• Fetal macrosomia. Although most macrosomic infants deliver without complication, fetal macrosomia was involved in more than 72% of the cases reviewed. Because macrosomia represents a risk not only for shoulder dystocia but also for the litigation that may arise from it, it is important to:
- know and document the estimated fetal weight (EFW);
- discuss the risk of dystocia and its sequelae with the mother and her partner; and
- consider cesarean delivery for estimated fetal weights that suggest macrosomia (see the recommendations on page 82 for specifics).
It also is advisable to mobilize a team for the possibility of shoulder dystocia if vaginal delivery is attempted.
Preparing for the increased risk of a macrosomic fetus can be successful only if macrosomia is both diagnosed and anticipated.
Because macrosomia often is accompanied by maternal diabetes, serum glucose testing is recommended for all gravidas, with follow-up of both abnormal and borderline values.
Labor and delivery interventions were cited in all cases, with data indicating a decreasing ratio of wins to losses with the use of oxytocin, forceps, or fundal pressure, and prolonged second stage.
- Use of oxytocin to augment an already established labor carried less risk than oxytocin for labor induction. Ten of the 12 cases (83.3%) in which oxytocin was used for induction closed with an indemnity payment. However, of the 30 cases in which oxytocin was used for labor augmentation, 50% closed with payment.
- • Forceps and a prolonged second stage. Eight of 9 cases (88.9%) involving forceps and 6 of 7 cases (85.7%) involving a prolonged second stage closed with indemnity payment.
Consider cesarean delivery when the second stage is prolonged or labor fails to progress. Be cautious using forceps and vacuum extraction in these circumstances, and limit the number of attempts with either.
Maneuvers performed at the time of dystocia. The most common maneuverswere McRoberts, suprapubic pressure, and Wood’s corkscrew. The ratio of wins to losses decreased with traction of the fetal head and use of fundal pressure.
Part of the risk-management protocol for obstetricians should be appropriate use of McRoberts maneuver, suprapubic pressure, and Wood’s corkscrew, and cutting a large episiotomy. In addition, be careful not to push, pull, rotate the head, or apply fundal pressure.
Fetal outcomes. All cases involved neonatal injury (Erb’s palsy, fractured humerus) or death.
For this reason, we recommend an action plan that includes immediate pediatric or neonatal assessment of neuromuscular function of the infant’s anterior shoulder. Assess the Moro reflex and the possibility of brachial plexus injury and fractures of the clavicle and humerus. Also examine the placenta, send it to pathology, and perform a cord blood gas analysis.
Last words
Shoulder dystocia is the unfortunate complication of a small number of deliveries, but the focus of an increasing number of lawsuits. Because the neonatal injuries that so often accompany shoulder dystocia often lead to litigation, obstetricians should prepare to identify risk and help patients make informed choices. We should be prepared to manage this emergency whenever it occurs and thoroughly document actions.
Dr. Zylstra reports no financial relationships relevant to this article.