Introduction:
Shoulder dystocia is considered an obstetric emergency at childbirth that can lead to significant neonatal morbidity and mortality. The primary objective of the SAFE study is to explore and quantify how the knowledge and skills on shoulder dystocia management of Greek Midwives may improve following high-fidelity simulation with integrated force-monitoring systems.

Material and Methods:
A high-fidelity simulator that consisted of a pelvic model and a computerised neonatal mannequin with an embedded force-monitoring system was utilised for the purposes of shoulder dystocia management in a one-day workshop. Midwives were invited to participate in groups of five in a 90-min training session during the workshop. The training session consisted of a 30-minute initial evaluation, a 30-minute theoretical and hands-on training from the instructor, and a 30-minute final evaluation of participants. The outcomes measured involved the performance of maneuvers (scale:0-20), the force applied on the neonatal head, the level of communication skills (scale:0-5) and self-reported confidence (scale:0-10). These outcomes were recorded at the start and at the end of the training session. The pre- and after- training scores of all four outcomes were compared and statistical analysis was applied. The workshop was repeated at 6 and 12 months to determine the retention of skills over time.

Results:
There were 102 midwives participating in total at the baseline workshop, with a median age of 26 years old, and with approximately 1 in 3 having labour ward experience. Prior to training, only 8,8% managed to successfully deliver the impacted shoulder (defined as successful delivery of the posterior arm), with this increasing to 89% after training. The mean force applied to the neonatal head was in excess of 100 Newtons and was similar pre- and after- training, with a convergence of the outliers to the mean value. Performance of maneuvers scores, the self-reported confidence of participants, and the communication skills of the participants improved significantly almost two-fold after-training. Those that benefited most were the participants with less clinical experience. High scores in clinical skills were retained even after 6 and 12 months.

Conclusions:
High-fidelity simulation with use of force-monitoring systems on the management of shoulder dystocia at childbirth, can significantly improve the performance score of maneuvers, the levels of confidence and the communication skills of Midwives, with this effect being retained after 6 and 12 months from baseline training.