Practice of Medicine
Communication Breakdown Contributes to Shoulder Dystocia Claim
When presented with a pregnant patient, it is important for physicians to follow the agreed-upon delivery arrangements and effectively communicate when changes are necessary to all relevant staff. Verbal handoffs and verbal orders increase the potential for errors and miscommunication.
- Ensure that a physician is immediately available or present during a delivery.
- Use collaborative practice agreements and ensure that all midlevel staff follow the protocols as written.
- Ensure that a physician is primarily available and responsible for high-risk deliveries.
A 29-year-old female patient (G2, P1) presented with a history of shoulder dystocia in her first delivery. Her estimated delivery date (EDD) was April 24. At her next prenatal visit on April 5, she was seen by a certified nurse midwife (CNM). At that time, the patient weighed 226 pounds and the clinical assessment estimated the fetal weight to be over 8 pounds.
The patient was admitted on April 13 at 6 a.m. for Pitocin induction. The attending obstetrician (Dr. A) examined her at 8 a.m. then turned the induction over to the CNM and left the hospital.
At 11:30 a.m., Dr. A signed out to his partner, Dr. B, due to a family emergency. Dr. A allegedly asked Dr. B to cover the call from 2 p.m. until he returned the next morning. However, Dr. A did not advise the patient, CNM or hospital nursing staff of his emergency. In contrast, Dr. B claims that Dr. A asked that he assume the call coverage only at 4 p.m., so Dr. B left the hospital to go to a previous social commitment.
The patient's labor progressed uneventfully until 2:05 p.m. when she began pushing and the CNM noted shoulder dystocia. The CNM attempted to contact Dr. A but the doctor didn't respond to cell phone calls or return pages. The CNM then made three attempts to turn the baby, and finally delivered the posterior arm by reaching under the axilla and sweeping the arm over the chest.
The baby delivered rapidly after this maneuver. The female infant weighed 9 pounds 10 ounces. The shoulder dystocia complication caused severe Erb's Palsy. Documentation confirmed that the patient intended the CNM to deliver the baby, but she had specifically requested that Dr. A be immediately available since she had a shoulder dystocia history.
Commentary and Advice
Dr. A failed to comply with delivery arrangements given the fact that the patient was high risk for shoulder dystocia. If a physician promises to be present during the delivery or immediately available, then either that physician or another should be present. Since this patient was high risk, the physician should have been primarily responsible for her delivery, not the CNM.
Verbal handoffs and orders increase the potential for miscommunication and errors. The doctors differed on whether call was to begin at 2 p.m. or 4 p.m. A change in call status should be communicated to both staff and the hospital to ensure that a physician can be reached.
Midlevel staff supervision
The supervising physician must utilize collaborative practice agreements, monitor the midlevel staff for competency and ensure that the midlevel staff follows protocols as written.
Midlevel staff compliance
The CNM needs to follow the agreed treatment plan, call and update the attending during the induction and document the telephone calls in the medical record. When the CNM encountered the problem, she attempted to contact the attending physician and decided to attempt delivery without placing a stat page for any physician in the hospital to come to the delivery.
This case settled for a substantial amount.
General Strategies with Shoulder Dystocia
- Reducing clinical risks: Assess pre-labor risk of shoulder dystocia including maternal diabetes (and diabetes screen), estimate fetal weight over 9 pounds (confirmed by exam and ultrasound), maternal weight and body habitus, previous birthweight and delivery history. In cases with increased risk, consider co-managing with maternal fetal medicine or consider appropriateness for induction.
- Reducing non-clinical risks: Participate in simulation training that allows providers to practice technique and force applications and allows the entire OB team to practice response and management. Use a shoulder dystocia checklist and scribe to consistently manage and document shoulder dystocia incidents.
- Ensure that all mid-level staff know the protocol for handling emergency situations and how to contact a physician when necessary.
- Document all hand-offs of care thoroughly, including who is receiving the patient and the time in which the hand-off is to occur.
- Reference and follow delivery arrangements, especially in circumstances when there is a high risk for a birth complication.
Claims surrounding delivery complications are frequent, and errors in patient handoffs can lead to significant patient harm. Defending against such claims, especially when little-to-no written documentation of the patient handoff exists, can be difficult and lead to costly damages for providing negligent care.
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The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.