What improves shoulder dystocia outcome: inducing patients with suspected macrosomia (macrosomia) at 38 weeks, cutting a generous medio-lateral episiotomy, planned cesarean section (CS) for patients with body mass index (BMI) > 45, or conducting team mock drills of shoulder dystocia management?

Conducting Team Mock Drills is the Most Effective Intervention for Improving Shoulder Dystocia Outcomes

Conducting team mock drills of shoulder dystocia management is the most effective intervention for improving shoulder dystocia outcomes by enhancing team performance and reducing fetal injury. 1, 2

Evidence for Each Intervention Option

Team Mock Drills for Shoulder Dystocia

• The American College of Obstetricians and Gynecologists strongly recommends simulation-based training for managing shoulder dystocia 1
• Simulation training has been shown to:
  • Improve physician and team performance during actual shoulder dystocia events
  • Facilitate implementation of effective techniques like the all-fours maneuver
  • Improve documentation of maneuvers used 2
  • Reduce fetal injury rates (RR 0.50,95% CI: 0.21-1.2) 2
• Training should be multiprofessional and use validated, high-fidelity birth simulators 1
• Simulation should include practice of all disimpaction techniques and management algorithms 1

Inducing Patients with Suspected Macrosomia at 38 Weeks

• Current evidence does not support early induction of labor for suspected fetal macrosomia 3
• Induction of labor at least doubles the risk of cesarean delivery without reducing the risk of shoulder dystocia 3
• The American Academy of Family Physicians specifically recommends against induction for suspected macrosomia 1

Medio-lateral Episiotomy for Shoulder Dystocia

• No evidence from the provided guidelines supports that a generous medio-lateral episiotomy improves shoulder dystocia outcomes
• Episiotomy is not mentioned as a primary intervention in any of the shoulder dystocia management algorithms in the guidelines 1

Planned CS for Patients with BMI > 45

• Guidelines recommend considering prophylactic cesarean delivery only for estimated fetal weights >5,000g in non-diabetic women and >4,500g in diabetic women 1
• BMI >45 alone is not specified as an indication for planned cesarean section in the guidelines
• Vaginal delivery is not contraindicated for estimated fetal weights up to 5,000g in non-diabetic women 1

Recommended Management Algorithm for Shoulder Dystocia

1. Recognition and Team Activation

   • Announce the emergency and call for additional help 1
   • Ensure proper documentation throughout the event 2

2. First-line Interventions

   • McRoberts maneuver (mother's legs hyperflexed tightly to abdomen) 1
   • Suprapubic pressure (not fundal pressure) 1

3. Second-line Interventions

   • Delivery of the posterior arm
   • All-fours maneuver (shown to be implemented more frequently after team training) 2
   • Internal rotational maneuvers 4

4. Avoid Harmful Techniques

   • Excessive traction on the fetal head
   • Fundal pressure
   • Attempting to rotate the fetal head 180 degrees 1

Key Non-technical Skills Associated with Better Outcomes

• Effective patient communication - calming the mother and guiding her collaboration 4
• Situation awareness - promptly mobilizing all essential personnel 4
• Role clarity and team coordination 5

Common Pitfalls to Avoid

• Failure to recognize that a shoulder dystocia is occurring 5
• Difficulty with efficient summoning of additional staff 5
• Lack of role clarity among team members 5
• Reduced situational awareness during the emergency 5
• Variable or poor documentation of maneuvers used 2, 5
• Encouraging the mother to push (should be discouraged during shoulder dystocia) 4

Team training through simulation is the only intervention among the options that has demonstrated a reduction in fetal injury rates and improved management of shoulder dystocia, making it the most effective approach for improving outcomes in this obstetric emergency.