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Severe Shoulder Dystocia: 5 Minutes of Sheer Terror?

Ronald T. Burkman, MD; Jennifer L. Fennell, Esq

Specific suggestions for avoiding bad patient outcomes and subsequent legal actions associated with a delivery complicated by shoulder dystocia are presented in this hypothetical scenario.

You are covering for another clinician in addition to attending to your own practice. It has been a busy night so far. At 2 AM, a multiparous patient from the other clinician’s practice presents in active labor at 39 weeks. She was placed on glyburide for her gestational diabetes. There is no information in the prenatal record regarding recent estimates of fetal size or counseling relative to the delivery. She is obese, and you determine that the infant seems large, but she had previously delivered an 8½-lb infant without problems. Since you are busy, you very briefly document her history but do not comment on the infant’s weight.

The patient progresses to full dilation by 5 AM. She pushes well, and after 15 minutes the head is at +2 station. A nurse tells you another very active patient is coming to the floor. You elect to apply forceps and deliver the infant’s head. It immediately retracts against the mother’s buttocks. The nurse who is working with you is a recent graduate who just finished orientation. Somewhat clumsily, she and the patient’s husband attempt a McRoberts maneuver while shouting at the patient to push. The maneuver doesn’t work, and you tell the nurse to apply suprapubic pressure, which she does leaning over the bed and pushing straight down over the symphysis. This does not result in delivery.

The husband continues to exhort his wife to push while you attempt a Woods maneuver, recognizing that in all your prior cases of shoulder dystocia you only needed to perform a McRoberts maneuver and apply suprapubic pressure to deliver the infant. Sensing that time is flying by, you use forceful downward traction to ultimately deliver the anterior shoulder and the rest of the infant, who weighs nearly 10 lb. You mumble to the family that it was a tough delivery and rush off to see the next patient. Your delivery note is very brief with little discussion of the operative delivery or release maneuvers, a statement that the head-to-shoulder delivery time was about 1 minute, and that gentle traction was used; you don’t see the patient again since you go off duty at 8 AM.

Later you find out that the infant suffered a brachial plexus injury which did not resolve. A lawsuit is brought against you and the hospital. During a subsequent review of the chart, you notice the nurse’s note states there was fundal pressure, not suprapubic pressure, and that the delivery took 5 minutes, not 1 minute. At deposition she testifies that there appeared to be a lot of traction on the baby. The case settles out of court for more than $1 million.

DISCUSSION

Several problems contributed to the legal outcome in this hypothetical scenario. Certainly it is rare to have all of these factors come into play in a single case, but we each may have seen one or more present in cases of our own or ones we have reviewed. The issues that arise here can be divided into 4 categories: risk factors, management, documentation, and counseling.

Risk Factors

Although a significant percentage of shoulder dystocias occur in the absence of risk factors, there are several interrelated risk factors that should have gotten the attention of both the patient’s obstetrician and the covering obstetrician. The possibility of macrosomia (estimated fetal weight of 4,500 g) should have been considered, given her prior delivery and the presence of diabetes and obesity. Estimating fetal weight is difficult in the late third trimester with obese patients. Although many resort to ultrasound, clinicians should keep in mind that the precision of ultrasound estimates at this time is roughly ±10%. Thus, an ultrasound estimate of 4,000 g is likely to result in the newborn’s weight ranging from 3,600 to 4,400 g. In addition, because infants of diabetic women tend to put more weight on their trunks than infants of nondiabetic women, the possibility of shoulder dystocia is increased. Offering a cesarean delivery to a woman with diabetes whose infant could be 4,500 g is reasonable, but it was not done in this case, nor was the presence of the risk factors acknowledged.

