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Shoulder Dystocia OBG_0806_Lerner.Final 7/21/06 9:46 AM Page 56 OBGMANAGEMENT Henry M. Lerner, MD Clinical Instructor in Obstetrics and Gynecology, Harvard Medical School Newton-Wellesley Hospital Newton, Mass Labor and delivery nurses should know when and how to perform the McRoberts maneuver and apply suprapubic pressure. These meas- ® ures often resolve the dystocia by flat- Dowden Health Media tening the sacrum and altering the angle between the pubic bone and the baby’s anterior shoulder. Family Copyright members can assist, contrary to For personal use only plaintiff attorneys’ contentions. IN THIS ARTICLE Shoulder dystocia: What is ❙ Is your team prepared? the legal standard of care? 4 standards of care Page 61 It’s your job to educate the jury that, even in the best of hands, permanent brachial plexus injuries can occur ❙ The traction reaction: Why plaintiffs focus on “force” o matter how excellent the care you textbook perfection. Lawsuits involving Page 62 provide, you have good reason to brachial plexus injuries following shoulder Nworry about shoulder dystocia. It is dystocia are now the second most common Visit our Web site for: one of the most difficult and frightening com- type of lawsuit in obstetrics, exceeded only ❙ Shoulder dystocia plications, and is essentially unpredictable by those due to neurologic damage from and unpreventable. It can happen even in birth asphyxia.1 Brachial plexus injury is documentation form apparently routine deliveries, and can cause often difficult to defend in court and results www.obgmanagement.com permanent injury to the child despite the best in scores of millions of dollars in damages possible care by experienced obstetricians. each year. The plaintiff is usually a lovely IMAGE: If permanent injury occurs after shoul- child with an obvious and permanent injury, RICH der dystocia, it can also trigger a lawsuit and the defense is typically an undocument- LaROCCO that can last for years and end in a large jury ed claim that the obstetrician applied no verdict—even if you handled the case with undue force at delivery. 56 OBG MANAGEMENT • August 2006 For mass reproduction, content licensing and permissions contact Dowden Health Media. OBG_0806_Lerner.Final 7/21/06 9:46 AM Page 57 Given the difficulties of knowing when TABLE shoulder dystocia will occur, how best to How fetal weight affects the rate of dystocia resolve it, and whether a claim is likely, how can we prepare for this event? What is ESTIMATED RATE OF SHOULDER DYSTOCIA (%) FETAL WEIGHT NONDIABETIC MOTHERS DIABETIC MOTHERS the accepted standard of care? This article <4,000 g answers these questions by surveying the 1.1 3.7 evidence on these aspects of management: 4,000–4,499 g 10 23.1 • risk factors for shoulder dystocia >5,000 g 22.6 50 • how to choose mode of delivery Source: Acker D et al2 • specific labor-management practices • the 4 most widely used maneuvers to resolve shoulder dystocia to the due date to prevent a baby from • what information the documentation becoming “too big” has been shown in should include. many studies to be ineffective in lowering the shoulder dystocia rate.16–18 No single “standard of care” In many states, the term “standard of care” Risk factors are not clinically useful has a specific legal meaning, but in most of The American College of Obstetricians and the United States—and to most physi- Gynecologists (ACOG) and Williams cians—the term means care that would be Obstetrics concur that risk factors for rendered by the majority of well-trained shoulder dystocia cannot be applied in a individuals. Complicating this definition is clinically useful way to prevent brachial the fact that medicine often offers no single plexus injury. As the ACOG practice bul- “right way.” Thus, it may be more appro- letin on shoulder dystocia19 observes: priate to speak of “standards of care”: the • “Shoulder dystocia cannot be predicted range of therapeutic choices a reasonable or prevented because accurate methods practitioner might decide to use. for identifying which fetuses will expe- rience this complication do not exist.” • “Elective induction of labor or elec- FAST TRACK ❚ Why dystocia cannot tive cesarean delivery for all women Women suspected of carrying a fetus with be predicted macrosomia is not appropriate.” with gestational …despite known risk factors diabetes and/or The risk of shoulder dystocia is higher in Identify highest risk a macrosomic 2–5 women with diabetes, a macrosomic Nevertheless, there are generally accepted fetus are at highest fetus,2,6–8 obesity,5,8 or a previous shoulder guidelines for attempting to ascertain dystocia.9–11 The problem: The predictive which patients are at the absolute highest risk for shoulder value of these factors is so low and their risk for shoulder dystocia: dystocia