Virtual Reality-Enhanced Haptic Simulation to Improve Self-Regulation of Applied Delivery Force During Shoulder Dystocia

Shoulder dystocia, the obstructed delivery of an infant's shoulders and body after emergence of the head in the final mo- ments of birth, occurs unpredictably as an obstetric emergency in up to 1 in 25 vaginal deliveries. Prompt recognition and performance of specialized delivery maneuvers mitigates against brachial plexus injuries associated with up to 40% of shoulder dystocia-complicated deliveries. Although some success with simulation training has been demonstrated, re- duced rates of brachial plexus injury has not been achieved consistently. Questions persist about differing simulation training schemes and instructional content utilized between successful and unsuccessful interventions. Unless content and methodology utilized for shoulder dystocia simulation training is proven effective in mitigating birth injury, use of simu- lation for skills acquisition is of limited utility in advancing patient safety. If simulation-derived metrics are not validated, otherwise competent obstetricians could be inaccurately deemed not to be appropriately skilled, leading to workforce re- ductions that negatively impact access to safe obstetric care for women and children. We delineate specific positive (pre- scriptive) instructional content emphasizing maneuvers shown to decrease strain on the brachial plexus. We also consider several negative (proscriptive) instructions – to avoid excessive and laterally-directed or torsional traction – to be essential for inclusion in simulation training. We deliver relevant learning content using virtual (video) and haptic (mannequin) for- mats and perform objective (force measurement) and subjective (preceptor scores) assessments of provider technique. Although successful in reducing clinical brachial plexus injuries, such programs are labor-intensive and rarely tailored to providers' educational needs. Our multidisciplinary collaborative team of obstetric, biomedical engineering and simulation educators from Albert Einstein College of Medicine-Montefiore Medical Center proposes a virtual reality-enhanced haptic simulation to improve obstetric providers' self-regulation of applied delivery force during shoulder dystocia. A mixed meth- ods approach will be used to evaluate our novel content and format for skills acquisition and competency assessment of providers' management of shoulder dystocia. The overall objective for this application is to determine the relative contribu- tion of positive and negative instructional content and of virtual and haptic methods of simulation training. Our central hy- pothesis is that deliberate demonstrative instruction improves skill acquisition and reduces improper potential injury- producing techniques. We aim to 1) assess the relative contribution of positive and negative instructional content to effec- tive simulation-based skill acquisition and competency; 2) evaluate virtual and haptic methods of simulation training for shoulder dystocia management and 3) validate objective and subjective simulation-derived metrics for demonstrating transfer of skills to clinical practice. The expected outcome of the proposed research is the ability to reliably, efficiently and effectively deliver an evidence-based validated simulation program with integrated virtual and haptic components tailored to provider experience that positively impacts the ability to reduce brachial plexus injuries following shoulder dystocia.