be improved by systematic simulation based training. A significant improvement in successful posterior arm delivery was detected.
Regular training of midwives and doctors and high-quality management of SD remain the most effective method for reducing maternal and fetal morbidity and preventing complications associated with substandard care. This requires a dedicated team of educators and institutional investment so that staff can be regularly released from their clinical duties. However, future research on clinically measurable obstetric outcomes is still needed.
Source: Kaijomaa M, Gissler M, Äyräs O, Sten A, Grahn P. Impact of simulation training on the management of shoulder dystocia and incidence of permanent brachial plexus birth injury: An observational study. BJOG: Int J Obstet Gy. 2022;00:1–8.https://doi.org/10.1111/1471-0528.17278
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