SHOULDER DYSTOCIA:
PLAINTIFFS’ THEORIES AND
DEFENSE STRATEGIES
By: Rodney Cate
Hand Arendall, LLC
11 North Water Street
RSA Tower, Suite 30200
Mobile, Alabama 36602
Email: rcate@handarendall.com
Direct Dial: (251) 694-6274
INTRODUCTION
Shoulder dystocia is an obstetrical emergency occurring when the fetus’s shoulder becomes
lodged beneath the mother’s pubic bone causing the fetus to become stuck just prior to delivery.
The obstetrician must react quickly to effectuate the delivery to prevent an hypoxic event. In a
typical shoulder dystocia lawsuit, the damage to the fetus is a brachial plexus injury, which
typically results in paralysis, temporary or permanent, to the fetus’s arm. This paper discusses
shoulder dystocia, accepted delivery protocols, plaintiffs’ lawyers’ theories and strategies for
defense.
SHOULDER DYSTOCIA - BACKGROUND
Shoulder dystocia results from the failure of the fetal shoulders to deliver spontaneously. The
fetal head is delivered but the baby’s anterior shoulder gets stuck behind the mother’s pubic
bone. This typically results in the “turtle sign,” when the fetal head retracts back toward the
uterus resulting in the baby’s cheeks puffing out. The baby remains stuck in this position until
the anterior shoulder is released. Shoulder dystocia is an obstetrical emergency because the
umbilical cord can get trapped or compressed resulting in decreased or cessation of oxygen to the
brain. When injury does occur to the baby, the injury is typically a brachial plexus injury
resulting in either transient or permanent damage or paralysis to the baby’s impacted arm. The
brachial plexus is the area where the nerve roots controlling movement of the arm attach to the
spinal cord. Erb’s palsy results from a stretching of upper nerves or avulsion of upper nerve
roots C5 through C7. Klumpke’s palsy results from damage to the lower nerves or roots C8
through T1.
2
Although some obstetrical literature describes brachial plexus injuries occurring in the absence
of shoulder dystocia, the prevailing view is brachial plexus injuries occur as a result of excessive
lateral traction on the head of the baby away from the impacted shoulder. Some traction on the
fetal head is typically required in any delivery. With shoulder dystocia, a greater amount of
traction on the fetal head may be necessary to effectuate the delivery. A stretching or avulsion of
the brachial plexus nerves can occur when lateral traction is placed on the baby’s head in
attempting to effectuate delivery. No movement occurs as the baby’s shoulder is stuck, resulting
in a stretching or tearing of the nerve roots from the spinal cord to the arm.
Shoulder dystocia has been reported to occur in 0.6% to 2.4% among vaginal deliveries of
fetuses in the vertex presentation.1 It has been reported that the incidence of brachial plexus
injuries following a delivery complicated by shoulder dystocia varies widely from 4% to 40%.2
Of the 4% to 40% of deliveries complicated by shoulder dystocia with a reported brachial plexus
injury, fewer than 10% of those cases of shoulder dystocia result in persistent brachial plexus
injury.3
MANAGEMENT OF SHOULDER DYSTOCIA
Once there is recognition of shoulder dystocia, typically from the turtle sign, the obstetrician
should first ask for help from a second obstetrician and extra personnel. Because of the risk of
an hypoxic-ischemic event, a delivery room nurse should note the time on the fetal heart strip
when the shoulder dystocia has occurred and alert everyone in the room as to the elapsed time.
ACOG has developed a patient safety checklist for documenting the significant events occurring
during the delivery following shoulder dystocia. Initially, the obstetrician should attempt gentle
1
ACOG Practice Bulletin, Clinical Management Guidelines for Obstetricians-Gynecologists, Number 40,
November 2002.
2
Id.
3
Id.
3
traction with assisted maternal efforts to deliver the baby. Whether to perform an episiotomy is a
clinical decision made by the obstetrician. Reports are inconclusive as to the effectiveness of an
episiotomy. If delivery is unsuccessful, the first suggested maneuver is known as the McRoberts
maneuver. McRoberts consists of removing the legs from the stirrups and sharply flexing the
thighs up onto the abdomen in an attempt to rotate the symphysis pubis toward the maternal head
and decrease the angle of pelvic inclination. This does not result in an increase in pelvic
dimension but pelvic rotation cephalad tends to free the impacted anterior shoulder.4 McRoberts
also involves a labor nurse applying supra pubic pressure in an attempt to dislodge the impacted
shoulder. It must be noted, fundal pressure is contraindicated in shoulder dystocia as fundal
pressure may further worsen the impaction of the shoulder and also may result in uterine
rupture.5 The McRoberts maneuver resolves 50% to 60% of shoulder dystocias.
If McRoberts maneuver is unsuccessful, multiple other obstetrical maneuvers are then
recommended: Woods’ corkscrew maneuver, delivery of the posterior shoulder and Rubin
maneuvers. There has been no consensus as to whether these maneuvers should be performed in
any order. If these are not successful, deliberate fracture of the clavicle, and in a worst case
scenario, Zavanelli maneuver in which the fetal head is pushed back into the pelvis and a
cesarean section can be performed.
CAN SHOULDER DYSTOCIA BE PREDICTED?
