NEW YORK (Reuters Health) – Implementation of shoulder dystocia training was correlated with a greater than 3-fold decrease in obstetric brachial plexus injuries (OBPI) in a new retrospective cohort analysis published in the American Journal of Obstetrics and Gynecology.

Rates of shoulder dystocia have increased in recent decades, but shoulder dystocia is nearly impossible to predict and researchers have largely failed to develop a standardized and systematic approach for managing these emergencies, the authors say.

Their study included 11,862 vaginally-delivered singleton infants that were born between August 2003 and December 2009 at the Jamaica Hospital Medical Center in Jamaica, NY. Of those, 6,269 were born before the training program was implemented and 5,593 afterwards. In the pretraining period, there were 83 cases of shoulder dystocia (1.32% of births), compared to 75 cases in the posttraining period (1.34%, P = 0.93).

In July of 2006, all hospital labor delivery staff underwent training in managing shoulder dystocia and were taught a standardized “hands-off” procedure that involved assessing the position of the anterior shoulder, rotating the shoulder to the oblique position, delivering the posterior arm, and completing delivery. Staff members were recertified in 2008.

The overall incidence of OBPI dropped significantly when the new training program was implemented, from 0.40% during the pretraining period to 0.14% during the posttraining period (P < 0.01). OBPI following shoulder dystocia dropped from 30% during pretraining to 10.67% during posttraining (P < 0.01). In cases of shoulder dystocia that occurred during the pretraining period, infants were 3.61 times more likely to develop OBPI than during the posttraining period (relative risk, 0.277). Maternal BMI (P < 0.01) and neonatal birth weight (P = 0.02) were lower in the posttraining period, but in a logistic regression analysis only shoulder dystocia training was still associated with reduced OBPI (P = 0.02). During the posttraining period, there was a significant decrease in the use of the McRobert maneuver and a significant increase in the use of posterior arm delivery and the Rubin maneuver. Dr. Robert Allen of Johns Hopkins University, who studies shoulder dystocia but was not involved in the current research, said that they key element of the training program was the protocol to reposition the baby, rather than the mother. “Most management schemes deal with reorienting the mother, pressing the legs all the way back,” he told Reuters Health. “Turning the baby is far more effective.” Dr. Allen praised the department-wide protocol change initiated in the study, but questioned whether such a protocol could be implemented widely. “Getting protocols established is exceedingly difficult,” he said. “People are used to doing something in a certain way. It’s really a question of culture.” However, “this study demonstrates that with a simple and standardized protocol in place, it is possible to improve the outcome of this dire emergency in obstetrics,” the authors write. “Further studies are required to determine which part or parts of the protocol reduce morbidity for the neonate.” The findings were previously presented at the 31st Annual Meeting of the Society for Maternal-Fetal Medicine in San Francisco, February 7-12, 2011. Am J Obstet Gynecol, online February 25, 2011.