In the normal delivery of an infant, the mother’s contractions and voluntary pushing help the baby move through the birth canal to delivery. However, sometimes there are complications that prevent the normal progress of the baby through the birth canal. One such complication is shoulder dystocia.
Shoulder Dystocia Injuries are Preventable.
Shoulder dystocia is a relatively uncommon occurrence, happening in between 0.5-3% of deliveries. (Gherman, RB. Shoulder dystocia: an evidence-based evaluation of the obstetric nightmare. Clin Obstet Gynecol. 2002 Jun. 45(2):345-62.) This complication occurs in vaginal births when one or both shoulders of the infant becomes impacted or “stuck” against the bones of the mother’s pelvis and prevents or delays delivery.
While it is impossible to predict every case when shoulder dystocia may occur, some risk factors make it more likely:
- • Disproportionally large fetal body compared to the fetal head.
- • Diabetes or obesity in the mother.
- • History of shoulder dystocia in previous deliveries of the mother.
- • Past-due infant delivery.
If these risk factors exist, a well-trained OB/GYN doctor will talk with the mother about the risk of shoulder dystocia and what can be done to address the complication if it arises during the delivery.
Doctors Need to Act Quickly and Intelligently to Address Shoulder Dystocia
Once a shoulder dystocia is identified (the baby becomes stuck in the birth canal), doctors must immediately understand and address two competing issues that can affect the baby’s health: 1) taking time to perform the appropriate maneuvers to address the shoulder dystocia without injuring the infant’s muscles or nerves; and, 2) moving quickly enough to avoid depriving the infant of oxygen, which can cause brain damage. The time window for the doctor to act before a brain injury becomes a significant risk is about 4-6 minutes. (Crofts JF, Fox R, Ellis D, Winter C, Hinshaw K, Draycott TJ. Observations from 450 shoulder dystocia simulations: lessons for skills training. Obstet Gynecol 2008;112(4):906–912).
Well-trained, experienced doctors have several tools available to them to safely and timely address a shoulder dystocia. These maneuvers include:
- • McRoberts Maneuver – full flexion of the mother’s knees and hips against her abdomen to change the pelvic dimensions to favor delivery.
- • Suprapubic Pressure – applying pressure above the pubic bone of the mother to rotate the front shoulder of the baby.
- • Delivery of the Posterior Arm – pulling the baby’s arm out of the birth canal to allow more space for the baby’s body to progress down the canal.
- • Rotational Maneuvers – procedures to rotate the infant while still in the birth canal.
Many doctors are taught a pneumonic device or acronym to help them remember how to address a shoulder dystocia. The most common mnemonic device is: HELPERR (H-Call for help; E-Evaluate for episiotomy; L – Legs (McRoberts maneuver); P – Suprapubic pressure; E – Enter maneuvers (international rotation); R – Remove posterior arm; R – Roll the patient. A well-trained doctor can usually quickly address the shoulder dystocia without any injury to mother or baby.
An Untrained or Inexperienced Doctor Can Make a Mistake That Can Cause Permanent Injury to the Baby.
In performing all the maneuvers listed above, the doctor must always focus on finesse rather than force because excessive force (or traction) on the baby’s neck can cause serious and permanent injury to the baby’s brachial plexus. The brachial plexus is a network of nerves in the neck that sends signals from the spinal cord to the shoulder, arm, and hand. When a doctor is addressing a shoulder dystocia, brachial plexus injury can be caused by the doctor applying downward force or traction while trying to pull the baby out of the birth canal. In fact, the amount of force applied by the OB/GYN doctor is the single biggest factor in determining whether a brachial plexus injury will occur.
Doctors in this position should do everything possible to avoid excessive traction. This can be difficult because the natural instinct may be to use increasing force attempting to extract something that is unexpectedly stuck. Doctors that forget their training can inadvertently apply excessive traction and cause injury to the baby’s brachial plexus.
Brachial Plexus Injuries Can Be Permanent and Life-Changing
Some signs of a brachial plexus injury include:
- • Decreased strength in the arm.
- • Severe pain.
- • Muscle atrophy.
- • Decreased range of motion of the shoulder.
- • Decreased dexterity in the hand.
- • “Floppy arm” syndrome.
Some brachial plexus injuries recover fully with the passage of time. However, more severe stretch injuries can be permanent. In severe cases, the child may have limited or no significant use of the arm or hand for the remainder of the child’s life.
Treatment for a Brachial Plexus Injury
Thankfully, treatment options do exist that can improve the quality of life of an infant that suffers a brachial plexus injury. These options include:
- • Physical therapy.
- • Pain/nerve medication.
- • Nerve graft surgery – the damaged part of the brachial plexus is removed and replaced with sections of nerves harvested from other parts of the body.
- • Nerve transfer – connecting the torn nerve to an existing nerve that is still attached to the spinal cord.
- • Muscle transfer – transferring of a muscle or tendon from another part of the body (usually the thigh) to the arm, reconnecting the blood vessels and nerves supplying the muscles.
Know Your Legal Rights Regarding a Shoulder Dystocia Brachial Plexus Injury
In order to avoid brachial plexus injuries, OB/GYN doctors need to be trained and experienced in recognizing and managing shoulder dystocia. Additionally, hospitals should have established protocols and policies in place to address the occurrence of shoulder dystocia during delivery. Unfortunately, when these things do not occur, the life of the infant can be permanently altered.
Shoulder dystocia/brachial plexus injury medical malpractice cases are very complex and require specific and unique expertise. If you or someone you know has been injured as a result of a shoulder dystocia birth, it is important that you contact an attorney who has the knowledge and experience to address the issues that may arise.
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