Obstetric Liability Risk: Shoulder Dystocia
Shoulder dystocia is an obstetric medical emergency that places the pregnant mother and baby at risk for temporary or permanent injury. Most doctors or health care providers are not familiar with shoulder dystocia due to its unpredictability and rare occurrence. The reported incidence of brachial plexus injuries is between 4-40 percent. Permanent damage is found only in 9 to 25 percent of those injuries. The best way for a physician to avoid the risk of obstetrical negligence due to shoulder dystocia is to follow an applicable standard of care by predicting certain risk factors - and ultimately avoid the complication all together. Risk factors include an oversized fetus (macrosomia), maternal diabetes, and obesity. Also pregnant women with gestational diabetes have a greater chance of having a baby with shoulder dystocia. Risk factors or not, a plan is in order to provide obstetric assistance and ask the mother to stop pushing once shoulder dystocia is diagnosed at delivery.
Additionally, any further attempts at vigorous downward traction should stop and no fundal pressure should be applied because it increases the potential for a brachial plexus injury. The goal of the physician at this point is to free the impacted shoulder quickly as a fetus may only endure up to 8 to 10 minutes of asphyxia before permanent neurological injury occurs. The standard of care demands that the physician know and use certain maneuvers that will relieve shoulder dystocia
No maneuvers have been shown to prevent all injuries. The one maneuver known to be effective is the McRoberts maneuver with flexion and slight rotation of the maternal hips onto the maternal abdomen. This maneuver is considered the current recommendation for relieving shoulder dystocia. One important recommendation that is sometimes overlooked by physicians is thorough documentation of the entire pregnancy, especially the delivery. Proper documentation shows the standard of care used, the maneuvers used, and whether or not risk factors were present. Good record keeping leads to better obstetrical management, which in turn leads to a decrease in the severity of brachial plexus injuries and thereby reduces the potential for medico-legal action.
There can be many legal defenses utilized in litigation for shoulder dystocia cases. The most important argument lies in whether the delivering physician caused the brachial plexus injury. Recently, it has been reported that perhaps labor itself, position of the fetus during labor, uterine anomalies, or increased intrauterine pressures during labor with a uterine abnormality might all predispose to brachial injury.
Source: Department of Obstetrics and Gynecology at the University of Washington School of Medicine:
http://209.85.165.104/search?q=cache:1W3qJIdiO4YJ:www.afip.org/Departments/legalmed/legmed2000/articles/shoulder.pdf+engineering+perspective+on+shoulder+dystocia&hl=en&ct=clnk&cd=1&gl=us
