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Year : 2022  |  Volume : 25  |  Issue : 6  |  Page : 773-778

Effects of high fidelity simulation model on midwives' shoulder dystocia management skills: An educational İntervention study

Department of Midwifery, Faculty of Health Sciences, Manisa Celal Bayar University, Manisa, Turkey

Date of Submission04-Apr-2021
Date of Acceptance29-Mar-2022
Date of Web Publication16-Jun-2022

Correspondence Address:
Dr. S I Calim
Department of Midwifery, Faculty of Health Sciences, Manisa Celal Bayar University, 45030 - Manisa
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_1393_21

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Background: Shoulder dystocia is an emergency and risky situation that most likely directly involves midwives. Aim: The aim of this study is to determine the effects of simulation training with a high fidelity mannequin on midwives' shoulder dystocia management. Subjects and Methods: This study utilized a quantitative, quasi-experimental research design. No sample selection was made. The study included all midwives (n:16) working in the maternity unit of Manisa Province Hospital, Turkey. Management of shoulder dystocia was lectured both theoretically and practically, using a high fidelity simulation. Midwives' shoulder dystocia management skills and knowledge were evaluated before and after training using shoulder dystocia knowledge form and management skill checklist. Results: There was a statistically significant increase in their shoulder dystocia management knowledge scores and management skills after simulation-based shoulder dystocia training (P < 0.05). Before the training, the midwives (62.5%) mostly used the McRoberts maneuver and suprapubic pressure as the primary interventions in shoulder dystocia management. After training, all the midwives were able to apply secondary maneuvers (Wood's or Rubin's maneuvres or posterior arm delivery) along with the primary maneuvers, in accordance with the shoulder dystocia management algorithm. Conclusion: Using a high fidelity simulation model in training increased midwives' shoulder dystocia management skills and knowledge.

Keywords: High fidelity simulation, midwifery skills, shoulder dystocia, simulation training

How to cite this article:
Calim S I, Ulas S C, Demirci H, Tayhan E B. Effects of high fidelity simulation model on midwives' shoulder dystocia management skills: An educational İntervention study. Niger J Clin Pract 2022;25:773-8

How to cite this URL:
Calim S I, Ulas S C, Demirci H, Tayhan E B. Effects of high fidelity simulation model on midwives' shoulder dystocia management skills: An educational İntervention study. Niger J Clin Pract [serial online] 2022 [cited 2022 Dec 3];25:773-8. Available from:

   Introduction Top

Shoulder dystocia (SD) is an unpredictable and unpreventable obstetric emergency, requiring rapid and coordinated action.[1],[2],[3] It occurs when either the anterior or less commonly the posterior fetal shoulder impacts on the maternal symphysis or sacral promontory.[4] It is associated with significant neonatal, maternal, and medicolegal consequences.[2],[3] SD frequency ranges from 0.58% to 7% of vaginal births while brachial plexus injury, which is one of the most important fetal complications of SD, occurs in 2.3–16% of SD deliveries.[4] Fetal morbidity and mortality commonly result from inappropriate management of SD.[2],[5],[6] Therefore, the management of SD is a crucial midwifery skill that must be taught.[7],[8]

SD is an emergency and risky situation that most likely directly involves midwives.[4],[9] All midwives should be aware of the signs of SD and timely manage it using appropriate maneuvers when it occurs.[8],[9] When managing SD, it is important to follow the SD algorithm to make the best decision within 5 minutes. The algorithm [Figure 1] can help healthcare professionals managing the birth to make faster and more effective decisions as well as the active participation of other support team members. RCOG recommends that all maternity staff should participate in at least one such simulation training for SD annually.[4],[10]
Figure 1: Algorithm for the management of shoulder dystocia (RCOG 2012)[4]

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SD training on a high fidelity mannequin is more successful than on a lower fidelity mannequin due to the former's realistic properties. Low-fidelity mannequins cannot simulate shoulder impaction on the symphysis pubis or provide feedback on the traction applied. Practical SD training with a high fidelity mannequin improves midwives' knowledge, confidence, and management skills.[5],[11],[12],[13],[14],[15] In recent years, using the high fidelity mannequin in training has offered a new approach to teaching clinical midwifery skills in Turkey, but only it can be used in student midwife training. High-fidelity mannequins are not widely used as they are expensive and require technical skills. The aim of this study is to determine the effect of simulation training with a high fidelity mannequin on the SD management of midwives in Turkey.

