A 25-year-old woman presented to the hospital in
labor and at full gestation after receiving uncomplicated prenatal
care. A third-year obstetrics and gynecology resident delivered the
infant under attending supervision via vacuum-assisted vaginal
delivery. Following delivery of the shoulders, the resident turned
to place the vacuum device on a nearby equipment stand. During that
time window, the patient adjusted her positioning while on the
birthing bed (creating an inadvertent push), and the infant slid
out of the vaginal canal, slipped out of the resident’s
hands, and dropped headfirst onto the floor.
The infant suffered a left parietal fracture and
hematoma at the site of impact. Although he required close
observation and neurosurgical consultation, no intervention was
indicated. In reviewing the incident, staff interviews suggested
that both noise and confusion of roles among the labor and delivery
team contributed to the error, which, through luck alone, led to no
long-term sequelae for the infant.
1. Halamek LP. Improving performance, reducing
error, and minimizing risk in the delivery room. In: Stevenson DK,
Benitz WE, Sunshine P, eds. Fetal and Neonatal Brain Injury:
Mechanisms, Management and the Risks of Practice. 3rd ed.
Cambridge, England: Cambridge University Press;
2. Joint Commission on Accreditation of
Healthcare Organizations. Preventing infant death and injury during
delivery. Sentinel Event Alert. July 21, 2004; Issue 30. Available
3. Halamek LP, Kaegi DM. Who’s teaching
neonatal resuscitation to housestaff? Results of a national survey.
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4. Murphy AA, Halamek LP, Lyell DJ, Druzin ML.
Training and competency assessment in electronic fetal monitoring:
a national survey. Obstet Gynecol. 2003;101:1243-1248.
go to PubMed ]
5. Halamek LP, Kaegi DM, Gaba DM, et al. Time for
a new paradigm in pediatric medical education: teaching neonatal
resuscitation in a simulated delivery room environment. Pediatrics.
go to PubMed ]
VIDEO: This 5-minute video shows a simulated post-delivery
situation. A depressed neonate is being resuscitated after a
delivery complicated by fetal blood loss. The providers of bedside
care are all trainees with varying degrees of clinical experience
enrolled in NeoSim, a simulation-based training program in neonatal
resuscitation at the Center for Advanced Pediatric Education at
Packard Children’s Hospital at Stanford. Pay attention to the
multitude of visual, auditory, and tactile cues that are present in
the simulated environment and the seriousness with which the
trainees go about their tasks; these cues enable the trainees to
effectively “suspend their disbelief” and behave as
they would in real life. Note that it takes the team some time to
establish effective communication and a clear chain of command.
Compared to a commercial airline cockpit, the language used in the
delivery room often is not standardized, important communications
are rarely read back or confirmed, and a large number of
distracters are present. All of these issues and more are reviewed
during playback of the video during a constructive debriefing held
immediately at the close of the scenario. Together with the
instructors, the team of trainees discusses both the negative and
positive aspects of their performance in a safe and nonjudgmental
[Note: It may take several minutes for the video to begin
Slippery Slide into Life