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SHOULDER DYSTOCIA: MINIMIZING MALPRACTICE RISK
SD is an unpredictable high-stress medical situation for which there is no uniformly helpful protocol. In addition, some ob/gyn doctors define SD’s occurrence when basic maneuvers are required; others call it SD when more difficult measures are required. All ob/gyns frequently encounter these situations so strict definitions are somewhat arbitrary. Most ob/gyns have encountered many a case of significant shoulder dystocia where there are absolutely no risk factors. There are various guidelines that are for handling such deliveries well-known to the practicing ob/gyn including ACOG educational bulletins on the subject. Despite studies dating back over thirty years that attempted to define reliable predictors of SD, there are no management protocols that, if followed, will consistently prevent SD-related brachial plexus injury. For example, the most recent ACOG practice bulletin states, “shoulder dystocia is most often unpredictable and unpreventable…. In each case, risk factors can be identified, but their predictive value is not high enough to be useful in a clinical setting.”
To minimize the risk of a SD related injury claim, the medical record should contain evidence that the physician (or nurse midwife) has addressed known risk factors for shoulder dystocia during antepartum care. Such factors should include at least the following checklist:
- Screening for gestational diabetes.
- Method of testing maternal glucose levels from the onset of diagnosis of GDM.
- Evidence that unsatisfactory glucose control is addressed (e.g. Hgb A1C in cases of poor monitoring, and compliance.)
- In any case of prior SD, an informed consent discussion describing the risks and benefits of vaginal birth in the current pregnancy. This discussion should be documented in the patient’s medical record.
- Liberal use of ultrasound (despite its own limitations) in situations where macrosomia is suspected or more likely e.g. non-compliant gestational diabetic patient.
Whenever fetal weight (by clinical assessment or ultrasound) is estimated 4500 grams in patients with GDM, or 5000 grams in non-GDM patients, cesarean section is desirable (although there are circumstances that justify a different approach). In addition, whenever the mother’s prior obstetrical history includes a SD of any degree, cesarean section is an acceptable form of delivery. When any shoulder dystocia occurs in one delivery, inform the patient that she should make specific mention of this fact during her enrollment visit at any subsequent pregnancy. As with all patients with prior SD deliveries, discuss the SD risks and alternatives considering that some patients with very mild shoulder dystocia may choose to have a subsequent cesarean section if offered. Please note that the combination of history of shoulder dystocia and unattended midwife delivery of the subsequent pregnancy is problematic and should be avoided. Good documentation of discussion of SD risks and delivery options provides a written record of patient awareness and your actions which are important to defend you in a legal action.
In addition, the intrapartum record should reflect that the following suggested checklist is followed:
- Before undertaking vaginal delivery note that the pelvis seems clinically adequate.
- In cases of prolonged second stage labor the physician should evaluate and note that the risk for SD is low.
- When SD is encountered, document:
- Which shoulder is anterior.
- The time of onset of SD and the time the impacted shoulder delivered (perception of “frantic” or “chaotic” not favorable).
- Clear detailed description of the maneuvers employed to dislodge the shoulder (suprapubic pressure, McRobert’s, direct fetal manipulation, such as Rubin, rotational maneuvers or delivery of posterior arm). Dictated note is desirable; legible and detailed more important.
- That the traction force did not exceed the quality used in your standard procedure for non-SD deliveries.
- If dystocia was anticipated, whether pediatric support was or was not requested.
- Suprapubic pressure by experienced nurse. Do not use or make mistake of stating “fundal pressure” when you mean suprapubic pressure. As you know, fundal pressure is frowned upon although it might be used in clinical practice in appropriate situations. It is possible to worsen the dystocia by use of fundal pressure.
- Whether episiotomy is done. There is no consistent evidence that an episiotomy is needed, although it does help in certain situations; this is a judgment call. If no episiotomy is done, it may be reassuring to state your reason. (e.g. that the patient’s body habitus or introitus would negate the effectiveness of an episiotomy as in the markedly obese patient with large buttocks that obliterate or extend pas the introitus.)
- If usual measures are exhausted and the physician suspects that brain damage is imminent, it is reasonable to so state and proceed to deliver using whatever measures seem appropriate at the time.
For your consideration, a website www.shoulderdystociainfo.com, published by a practicing ob/gyn doctor in the mid-Atlantic area, provides a useful review and summary of the dilemma as well as extensive literature on the subject.
The risk management advice presented in this Site is intended as general information of interest to physicians and other healthcare professionals. The recommendations and advice published on this Site do not reflect or establish a standard of care and do not establish rules for the practice of medicine. The publication of this information is not intended as an offer to insure such conditions or exposures, or to indicate that MAG Mutual Insurance Company will underwrite such risks for the reader. Our liability is limited to the specific written terms and conditions of actual insurance policies issued.