   Subjects and Methods Top

This study utilized a quantitative, quasi-experimental research design.

Participants and data collection

The study was carried out in the Health Sciences Faculty Birth Simulation Laboratory of Manisa Celal Bayar University, Turkey. No sample selection was made. All midwives working in the maternity unit of Manisa Province Hospital were included (n:16). As the only public hospital with a maternity unit in Manisa, most deliveries take place here. A schedule was prepared with all the midwives working in the maternity ward according to factors such as their shifts and the availability of the faculty's training facilities. The midwives were divided into eight pairs according to their shifts. Theoretical and practical training was given to each pair. This schedule ensured that sufficient midwives were present in the maternity unit during working hours while having only two midwives in the birthing room provided a realistic environment for the simulation training. The midwives could ask further questions and have extra practice during the one-to-one theoretical and practical training sessions.


Sociodemographic form

This form had eight questions regarding the midwives' sociodemographic characteristics (age, education level, years of employment, years of employment in the birthing room, prior in-service training on SD, and prior experience in managing SD).

Management of SD knowledge form

This form had 40 true/false questions to evaluate the midwives' knowledge level regarding SD management. It was prepared by the researchers based on the evidence-based RCOG guideline[4] for SD management. Each correct answer scored 1 point, so the maximum possible score was 40 points.

SD management skill checklist

This checklist provided an algorithm for SD management (7 tasks/steps). It was adapted from the RCOG Green-top Guideline: Shoulder dystocia (2012) and the American College of Obstetricians and Gynecologists (ACOG) Practice bulletin Shoulder Dystocia (2017). These documents provide guidance for skills training in SD management.[4],[16]


A full-size anthropomorphic high-fidelity female robot simulator (Noelle®, 554.555, Gaumard Scientific, Coral Gables, Florida) was used for training and evaluation of SD management skills. This simulator is a computer-based mannequin attached to a monitor that physically moves the baby through a fully automated birth canal. The SD scenario recorded on the computer was used. The simulation environment recreated the appearance and feel of a labor and birthing unit, with visual and auditory cues to simulate a real-life encounter. The simulation scenario started as normal labor and ended after secondary maneuvers (Woods, Rubin's, or birth posterior arm) performed when SD developed. SD was resolved by performing one of the secondary maneuvers. All fours position was not implemented because the simulator was not suitable.

One instructor who lectures at the Midwifery Department conducted the theoretical and practical training for the simulation, evaluated the midwives' SD management skills, and attended the planned briefing and debriefing sessions. The other instructor conducted the simulation in real time or ran the computer, depending on the scenario.

Three stages of the research

First stage (before training)

Small group sessions were conducted with each pair of midwives, who were asked to complete the Sociodemographic Form and the Management of Shoulder Dystocia Information Form without sources to aid them and without conferring with colleagues. Each midwife then took a baseline assessment in which they managed a standardized simulated SD scenario. All the midwives were experiencing high-fidelity simulation training for the first time. They were encouraged to examine and touch the model, and the sound of the mannequin was demonstrated. The instructor provided a 10-minute briefing to the midwives, together with a written copy of the scenario. The briefing reassured the midwives that they were in a safe environment and introduced the equipment and the standard scenario, including all the associated history and details. As in a real birthing room, one midwife delivered the baby while the other was the assistant midwife. Each pair swopped roles between simulations. Having observed each midwife's simulation performance, the instructor used a checklist to evaluate their SD management skills. Immediately following the simulation, the instructor conducted a debriefing with the two midwives.

