What Is Shoulder Dystocia? A potentially serious obstetric emergency involving shoulder delivery which should follow the head in the same contraction.,

INCIDENCE Approximately 0.5 – 1.5% “…this delivery complication will be experienced by roughly 20,000 women a year…” in USA with 4 million deliveries annually

Can shoulder dystocia be reliably predicted? Low positive predictive value High false positive rate ANTENATAL History Clinical pointers Ultra – sound INTRA – PARTUM Duration Augmentation Mode of delivery

RISK FACTORS/POINTERS Antenatal • Post-term pregnancy • High parity • Previous history of shoulder dystocia • Previous large babies • Maternal obesity (weight > 90kgs at delivery) • Maternal age over 35 years • Maternal diabetes and gestational diabetes • Excessive weight gain in pregnancy • Clinically large baby/symphysis-fundal height measurement larger than dates – • Fetal growth > 90th centile on ultrasound scan (Fetal macrosomia) (Coates 2003; Arulkumaran et al 2006) Intrapartum • Prolonged labour, notably protracted late first stage with a cervix that is loosely applied to the presenting part • Syntocinon augmentation • Prolonged second stage • Mid-pelvic instrumental delivery

Shoulder Dystocia Attorneys

Medico-Legal Issues Shoulder Dystocia involved brachial plexus injury is the second largest category of indemnity payments in the USA, after neurological damage from birth asphyxia. (Professional Insurance Association of America risk management data, 2005. )

“….A properly trained obstetrician will identify any shoulder dystocia risks and take steps to avoid injury during the delivery. Increased risks of shoulder dystocia are linked to high birth-weight babies, obese mothers, and a long second stage of labor. Shoulder dystocia can be prevented by scheduling a caesarean section for high-risk mothers, and if shoulder dystocia occurs during birth, sixteen different maneuvers can free the trapped shoulder, ensuring safe delivery. Shoulder dystocia is a serious situation, but does not have to result in injury. If a shoulder dystocia injury has occurred to you or a loved one, and you feel that the shoulder dystocia was improperly handled, you may wish to speak to a lawyer. Attorneys experienced in shoulder dystocia cases can help you understand your rights.”

Court Issues Could you have expected shoulder dystocia? Could you have chosen a safer mode of delivery? Were the parents informed of the risks ? At what level was the decision made ?

IS DYSTOCIA AVOIDABLE? BEING NON-PREDICTABLE IN MOST CASES IT IS UNAVOIDABLE THERE ARE STEPS WHICH IF TAKEN DIMINISH OR ELIMINATE MEDICO – LEGAL NEHGLIGENCE/INEFFICIENCY

The 2 claims generally made against obstetricians are: The obstetrician should have known or predicted that the risk of shoulder dystocia was high, and should have performed a cesarean section or at least offered the mother that choice. As the baby has a permanent brachial plexus injury, the obstetrician must have pulled too hard at delivery.

ON DIAGNOSING DYSTOCIA: CALL SENIOR HELP OR A SECOND CONSULTANT ENSURE MAXIMAL NECESSARY PERSONNEL AVAILABLE ENSURE PAEDIATRICIAN IMMEDIATELY AVAILABLE THE MANOEUVRES FATEFUL, ACCURATE DOCUMENTATION KEEP COMMUNICATION LINES OPEN WITH PARENTS

EPISIOTOMY McROBERTS SUPRAPUBIC PRESSURE MANOEUVRES IDEALLY 2 AND 3 APPLIED SIMULTANEOUSLY

PERSONNEL REQUIRED The delivering doctor or midwife A trained assistant familiar with McRoberts maneuver and suprapubic pressure A third person to assist the McRobert’s manoeuvre by flexing one of the mother’s thighs

EPISIOTOMY OBSTRUCTIONIS AT THE SYMPHYSIS PUBIS EPISIOTOMY ONLY USEFUL IF THE POSTERIOR SHOULDER IS BEING DELIVERED AND POSTERIOR VAGINAL SPACE IS REQUIRED FOR YOUR HAND OTHERWISE EPISIOTOMY IS UNNECESSARY NO MATTER WHAT BOOKS SAY

MCROBERT’S MANOEUVRE Place the woman flat with her legs slightly abducted and hyperflexed at 45 degrees to her abdomen – this position will rotate the angle of the symphysis pubis superiorly, helps flatten the sacral promontory, increase the diameter of the pelvic outlet and release pressure on the anterior shoulder. The manoeuvre is associated with the lowest level of morbidity (Coates 2003

FUNDAL PRESSURE Fundal pressure, only further jams the stuck shoulder against the maternal pubic bone. It may also injure the fetus or even rupture the uterus. Fundal pressure is often cited in court as a definite standard of care violation.

Documentation The best defense is thoughtful, articulate and timely documentation of each decision made in the course of treatment. Poor documentation even of correct action Is a serious flaw Retraction/negation/correction of documentation is a serious defence drawback

Minimal Documentation When and how shoulder dystocia was diagnosed which shoulder was anterior and which was posterior quantification of the force applied initially and in subsequent traction attempts, using terms such as “mild,” “moderate,” or “significant” duration of attempts to resolve the dystocia maneuvers performed approximate length of time each maneuver was tried condition of the baby at delivery, including Apgar scores, a description of all injuries and bruises, and cord pH, if obtained time from delivery of the fetal head to delivery of the body documentation of the discussion with the patient following delivery

…Years into your law suit, you have to convince the court that you made appropriate prenatal judgments and were aware of risk factors informed the mother of such risk factors when they are significant provided proper obstetrical care documented in the medical record that you knew what you were doing and did it correctly