What is Shoulder Dystocia
According to the Royal College of Obstetricians and Gynocologists (RCOG) guide for mothers – the best description of shoulder dystocia is: “…when the baby’s head has been born but one of the shoulders becomes stuck behind the mother’s pubic bone, delaying the birth of the baby’s body…”
If this happens, extra help is usually needed to release the baby’s shoulder. In the majority of cases, the baby will be born promptly and safely…” While shoulder dystocia only affects approximately one in 150 (0.7%) vaginal births, the difficulty in predicting or preventing it makes rapid decision making on the spot and appropriate responses essential. From a lawyers perspective, negligence in the managment of shoulder dystocia is rarely (but sometimes) going to be a fruitful ground for negligence. The real issues lie in the prevention of the condition and any failures associated with lack of proper planning for it in the face of obvious risk factors.
However, the injuries caused by shoulder dystocia can have long-term effects for the baby in particular, and sometimes this can be the result of a negligent delivery, delay in reaching the right conculuson on the facts and often incorrect or inappropriate methodology.
Can Shoulder Dystocia be Predicted?
Again according RCOG, yes it can: they do go on to say in most cases it is unexpected but that is the catch, should it be expected, there are predictive factors and in fact they are fundamentally clear about this: “…it is more likely to occur if:
• you have had shoulder dystocia before
• you have diabetes
• your body mass index (BMI) is 30 or more
• your labour is induced
• you have a long labour
• you have an assisted vaginal birth (forceps or ventouse).
Shoulder dystocia is more likely with large babies but nevertheless there is no difficulty delivering the shoulders in the majority of babies over 4.5kg (10 lb). Half of all instances of shoulder dystocia occur in babies weighing less than 4kg (about 9lb). Ultrasound scans are not good at telling whether you are likely to have a large baby and therefore they are not recommended for predicting shoulder dystocia, if you have no other risk factors…” The issue is typically one of maternal size v fetal size. Ultimately a 60kg women of primagravida and of small frame is going to struggle much more with a 4kg baby than a 90 kg mum of 3 who is built like a – ahem, a 90kg mum of three!
Can Shoulder Dystocia be Prevented?
A very good question, ultimately though, that really depends on when the quesiton is being posed. If there are no risk profile / factors that make the presence of dystocia likley then there are no reasons to plan for it. It has to be accepted that in many cases, dystocia simply just happens and it happens without warning or reason. It is possible that this is an evolutionary hiccup in human development but the studies go on. If however, the question is being posed in the presence of risk factors then that is quite a different story.
The emerging situation across the developed world is that ceasarean section is not the risk filled procedure it used to be and in fact in many cases it presents a much more stable and safe route for delivery. That being the case, planning for a ceasarean is something that every mother with a potential risk factor needs to be consulted on. That consultation should not be a biased one and should enable mum to be to come to terms (and to a conclusuion) over the delivery method by herself.
In a relatively “recent” study published on pubmed (Cesarean section on request at 39 weeks: impact on shoulder dystocia, fetal trauma, neonatal encephalopathy, and intrauterine fetal demise 06 ,Gary D V Hankins 1, Shannon M Clark, Mary B Munn ) The conclusions of the researchers were that “…It is reasonable to inform the pregnant woman of the risk of each of the above categories, in addition to counseling her regarding the potential risks of a cesarean section for the current and any subsequent pregnancies. The clinician’s role should be to provide the best evidence-based counseling possible to the pregnant woman and to respect her autonomy and decision-making capabilities when considering route of delivery…” It is very difficult to argue with that in the light of several very well publicised medical negligence cases in the English jurisdiciton (Montgomery v Lanarkshire anyone?). Arguably, it would seem that the study bore no overall conclusion on best practice only “reasonable practice” but compare that the to the work of the RCOG Green top guidelines and you will see the rather unequivical “Elective ceasarean section should be considered to reduce the potential morbidity for pregnancies complicated by pre existing or gestational diabetes with a estimated fetal weight of greater than 4.5kg…” Whilst that is clearly an indication of those mothers with type 2 or gestational diabeties, it is, as mentioned previously, the fetal size and wieght relative to the mother that is important and here there can be no doubt, 4.5kg is an arbitary figure and the matter of large (relatively) fetal development for age is the primary reasoning for a discussion on normal vaginal birth v ceasarean. It would be a brave mother in the presence of the risks to opt for NVB in such a situation.
Can Shoulder Dystocia be Managed Then?
It certainly seems as though there are things that should be done: The McRoberts Manoeuvre – this is when the thighs of the mother are pushed outward and towards their chest (not just knees to chest as some guides suggest), in order to assit with the widening of the the pelvic gap. It essentially increases the potential for baby to exit without impact on the pubic bone. The RCOG guidance is that this manouvre should be applied first and can be enhanced by suprapubic pressure. Which is essentially pressing down on the lower abdomen and/or sometimes placing hands on or above the pubic bone and pushing the shoulder of the baby from one side to the other (not for the inexperienced).
