Attempts at vigorous downward traction should be avoided, and no fundal pressure should be applied, as these are known to increase the potential for brachial plexus injury. Gentle downward traction is considered the standard of care.17
The obstetrician’s goal is to free the impacted shoulder as quickly as possible, since a fetus can endure only 8 to 10 minutes of asphyxia before permanent neurologic damage occurs.17 The standard of care requires the obstetrician to know and use certain maneuvers to relieve shoulder dystocia. These maneuvers are designed to facilitate vaginal delivery and reduce the risk of permanent brachial plexus injury. The McRoberts maneuver, with flexion and slight rotation of the maternal hips onto the maternal abdomen, is the standard for initial relief of shoulder dystocia.17,23
CASE 2 Appropriate action was misunderstood
This shoulder dystocia case from an insurer’s closed claim file illustrates a problem often linked to litigation. Minor changes were made to conceal the identities of the involved parties.
Prompt maneuvers, good outcome
A 28-year-old gravida weighing 214 lb has had 2 previous spontaneous deliveries of infants weighing 8 lb 5 oz and 9 lb 3 oz. Except for a weight gain of more than 60 lb, the pregnancy progressed without complications, and a 3-hour glucose tolerance test was normal. At 40 weeks, the obstetrician notes “concern” about an estimated fetal weight of 10 lb. Induction is planned, but spontaneous labor begins before oxytocin can be given. After 5 hours, the head is delivered without difficulty, but shoulder dystocia follows. The obstetrician extends the episiotomy and performs McRoberts and Wood’s corkscrew maneuvers, but the dystocia persists. Upon noting cyanosis, the obstetrician fractures the infant’s clavicle and quickly delivers a 10 lb 9 oz infant with Apgar scores of 8 and 10. Pediatricians examine the child immediately and diagnose Erb’s palsy, which subsequently resolves. X-rays confirm an undisplaced fracture of the right clavicle. Although the child recovers completely, the family sues, alleging a failure to perform cesarean delivery.
Outcome
Case closed with no payment.
What the defense experts said
Key issues are documentation and informed consent. The overriding opinion of 3 experts who reviewed the case for the defense was that cesarean delivery was not indicated and that in fracturing the clavicle, the physician acted responsibly, quickly, and within the standard of care. One defense expert said failure to document exact maneuvers used to relieve shoulder dystocia deviated from the standard of care. Another defense expert said the physician should have obtained informed consent from this at-risk patient, and explained the risks of shoulder dystocia, including neonatal injury, so that the she might have been better able to appreciate the fact that the obstetrician’s fast action may have saved her child from brain damage or death.
Factors that lead to litigation
In a review article, Hickson24 cited factors that prompted families to file medical liability claims following perinatal injury. Some families observed that, in their search for the cause of an injury, they found 1 or more aspects of care to be inappropriate.
The desire for information, perception of being misled, anger with the medical profession, desire to prevent injuries to others, recognition of long-term sequelae, and advice by knowledgeable acquaintances, as well as the need for money, all appeared to contribute to the decision to file medical liability claims.
Convey the risks, and listen carefully. Communication problems between physicians and patients are a contributing factor. Even when physicians provide technically adequate care, families expect answers to their questions and want to feel as though they have been consulted about important medical decisions.24 If these expectations are not met, even patients who have not experienced an adverse outcome may become angry and express dissatisfaction with care.24
The need for communication is critical when shoulder dystocia results in neonatal injury. Empathizing with the family, helping them understand that most brachial plexus injuries are not long-term, and offering to answer their questions both at the moment and later, may help prevent litigation.
This type of communication can be difficult. It helps to realize that an acknowledgment of distress and concern is not an admission of guilt, and an explanation is not an apology.15 However, an absence of communication or an attempt by the physician to place blame may be perceived as an admission of guilt that gives rise to a lawsuit.
Action plan is what counts in court. A review by Gross et al11 concluded that obstetricians should have a shoulder dystocia plan that enables an instant and orderly response. Also recommended is a protocol to help anticipate clinical problems and prevent medicolegal problems.