false-positive rate so high they cannot be • Any woman with gestational diabetes. used reliably in clinical decision-making.11–13 For any given week of gestation in the third trimester, the ratio of thorax and Prevention is impossible shoulder size to head volume is larger in Even if prediction were possible, the only babies of diabetic mothers.20 Thus, in preventive option is elective cesarean sec- these women, it is important to estimate tion. After all, this is the only intervention fetal weight near term to determine that might potentially avoid the infrequent whether a trial of vaginal delivery makes but dreaded outcomes of asphyxia and per- sense. manent brachial plexus injury. But as the • If, for any reason, the fetus appears to be literature shows, even this is not an larger than average. Indications of size absolute guarantee.14,15 Moreover, the strat- may come from palpation of the maternal egy of inducing labor several weeks prior abdomen, fundal height measurements www.obgmanagement.com August 2006 • OBG MANAGEMENT 57 OBG_0806_Lerner.Final 7/21/06 9:46 AM Page 58 ▲ Shoulder dystocia: What is the legal standard of care? significantly greater than dates, ultrasound centage of even these high-risk patients estimation of large fetal weight, or mater- will have a shoulder dystocia that results in nal perception. In these cases, ultrasound a permanent brachial plexus injury? The imaging is advisable near term to estimate answer: Permanent injury is rare, even in fetal weight. This estimate can be factored highest-risk cases. into the selection of delivery mode. Only 10% to 20% of infants born after shoulder dystocia suffer brachial How big is “too big”? plexus injuries.16,21–23 Of these, only 10% There are 2 problems with using estimates to 15% are permanently injured.5,24,25 of fetal weight in determining mothers and Thus, even in women at highest risk, the babies at highest risk: odds of having an infant with permanent • How is “too big” defined? brachial plexus injury are roughly 1 in • What action should one take if a baby 450.14 In women at lower risk for shoulder is thought to be “too big”? dystocia, the odds of permanent brachial The rate of shoulder dystocia increases plexus injury are much lower: somewhere with the size of the fetus (TABLE). ACOG between 1 in 2,500 and 1 in 10,000. defines macrosomia in the context of shoulder dystocia as a fetal weight exceed- When is cesarean section ing 5,000 g in a nondiabetic woman and warranted? 4,500 g in a diabetic woman.19 In deciding the answer to this question, the As for what to do if a fetus is estimat- obstetrician must consider that cesarean ed to be in this size range, ACOG states: section is not without its own risks: exces- “Planned cesarean delivery to prevent sive bleeding, infection, injury to bowel or shoulder dystocia may be considered bladder, deep venous thrombosis, and the [emphasis added] for suspected fetal need for hysterectomy. macrosomia within the above weight These adverse events occur much more parameters.”19 The decision as to whether frequently than does permanent brachial to recommend or perform a cesarean sec- plexus injury.26 And the risks are higher yet FAST TRACK tion in these circumstances is intentionally for the very same patients at greatest risk Even in women left up to the physician and the patient. for shoulder dystocia—diabetic and obese The problem, of course, is that all our data women. at highest risk, are from measurements of babies after the odds of having delivery—information obstetricians do not Prevent “I didn’t know” accusations an infant with have at the time they must decide on the This is the point at which the patient’s permanent brachial mode of delivery. input becomes vital. It is important to con- vey to her in readily understandable terms plexus injury are the risks—to both her and her child—of roughly 1 in 450 ❚ Choosing a mode cesarean section versus attempted vaginal delivery. Plaintiff attorneys often claim of delivery: Not so simple that, had their client known there was a 1 The obstetrician must determine whether in 450 chance of her baby having a perma- the risk of shoulder dystocia is high enough nent injury, she would have opted for to outweigh the risks to a mother of elective cesarean section. The truth of this claim is, cesarean section. This is far from simple. of course, open to question. However, Although it is true that women at the high- from a medicolegal perspective, it is est risk for dystocia—those with gestation- extremely important that the woman be al diabetes and suspected macrosomia— informed of the degree of risk to herself have a risk for shoulder dystocia and her baby so that her decision is truly somewhere between 25% and 50%, this is informed—even if it is not the choice the not the main concern.
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