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Reducing Injury and Improving Accurate Documentation for Shoulder Dsytocia

Presented by Emily Armour, MD & Jack Maxwell, MD

Residents: Emily Armour, MD; Annaleigh Coleman, MD; Callie Farnell, MD; Danielle Hardin, MD; Jack Maxwell, MD; Hillary O'Brien, MD

Faculty Advisor: Kathryn Lindsay, MD


The incidence of shoulder dystocia nationally among vaginal deliveries  is 0.2-3%. At the University of Oklahoma, 70 out of 3781 vaginal deliveries experienced a shoulder  dystocia (1%). Shoulder dystocias are associated with significant morbidity and mortality to the mother or baby. They are associated with postpartum hemorrhage and a higher degree of perineal lacerations . Neonatal injuries include brachial plexus injuries and clavicular or humeral fractures. At OU, 29% infants that experience shoulder dystocia have an associated neonatal injury. This exceeds the NPIC benchmark of 15%. Additionally, documentation is important to guide counseling on future risks and inform other healthcare providers. Current practice at OU does not involve a standardized flow and physician/ nursing documentation often differs. From April to November 2021, physician and nursing documentation only aligned 32% of the time. Discrepancies include order of maneuvers, timing of interventions or both .

We hypothesized that if there is a standardized process for executing a shoulder dystocia and debriefing thereafter, then the rate of injury will decrease and the rate of discrepancy in documentation will also decrease.  The goal of the simulations was to increase preparation in the delivery room for those at increased risk of shoulder dystocia, educate participants regarding shoulder dystocia maneuvers and appropriate techniques , and implement clear and concise communication amongst team members.


Standardized ideal processes were created for both anticipated and unanticipated shoulder dystocias. Based on these standard processes, shoulder dystocia simulations were held with Labor & Delivery staff of all roles including physicians, supervisors, nurses, and baby advocates. A debrief form was created to be utilized after each shoulder dystocia in an effort to improve communication and understanding of the event.


A total of 6625 deliveries were performed at OUMC throughout the study period from April 2021 through December 2022 with a total of 94 shoulder dystocias analyzed and 20 total injuries reported. The injury rate from resultant shoulder dystocias improved from 29% to 15% with two humerus fractures to no fractures for pre-implementation and post-implementation, respectively. The percentage of time that physician and RN documentation matched varied per month from as low at 0% to as high as 83% with an overall improvement of 58% from 32% following implementation.


As is demonstrated in medical quality improvement literature, this project demonstrated the ability of unit- wide simulation to improve direct patient outcomes, such as the reduction in injury to infant from shoulder dystocia. Additionally, our QI project has shown that creating standardized forms with a formal debrief can increase concordance in documentation between nursing staff and providers. The results of this quality improvement effort  can provide the groundwork and structure for  the role of  simulation on the Labor unit for other obstetric emergencies, such as  postpartum hemorrhage.

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