Second stage (theoretical and practical training)

Each pair received a 45-minute lecture by PowerPoint presentation about SD risk factors, maneuvers, and the basic SD management algorithm. The theoretical training was prepared by the researchers based on the RCOG Green-top Guideline: Shoulder dystocia (2012)[4] and ACOG Practice bulletin Shoulder Dystocia (2017).[16] After the theoretical training, each pair received a 45-minute practical workshop on SD management, demonstrated on the full-size anthropomorphic high fidelity female robotic simulator. The aim of the applied simulation training was for the midwives to gain the skills to apply all primary and secondary maneuvers used in SD management.

Third stage (after training)

After completing the theoretical and practical training, the participants were reevaluated. First, they redid the Management of Shoulder Dystocia Information Form. Second, after the instructor had given a 10-minute briefing to each pair with the same scenario, each midwife was reevaluated in managing a standardized simulated SD. Each midwife had 10 minutes to complete the scenario. After SD developed, the other midwife assisted the midwife under evaluation. The instructor used a checklist to evaluate their SD management skills. Finally, a 30-minute debriefing session was conducted with each pair of midwives about their experiences using their checklist form.

Data analysis

Statistical analyses were performed using SPSS, version 22.0. In the analysis, descriptive statistics, Chi-square, and Wilcoxon signed-rank tests were used. A P value <.05 was considered statistically significant.

Ethical approval

The study received approval from Manisa Celal Bayar University's Medical Faculty Ethics Committee and from Manisa Provincial Health Directorate. Participation was voluntary and midwives could withdraw at any time. The participants completed an informed consent form. There were no incentives for participation. The researcher explained the study's purpose and rationale to ensure that participants understood the nature of the research. All participants signed the consent form. This study protocol conformed to the provisions of the Declaration of Helsinki and was approved.

   Results Top

The midwives' mean age was 36.00 ± 8.03 years; 68.8% were university graduates; they had been working for an average of 13.78 ± 9.12 years and for 6.46 ± 7.70 years in the labor ward; none had received in-service training on SD; only 31.3% had encountered SD in their work [Table 1].
Table 1: Sociodemographic and working characteristics of midwives constituting the research group (N=16)

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Regarding the midwives' use of specific SD management skills before and after training, the “call for help” step was carried out by 43.8% of midwives before training but by all of them after training. Before the training, two steps were not used by any of the midwives (“asked someone to keep track of time” and “lay flat”) whereas after training, these steps were performed by 81.3% and 87.5% of the midwives, respectively. Before training, 62.5% of the midwives implemented “suprapubic pressure together with the McRobert's maneuver” whereas they all did after training. “Consider episiotomy if it will enable internal maneuvers” was performed by 25.0% of the midwives before training and by 87.5% afterwards. Regarding the “Internal maneuver,” 12.5% of the midwives performed Woods' screw maneuver, while 25.0% performed the “Delivery of the posterior arm” maneuver and none performed Rubin's screw maneuver. In contrast, after training 6.2% performed the Wood's and “deliver posterior arm” maneuvers while 87.5% performed Rubin's maneuver [Table 2]. As shown in [Table 2], before the training, the midwives' mean SD knowledge score was 21.37 ± 7.48. After the training, the average knowledge score increased to 36.31 ± 1.53. There was a significant difference between the midwives' knowledge scores before and after training (P <.001).
Table 2: Shoulder dystocia management skills and knowledge of midwives before and after training

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The midwives' abilities after training varied by age and experience. Midwives who were younger than the average were not complete to perform the management skills. In contrast, SD skills were more likely to be performed completely by midwives who were university graduates, working for 14 years or more, working in the labor ward for one year or more, had not previously encountered SD, and/or had an above-average knowledge score. However, no statistically significant differences were found between these groups ([Table 3], P >.05).
Table 3: Comparison of some characteristics of midwives and their post-training shoulder dystocia management skills

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   Discussion Top

SD is a sudden onset complication of normal birth. It is the duty of a midwife to enable normal births on her own responsibility. When SD occurs, the midwife must carry out the necessary emergency interventions within the first five minutes and using the correct maneuvres until her team can gather. It is therefore vital that a midwife should have sufficient SD management knowledge and skills. Studies of interventions to develop midwives' SD management skills show that simulation-based training is particularly effective in the development of clinical skills.[2],[5],[6],[7],[15],[17],[18] Similarly, the present study found a statistically significant increase in midwives' SD management knowledge scores and management skills after simulation-based SD management training [Table 2]. Reynolds et al.[9] found that the use of simulation in normal birth and SD training increased midwives' knowledge scores. The statistically significant increase in midwives' SD knowledge after training is an important result for achieving the target.

