Shoulder dystocia is a delivery complication that requires additional obstetric maneuvers following failure to deliver the shoulders with gentle downward traction on the baby’s head. Most commonly, the baby’s shoulder is stuck behind a bone in the mother’s pelvis. This is a significant contribution to birth injury in the baby, including brachial plexus injuries and Erb’s palsy. These are conditions in which nerves in the baby’s neck and shoulder become stretched or torn, causing weakness or paralysis of the arm, which can be permanent. These injuries occur when excessive force or traction is applied to the baby during delivery.
Risk Factors for Shoulder Dystocia
A broad variety of conditions and circumstances that increase the risk of the shoulder getting stuck on the pelvis during delivery have been identified. These conditions are:
- Gestational diabetes
- Family or personal history of diabetes
- Macrosomia (large baby) or past history of macrosomia
- Past history of shoulder dystocia
- Postmaturity (baby past due date)
- Cephalopelvic disproportion (the baby’s head is too large for the size of the mother’s pelvis)
- Use of assistive delivery devices, such as forceps or vacuum extractors
- Prolonged or arrested labor
- Use of the labor-enhancing drugs Pitocin or Cytotec
- The mother is short
- The mother is obese or gained more than 35 pounds during pregnancy
- The mother has a narrow pelvis
- The mother is over the age of 35 (this is considered advanced maternal age)
- Conduction (local) anesthesia is used
Despite aggressive treatment of gestational diabetes, decreased use of vacuum extractors, and strict management guidelines for scheduled C-sections to prevent shoulder dystocia, the incidence of shoulder dystocia has not decreased.
Management of Shoulder Dystocia
It is very important that the size of the mother’s pelvis be measured at the first prenatal visit, so that as the due date approaches, the physician can use the measurements to assess the size of the mother’s pelvis in relation to the size of the baby. In addition, a thorough history of the mother should be taken by the physician to determine if the mother has any risk factors for shoulder dystocia. The mother and baby must be closely watched and evaluated during the pregnancy. The physician must discuss the risks and benefits of different delivery methods. The option of a scheduled C-section should be discussed, especially if the mother has one or more of the risk factors for shoulder dystocia. The greater the number of risk factors present, the greater the risk of shoulder dystocia and permanent brachial plexus injury.
A mother and baby should be closely monitored during labor and delivery, especially in high-risk situations. An essential monitoring tool is the fetal heart rate monitor, which measures a baby’s heart rate in response to contractions. When a baby’s heart rate is nonreassuring (abnormal) it almost always means that the baby is being deprived of oxygen. When this occurs, it is usually an indication that the baby should be delivered immediately. In the case of shoulder dystocia, a C-section delivery is usually the safest method. Failure to quickly deliver a distressed baby with a nonreassuring heart rate can cause severe oxygen deprivation and hypoxic-ischemic encephalopathy (HIE). Failure to monitor a baby can also cause HIE because without fetal heart rate monitoring, a baby could be severely oxygen-deprived with nobody noticing.
Shoulder dystocia is an emergency because the baby’s oxygen supply is reduced when the head is out but the body is still inside the birth canal. The key to avoiding injury is to have a delivery plan that is executed calmly, without excessive force or traction. Physicians are taught specific maneuvers to rotate the baby from the position in which the shoulder is stuck to an angled position that can allow the baby to pass through the birth canal. In most cases, the mother should be put into the McRoberts position, with her legs flexed back toward her chest. Usually, suprapubic pressure is applied just below the belly button and it helps move the shoulders into the correct position. Other approaches include pulling the lower arm out and then delivering the impacted shoulder. Physicians and the medical team should never apply fundal pressure, where force is applied just below the breast. Fundal pressure forces the baby’s shoulder more tightly against the pelvis.
When shoulder dystocia occurs, it is crucial for physicians to quickly deliver the baby. Often, physicians waste valuable time by attempting a vaginal delivery, and many times, use faulty delivery techniques. Physicians must follow standards of care (defined as what a reasonably prudent medical professional would do under similar circumstances). It is critical to quickly move on to a C-section delivery if the baby cannot be born in a safe and quick vaginal delivery.
Risks of Shoulder Dystocia
Shoulder dystocia increases the risk of the baby suffering numerous injuries, such as the following:
- Brachial plexus injuries and Erb’s palsy. The brachial plexus is a network of nerves in the shoulder and neck area. Sometimes when shoulder dystocia occurs, the physician attempts vaginal delivery and pulls too hard on the baby’s head. This excessive force can cause the brachial plexus nerves to be severely stretched and torn, which can cause the arm to be rotated toward the body and hang limply at the baby’s side. This is called Erb’s palsy, which is characterized by partial or total paralysis of the child’s arm.
- Birth asphyxia, neonatal encephalopathy (NE), and hypoxic-ischemic encephalopathy (HIE). Shoulder dystocia also places the baby at risk of experiencing birth asphyxia, neonatal encephalopathy, and hypoxic-ischemic encephalopathy. There are a number of reasons birth asphyxia, NE, and HIE can occur during a shoulder dystocia situation. Firstly, shoulder dystocia can cause labor to be prolonged or arrested, and a prolonged second stage of labor is associated with birth asphyxia, chorioamnionitis and sepsis, all of which can cause neonatal encephalopathy and hypoxic-ischemic encephalopathy. Secondly, shoulder dystocia can also cause the baby’s umbilical cord to be compressed, which can cause a lack of oxygen to the brain and birth asphyxia. Umbilical cord compression requires emergency intervention to prevent the baby from having brain damage and HIE.
- Clavicular and humerus fractures. When shoulder dystocia occurs, both of the baby’s arms can be injured, such as a fracture of the left arm (humerus) and a brachial plexus injury in the right arm. The baby’s collar bone (clavicle) can also be broken when shoulder dystocia occurs. Broken bones in a newborn are very troubling because often, the medical team cannot see or feel the broken bones and the baby is left in pain for too long.
These dangerous events associated with shoulder dystocia can typically be avoided if the medical team quickly recognizes the dystocia and/or abnormal and non-reassuring heart tracings and delivers the baby by prompt C-section delivery.
Legal Help for Shoulder Dystocia and Hypoxic-Ischemic Encephalopathy (HIE)
At Reiter & Walsh ABC Law Centers, we have extensive experience handling birth injury cases involving shoulder dystocia and hypoxic-ischemic encephalopathy (HIE). Our firm’s birth injury lawyers give personal attention to each child and family they help and they are available 24/7 to speak with you.
If you require the help of a birth injury lawyer, it is very important to choose a lawyer and firm that focus solely on birth injury. ABC Law Centers is a national birth injury firm that has been helping families and children impacted by birth injuries since the firm’s inception. Jesse Reiter, president of ABC Law Centers, has been focusing solely on birth injury cases since 1987, and most of his cases involve hypoxic-ischemic encephalopathy (HIE). Partners Jesse Reiter and Rebecca Walsh are currently recognized as two of the best medical malpractice lawyers in America by U.S. News and World Report, which also recognized ABC Law Centers as one of the best medical malpractice firms in the nation.
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