Next on the list is probably the Gaskin Manoeuvre – the mother is asked to position herself on all fours with an arched back, as this will, it is suggested, widen the pelvic gap (not the pelvis) . Gaskin is regularly reffered to in difficult labour but in shoulder dystocia births it can be difficult and uncomfortable for mother to repositon and frequently now it is being bypassed.
Episiotomy, it is worth stating at the outset that not all dystocia births will require an episiotomy however, where they are – an incision may be made to the perineuam to enlarge the vaginal opening or in some cases to avoid an uncontrolled tearing. The rule of episiotomy (according to a OBGYN who I used as a medico-legal expert) is do not half do it. In other words, if you are going to start slicing up someones perineum then do a proper job otherwise you are simply inviting further tearing (sounds rational). Although figuring out where a poorly sutured episiotomy ends and uncessary or avoidable tearing begins is not a job for any courtroom. Lawyers note, poor suturing technique is easily mentioned and hard to prove. The pernineum is not an easily accessable area and does not lend itself to neat stitching.
Instrumental delivery via forceps or vontuse devices is typically the last tick on the list however, sheer force and / or instrumental assistance can often exacerbate the positon – emergency surgery may be required.
What Does Shoulder Dystocia Cause by Way of Injury?
It is difficult to find good figures for it but in the region of 10% of births which suffer a shoulder dystocia to some degree also see the baby receive a degree of brachial plexus injury (BPI). BPI occours when the delicate bundle of nerve fibres linking the neck and shoulder are stretched and permanently damaged. The result can be anything from a mildly underveloped (yet serviceable hand and arm) all the way to a limb that is funcitionally nil. Think Kaiser Willhelm (Kaiser Bill of WW1 fame) the probable reason why he had his arm tucked into his coat was because of a birth injury a contempory account makes for interesting reading – It seems that William was in breech position at birth and was “…manipulated by several physicians and a midwife during delivery. Apparently the baby was not breathing when it emerged, but by “continuous rubbing . . . dousing in a hot bath, and a series of short, sharp slaps on his buttocks” the doctors managed to get the child to breathe…” The third day after delivery the midwife noticed that William’s left arm was slack. It was thought that the arm had been “wrenched out of the socket” and some of the muscle tissue torn. Most likely, William suffered a brachial plexus injury. A bad start for Queen Victoria’s grandchild.
Erb’s Palsy figures high on the list of shoulder dystocia related conditions. This occurs when the nerves in the upper arm and shoulder area are stretched resulting in reduced arm function and potentially total paralysis of the shoulder. This can be permanent and I looked but could not find figures for the split. In most reported cases though, it would seem that surgical and therepautic input is pretty effective. Permanent disability though does occour and I suppose like so many nerve related injuries it is realistically down to the likelihood on assessment of even more damage occouring if surgery is attempted. Watch this space and I will update frequently.
Fractures, I met once a Consultant Gynae who had a striking way of speaking about his colleagues who thought that the occaisional fracture in a fetal limb was an acceptable risk of practice. He said and I directly qoute “I would cut off one of thier own childrens fingers for each occourance”. Opinions differ, however, no parent is going to be impressed with the delivery of a child with a fractured limb and fewer still will be “reassured” by the comment “it will heal nicely”.
Next on the list of dangers is Oxygen starvation or as you will no doubt have gleaned in your practice thus far “hypoxic injury” . These episodes of hypoxic insult are usually caused while the fetus is impatiently waiting in the birth canal while the team outside consider the options. In moderate to severe cases, this is going to mean permanent brain damage and often, fetal death. This article is already too long for most lawyers (who have likely only reached this far by skipping) so there is little sense addressing the cirumsstances of hypoxic or ischemic injury here. That will wait for an other article for now though. Be aware, the longer the clock ticks on the delivery, the more likely the fetus is going to present with the signs of ischemic / hypoxic injury and the more likely it is to need urgent transfer to SCBU.
Aside fromt the already addressed issues of Vaginal Tearing and the complicaitonso fo repair there is also tPostpartum haemorrhage (heavier bleeding during and following birth, which may require surgery or a blood transfusion). Typically this can go unnoticed and cases abound of non diagnosis followed by emergency follow up. Negligent discharge from care is difficutl in such cases but the facts determine.
In conclusion, every incident is going to be different and many such deliveries are rescued by ultra pro Midwives or OBGYN. Where injury does occour it is on a spectrum of seemingly infinite range and complexity.
Regrettably it has been over 20 years since I saw my first case of Shoulder Dystocia and I see that they still are making good headlines for the newspapers. It is not for one such as me to comment but ultimately the cost to the NHS and the taxpayer is large. It would seem that research in the area is making minimal progress and the harm huge. We can only hope that innovations are on route.