SD requires an appropriate team to manage it. Therefore, as soon as SD is recognized, help must be called for, and someone must be asked to keep track of time.[4],[5],[16],[18],[19] Using a control group, Deering et al.[20] examined the effectiveness of simulation training in the management of SD. They reported that 95% of the participants who received simulation training and 35% of those who did not receive training called for help when SD developed while 56% of those who had received training and 12% of those who had not asked someone to keep track of time. In our study, only about half of the midwives called for help when SD occurred before training whereas all did after training. Before training, no one asked anyone to keep track of time, whereas most (81.3%) did this after training. The proportions of midwives calling for help and asking someone to keep track of time when SD occurred was similar in the present study to Deering et al.[20] Thus, simulation-based training develops the skills of calling for help and asking someone to keep track of time, which are critical in the management of SD.

Guidelines recommend first performing the McRoberts maneuver when SD occurs because it is fast, easy, and effective, has the least complications, and is the least invasive maneuver. In this maneuver, hyper flexing the mother's legs tightly to her abdomen, which helps the upward widening of the symphysis and increases the sacral angle. The success rate of the McRoberts maneuver varies from 60% to 90%. If this maneuver alone is not successful, the application of suprapubic pressure increases the chance that SD management will succeed. Laying the mother flat also makes it easier to perform the maneuvers.[3],[4],[19],[21],[22],[23],[24] Kallianidis et al.[8] found that midwives primarily use the McRobert's and suprapubic pressure maneuvers (65.6%) to manage SD. In our study, all midwives used the McRoberts maneuver and suprapubic pressure after training. Basing the training on the SD management algorithm enabled these midwives to apply the primary maneuvers in the correct order.

In the simulation scenario in our study, we expected the midwives to perform the primary and secondary level SD maneuvers. Thus, in the scenario, after the primary maneuvers of McRoberts and suprapubic pressure did not resolve the situation, SD was managed with secondary maneuvers. Before the training, two of the midwives used Wood's maneuver while four midwives delivered the posterior arm. After the training, however, most of the midwives (87.5%) chose to implement Rubin's maneuver. Hoffman et al.[25] examined hospital records of obstetric maneuvers used to manage acute SD. The most frequently selected secondary maneuvers were, in order, Wood's, posterior arm delivery and Rubin's maneuver. Deering et al.[20] found that the most frequently chosen maneuver following simulation-based training on SD management was posterior arm delivery. The RCOG SD management guide states that Rubin's and Wood's maneuvers and posterior arm delivery are equally effective. However, the choice of maneuvers depends on the clinician's experience.[4]

   Conclusion Top

The present study demonstrated that use of a high fidelity simulation model in training can improve midwives' SD management knowledge and skills. Before the training, the midwives mostly used the McRoberts maneuver and suprapubic pressure as the primary interventions in SD management. After training, however, they were able to apply secondary maneuvers (Wood's or Rubin's maneuvres or posterior arm delivery) along with the primary maneuvers, in accordance with the SD management algorithm.

The use of high fidelity birth simulators and simulation designs provides participants with an active learning environment through a realistic environment. Therefore, simulation training can be used effectively for updating midwives' skills training. There is a further need for studies providing stronger evidence to evaluate how SD management training is reflected in clinical practices.


We would like to acknowledge the midwives working in the maternity unit of Manisa Province Hospital for their participation in this study and Manisa Celal Bayar University Scientific Research Project Office, Turkey (TR).

Financial support and sponsorship

This work was supported by the Scientific Research Project Office of Manisa Celal Bayar University, Manisa, Turkey (grant numbers 2017-142).

Conflicts of interest

There are no conflicts of interest.

   References Top

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  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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