Management

The performance of an operative delivery, another known risk factor, in this case without an appropriate indication and without documenting the estimated fetal weight, clearly was problematic. As noted in ACOG liability surveys, the concomitant use of forceps or a vacuum device in cases of shoulder dystocia associated with fetal injury is often cited as an important factor in awards decided by a jury. Despite the presence of risk factors for shoulder dystocia, the obstetrical team was ill-prepared to manage the complication. The new nurse had inadequate training in the performance of the McRoberts maneuver. Suprapubic pressure was ineffective because the nurse did not elevate herself above the patient by either lowering the bed or standing on a chair, and the clinician did not indicate the direction for the pressure to be applied. Because of fatigue and not having managed difficult shoulder dystocias previously, the clinician panicked and resorted to excessive traction. The team did not call for help. Further, the patient’s husband was not well advised, in that he continued to urge the patient to push at a time when it was contraindicated. This likely led to further impaction of the anterior shoulder and guaranteed that attempting to rotate the shoulders with the Woods maneuver would fail. Finally, it is clear that a combination of sleep deprivation and multiple active patients interfered with the clinician’s ability to think carefully about the issues of concern with this patient.

Obviously, there is no guarantee that every resident in training will observe or participate in a case of severe shoulder dystocia. However, this shortcoming, the inexperience of other staff, and the need to work as a team can be improved through the use of repetitive training and simulation. Such simulations can be accomplished using fairly simple models. Published data show that training through simulation improves the management of patients and patient outcomes. In addition, a protocol should be established for the management of such cases, including an algorithm for the release maneuvers, instructions as to when to call for help, and how and when to document the case. The use of debriefing after each case allows the group to determine what went well and what needs improvement.

Documentation

The documentation in this case was cursory at best. Risk factors were not acknowledged, and the delivery note was inadequate in describing the rationale for an operative delivery and whether the necessary criteria were met. The release maneuvers were not well described. There was no discussion with the nurse during or after the case to be sure the team agreed on the timing related to the complication and the maneuvers employed, to ensure accuracy and prevent discrepancies in chart entries. The entry describing “fundal pressure” was extremely damaging for the defense of this case. Finally, the status of the infant was not commented upon, nor was any counseling of the patient documented.

Many institutions have developed forms or checklists specifically for shoulder dystocia cases to ensure key items are considered and documented, such as estimated fetal weight, presence or absence of diabetes, indications for operative delivery or oxytocin, release maneuvers employed and in what order, which shoulder was anterior, the head-to-shoulder delivery time, infant status, people present at the delivery, and patient counseling. In the case of a difficult shoulder dystocia, the health care team should employ maneuvers necessary to save the baby’s life, and then document those maneuvers as such. The use of phrases with adjectives such as “gentle traction” could be interpreted at a subsequent legal proceeding as an attempt to downplay inappropriate management. The team should also discuss the case after the delivery both to debrief and to ensure the documentation is accurate and consistent.

Counseling

It is important to discuss what occurred with the family immediately after the case, pointing out that the baby’s life was at stake. If evidence of poor arm movement is noted, one still can be cautiously optimistic with the family, since most of these injuries will resolve over time. Most parents are unable to immediately process all the events related to the delivery, so counseling should be repeated in more depth later, carefully coordinating with the pediatrician as to the baby’s condition. Even if a serious complication occurs, patients have a more favorable attitude toward the clinician if the situation is explained to them in depth and they are shown some degree of empathy.

Summary

Shoulder dystocia cannot always be prevented, but steps can be taken to reduce the likelihood of a severe case and improve overall management. Even if a case results in a permanent injury and a lawsuit is filed, following these suggestions will make the management far more defensible.

Dr Burkman reports that he helped develop with Veritech Corporation a CD-ROM regarding the epidemiology, management, documentation, and release maneuvers related to shoulder dystocia. Ms Fennell reports no actual or potential conflict of interest in relation to this article.

Ronald T. Burkman, MD, is Professor, Division of General Obstetrics and Gynecology, Baystate Medical Center, Springfield, MA; Professor, Department of Obstetrics and Gynecology, Tufts University School of Medicine, Boston, MA; and Editor-in-Chief, The Female Patient. Jennifer L. Fennell, Esq, is Attorney, Law Offices of William J. Fennell, PC, West Springfield, MA.