Improper Manuevers Used For Babies With Shoulder Dystocia Can Cause Brachial Plexus Injuries

Shoulder dystocia is a condition that occurs during birth when the shoulder gets stuck on the mother’s pubic bone, causing passage through the birth canal to stop. Once shoulder dystocia occurs, physicians have mere minutes to deliver the baby without injury. Sometimes the baby can be delivered with significant manipulation by the physician. Other times, an emergency C-section is required. Shoulder dystocia must be handled by a very skilled physician because it is an obstetrical emergency. Compression of the umbilical cord is common during shoulder dystocia and can cause severe oxygen deprivation in the baby. In addition, trauma to the baby is very common in dystocia situations and can cause brain bleeds and brain injury.

Michigan Family Awarded Damages Due To Child’s Permanent Injuries

Recently, an award of over $3 million was given to a Michigan family whose little girl had shoulder dystocia and suffered torn nerves in her shoulder, called a brachial plexus injury. Her injury is the most serious type because the nerves were completely torn from her spinal cord and cannot be fully repaired. In addition, she had a fractured clavicle after birth, and she is permanently disfigured. The little girl already has undergone one surgery, and she will require extensive physical and occupational therapy.

The award was given to the family because the medical team failed to follow standards of care for shoulder dystocia. Specifically, a nurse applied fundal pressure, which means his/her hands were used to press down on the upper part of the mother’s abdomen, which further impacted the shoulder behind the mother’s pubic bone. While the nurse was pushing down on the mother’s abdomen, the physician pulled down on the baby’s head (called lateral traction, or, as the court called it, excessive lateral traction). This resulted in immediate and permanent injury to the baby.

Standards Of Care During Shoulder Dystocia

Medical standards of care require that a sequence of maneuvers be attempted before pressure and traction are used. Furthermore, research states that excessive neck rotation, head and neck traction, and fundal pressure should be avoided because this combination of maneuvers can stretch and damage the brachial plexus, and these actions may further impact the shoulders and cause uterine rupture or other injury.

Research also emphasizes that the physician should be prepared for possible shoulder dystocia in all vaginal deliveries, be aware of the various procedures that have been shown to be effective for delivering impacted shoulders, and have a step-wise plan of action which allows for quick execution of diagnosis and treatment.

Other standards of care when shoulder dystocia is present include the following:

INITIAL STEPS

  • Nursing, anesthesia, obstetric and pediatric staff should be called into the room, if not already there, to provide assistance as needed.
  • The mother should be told not to push while preparations are made and maneuvers are undertaken to reposition the baby.
  • Less invasive methods should be employed before implementing more invasive techniques.
  • The mother should be placed with her buttocks flush with the edge of the bed to provide optimal access for executing maneuvers to affect delivery.  Her legs should be pulled in tightly to her abdomen (called the McRoberts maneuver).  This allows rotation of the pelvis and facilitates release of the baby’s shoulder.
  • Performing a generous episiotomy (incision on the perineum and lower vaginal wall) may be useful to facilitate delivery of the unimpacted shoulder, but does not by itself help to release the impacted shoulder.
  • A distended (full) bladder should be emptied.

FURTHER STEPS

  • The McRoberts maneuver with suprapubic pressure should be the initial approach for releasing the impacted shoulder, in most cases.
  • The difference between suprapubic and fundal pressure is slight, but when shoulder dystocia is involved, the difference is very significant. Suprapubic pressure is applied directly over the mother’s pubic bone and is meant to help push the baby’s shoulder downward and allow it to be freed from the pubic bone, thereby allowing the baby to be delivered through the birth canal. Fundal pressure, on the other hand, is applied on the  upper part of the mother’s abdomen. When fundal pressure is applied during the presence of shoulder dystocia, the baby’s shoulder is usually further impacted against the mother’s pubic bone, causing the brachial plexus additional stretching and possible damage.
  • If the McRoberts maneuver is unsuccessful, and the mother has good regional anesthesia, delivery of the unimpacted shoulder is recommended. If the mother does not have good regional anesthesia, the mother can be placed on all fours, called the Gaskin all-fours maneuver.
  • Research indicates that when shoulder dystocia is present, delivery should occur within 5 minutes to avoid oxygen deprivation. It is imperative for the physician to promptly move on to a C-section when the above maneuvers aren’t working and/or when the baby is in distress. Indeed, when umbilical cord prolapse or very serious fetal heart rate abnormalities are present, experts state that delivery must occur as expeditiously as possible.

Standards of care require that a physician evaluate a mother for shoulder dystocia risk factors, which include diabetes, macrosomia (large baby), maternal obesity and breech presentation. In addition, the physician must discuss these with the mother and thoroughly inform her of the options for labor and delivery. Throughout labor and delivery, the physician must keep the mother informed and obtain her consent when new issues arise.

Shoulder dystocia can cause permanent injury to the baby and the condition requires an extremely skilled physician and medical team. A prolapsed umbilical cord is a very serious complication associated with shoulder dystocia. Research shows that in general, when shoulder dystocia is present, a physician has up to five minutes to deliver a previously well-oxygenated term infant before an increased risk of oxygen deprivation (asphyxial) injuries occurs.

Brachial Plexus Injuries And Medical Malpractice

Brachial plexus injuries are preventable and often are the result of medical mistakes, such as improperly using forceps or a vacuum extractor, applying pressure in the wrong place, or applying too much traction or pressure to the baby’s head and neck during delivery. Simply failing to identify and treat risk factors for shoulder dystocia also can constitute negligence. In addition, a woman must be informed of the risks and alternatives of all procedures performed. If negligence leads to permanent injury in the child, it is medical malpractice.

When shoulder dystocia is recognized and standards of care are followed, permanent injury can be avoided. The physicians in this case did not perform to the required standards of care and this Michigan child suffered permanent damage that will require extensive therapy and treatment.

If you gave birth to a child diagnosed with brachial plexus injuries, call Reiter & Walsh ABC Law Centers today for a free case evaluation. Our nationally recognized attorneys have been handling brachial plexus and other birth injury cases for over 30 years. We have aggressively fought for and won money for our clients for medical costs, pain and suffering, and future medical expenses. Put our experience to work for your family by calling (888) 812-6009.

2 replies
  1. Manoj says:

    Dear readers,Our son is born with seerval bleedings, one subdural hemorrhage and intraventricular hemorrhage and a cephaal hematoom. During de childbirth (labour) the nurses have applied fundal expressure (many times) at the time that the head of the child was standing high into the birth canal (hodge 3 -)(not dyst) The docters in Holland are sure that the the bleeding is a consequence due to (form) the fundal expressure, but there is not evidence on paper (literature) that confirms ower story.I have read in seerval American newspapers that there is a connection between fundal pressure en head bleeding.I would like to have a medical document in which there is a correlation between expression and brain haemorrhage fundus (the so-called causality)Is it possible to send me some (med)literature?I hope that you can help me, I would be verry happy.Many thanx and I hope to hear from you soon!Kind regards,

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