Are emergency mnemonics help(err)ful?

14343115539_34e258f817A number of midwifery programs that I have been involved with offer an interesting session early on in the course, in which students undertake one or more exercises designed to help them identify their individual learning style and/or preferred ways of knowing.  In theory, this enables the future midwife to gain self-knowledge of their personal idiosyncrasies and learning preferences, which can be really helpful given the enormity of the educational journey upon which they are embarking.  In reality, the nature of teaching complex subjects to ever-larger cohorts of students with increasingly limited staff and resources means there may be little opportunity to accommodate different learning preferences throughout the three or four years that follow.  However, many lecturers do their best to include a variety of different approaches and these sessions do at least afford the student the opportunity to gain self-knowledge.


Recalling manoeuvres

Both these sessions and the notion that there is a wide range of preferred learning and knowing styles have been in my mind since I read a paper which looked at the use of mnemonics for remembering how to deal with shoulder dystocia.  Jan et al (2014) used a questionnaire to evaluate midwives’ and doctors’ knowledge of a number of emergency-related mnemonics including HELPERR, which is designed to aid recall of the progression of manoeuvres to be attempted when caring for a woman who experiences shoulder dystocia.

Of the 112 participants, which included 61 midwives, 42 doctors and 9 who didn’t state their profession, 90% were familiar with the HELPERR mnemonic, with 79% saying they used it in practice.  However, when those who said they used it in practice were asked to write out the mnemonic, only 32% could do so.  The same participants did better when asked to state whether descriptions of eponymous manoeuvres (that is, those named after people, like McRoberts) were correct or incorrect.  Their success rate at this was 84.6%, but they fared less well again when asked to match the descriptions of these manoeuvres with their names and got only a third of those relating to shoulder dystocia right.


The value of mnemonics

Mnemonics are taught for good reason; they serve as a helpful prompt for the individual that is understood by the whole team, who can then quickly work together with a shared plan.  HELPERR isn’t the only shoulder dystocia mnemonic; proposals by midwives include Anderson’s (2007) version for use in home birth settings, Jones’ (2010) ‘Help! MR SPARE’, which took into account the all-fours position and Tully’s (2012) ‘FlipFLOP’.  None of these have achieved the same prominence as HELPERR, perhaps because of its association with the ALSO course, but it is also important to note that mnemonics aren’t necessarily meant to be taught as a stand-alone tool, rather as part of a wider learning experience.

As a learner and a teacher, I appreciate the value of mnemonics and am not about to suggest that we ditch them.  They have many advantages and I am also mindful of Jenkins’ (2014) recent comment that midwifery students felt daunted by the updated RCOG (2012) guideline and algorithm and found the HELPERR mnemonic more useful.  This observation doesn’t totally contradict Jan et al’s (2014) findings; students may particularly value tools such as the HELPERR mnemonic because it is really helpful to have frameworks when you are learning a subject.

Mnemonics can be highly valuable in other ways too.  I often engage midwives in a mnemonic creation activity designed to help think through what is essential in an emergency situation, and to highlight the fact that – as Anderson (2007), Jones (2010) and Tully (2012) all highlight – a midwifery-model mnemonic might look quite different from one rooted in a medical approach.  One reason for this is that a midwifery model approach will not begin with the assumption that the woman is on her back on a bed.  Also, as Lewis (2014) points out, manoeuvres might be differently interpreted by different groups: ‘As midwives, especially when working in the community, we would be more likely to get a woman into a deep squatting position, which is exactly the same as the McRobert’s manoeuvre, but does not require two additional members of the team to apply it’ (392).


Learning from within

Jan et al’s (2014) results made me wonder whether people would be more likely to remember their own mnemonics because they have been created from within rather than imposed from outside.  But would teamwork suffer if we were all remembering different mnemonics, or would it improve if we were able to follow our own learning styles and use a numbered list, a picture, or a re-worded pop song to help us recall the steps we needed to take when facing shoulder dystocia?  We could take the view that there is a fundamental disparity between the notion that we need shared tools and the fact that we all favour different ways of thinking and knowing, and/or we could dismiss this concern on the basis that such fundamentals are too important to experiment with.  We could acknowledge that mnemonics, like lots of other things, need a context in which to be truly effective, and/or we could see this as a debate which might further our thinking and increase the chances that midwives and others would remember what to do when faced with this scenario.

Some elements of Jan et al’s (2014) findings are reassuring.  Given a forced choice, I imagine most women would probably choose a midwife or doctor who knew what to do when they encountered a shoulder dystocia over one who could name the creators of the manoeuvres but not apply them in practice.  Most of Jan et al’s (2014) participants were in the former group, which may be why they concluded that teaching should focus on learning without relying on mnemonics and eponyms.  But I think this would be a shame for those who find these useful, and premature given the bigger picture.  That said, I am all for a debate about how we can reconcile the perceived need for universal and shared solutions with the fact that different people do have such different learning styles.



Lewis P (2014). Discourse on dystocia: A much needed professional dialogue. British Journal of Midwifery 22(6):390-392.

Jenkins L (2014). Managing shoulder dystocia: understanding and applying RCOG guidance. British Journal of Midwifery 22(5):318-324.

Jones L (2010). Help! MR SPARE: a new mnemonic for shoulder dystocia? Practising Midwife 13(7):36-38.

Prusova K, Tyler A, Churcher L and Lokugamage AU (2014).  Royal College of Obstetricians and Gynaecologists guidelines: How evidence-based are they?  1-6.  doi:10.3109/01443615.2014.920794

RCOG (2012). Shoulder dystocia (Green-top guideline 42). London: RCOG.

Tully G (2012). FlipFLOP: Four steps to remember. Midwifery Today (103):9-11.


P.S. If I was giving out awards for my favourite titles for research articles, a 2014 paper by Roehr et al would almost certainly be on my shortlist.  These researchers not only impressed me by managing to mention ABBA in the title of their paper, but for carrying out one of those research studies that might truly be helpful in practice. The gist of their findings is that, although more research is needed, ABBA’s ‘SOS’ was the only one of five songs that seemed to help practitioners co-ordinate chest compressions and inflations while attempting to resuscitate a doll.  Good news, because mnemonics and tricks like this are really helpful for some people. If you need a bit of practice and it’s been a while, here’s a link to SOS online!


Roehr CC; Schmlzer GM; Thio M; et al, (2014). How ABBA may help improve neonatal resuscitation training: Auditory prompts to enable coordination of manual inflations and chest compressions. Journal of Paediatrics and Child Health , vol 50, no 6, 2014, pp 444-448.

photo credit: P2720654 via photopin (license)

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