According to ACOG, shoulder dystocia is most often unpredictable and unpreventable.6
Specifically, the ACOG Practice Bulletin states in its summary of recommendations: “Shoulder
4
Cunningham, et al., Williams Obstetrics, 22nd Edition, 2005, p. 515.
ACOG Practice Bulletin, Clinical Management Guidelines for Obstetricians-Gynecologists, Number 40,
November 2002.
6
ACOG Practice Bulletin, Clinical Management Guidelines for Obstetricians-Gynecologists, Number 40,
November 2002.
5
4
dystocia cannot be predicted or prevented because accurate methods for identifying which
fetuses will experience this complication do not exist.”7 According to Williams Obstetrics:
“Although there are clearly several risk factors associated with shoulder dystocia, identification
of individual instances before the fact has proven to be impossible.”8 Fetal macrosomia and
maternal diabetes increase the risk of shoulder dystocia. Maternal obesity is associated with
macrosomia and thus increases the risk for shoulder dystocia. Other antepartum conditions
associated with shoulder dystocia include multiparity, postterm gestation, previous history of
macrosomic birth, and a previous history of shoulder dystocia. Intrapartum risk factors include
labor induction, epidural anesthesia, and operative vaginal delivery.9
PLAINTIFFS’ THEORIES IN SHOULDER DYSTOCIA CASES RESULTING
IN BRACHIAL PLEXUS INJURIES AND POTENTIAL DEFENSES
In the majority of lawsuits involving shoulder dystocia and a brachial plexus injury, plaintiffs’
attorneys make two basic claims: (1) that there were considerable risk factors suggesting
shoulder dystocia was likely to occur and therefore a planned cesarean section should have been
recommended or at least offered by the obstetrician and (2) the obstetrician applied excessive
force when attempting to deliver the baby after shoulder dystocia was evident resulting in the
stretching or avulsion of the nerves in the brachial plexus causing paralysis of the baby’s arm.
Of course, the more antepartum risk factors present will make the case more difficult to defend.
However, as stated above, the accepted medical literature is very strong in stating shoulder
dystocia cannot be predicted or prevented. ACOG’s Level C recommendation on informed
consent states:
7
Id.
Cunningham, et al., Williams Obstetrics, 22nd Edition, 2005, p. 514.
9
ACOG Practice Bulletin, Clinical Management Guidelines for Obstetricians-Gynecologists, Number 40,
November 2002.
8
5
In patients with a history of shoulder dystocia, estimated fetal weight, gestational
age, maternal glucose intolerance, and the severity of the prior neonatal injury
should be evaluated and the risks and benefits of a cesarean delivery discussed
with the patient.10
Defending the allegation that the obstetrician should have been able to predict shoulder dystocia
is the easiest to defend based upon the medical literature. Retaining good obstetrical expert
witnesses to explain to the jury what the literature states and why predicting a shoulder dystocia
is nearly impossible is essential in defending these cases. Most good plaintiffs’ lawyers will not
file a shoulder dystocia/brachial plexus injury case unless there was permanent damage. It is
worth the expense of hiring two obstetrician experts to testify regarding standard of care. Having
a nationally-known expert who has written extensively on the subject along with a local expert is
typically a good combination to present an effective case.
The informed consent-type claim wherein plaintiff’s counsel alleges enough risk factors were
present to require the obstetrician to give the mother informed consent and the option of having a
cesarean section is somewhat more difficult to defend. Of course, with any case, the facts drive
the defense. For instance, if the patient had a history of shoulder dystocia along with an
estimated fetal weight higher than the prior pregnancy, a higher gestational age and diabetes, a
defendant will be hard-pressed to argue he or she had no duty to at least discuss the risk and
benefits of a planned cesarean delivery versus an attempted vaginal delivery. However, if the
only risk factor is a history of shoulder dystocia and no other risk factors, the defense is much
easier. According to ACOG, a history of shoulder dystocia is associated with a recurrence rate
10
ACOG Practice Bulletin, Clinical Management Guidelines for Obstetricians-Gynecologists, Number 40,
November 2002.
6
ranging from 1% to 16.7%.11 Additionally, fewer than 10% of cases involving shoulder dystocia
result in a persistent brachial plexus injury. Given the low percentage of brachial plexus with
permanent injury, even a patient with a history of shoulder dystocia has an extremely low
percentage of again having a shoulder dystocia resulting in a brachial plexus injury.
ACOG does recommend consideration of a planned cesarean delivery to prevent shoulder
dystocia for suspected fetal macrosomia with estimated fetal weights exceeding 5,000 grams in
women without diabetes and 4,500 grams in women with diabetes.12 In defending a case where
estimated fetal weight exceeds these parameters, the defense can argue ultrasound is not an
accurate predictor of macrosomia and most macrosomic infants do not experience shoulder
dystocia. Again, the facts will drive the defense.
CLAIM OF EXCESSIVE TRACTION CAUSING BRACHIAL PLEXUS INJURY
At trial, plaintiff’s counsel will play a day in the life video showing the injured child attempting
various tasks without the use of his arm. Plaintiff’s counsel most likely will bring the child into
court to demonstrate in front of the jury activities the child cannot perform without the use of
both his arms. Plaintiff’s counsel will make the argument that the child has no or limited use of
his arm because of the excessive traction used by the obstetrician in delivering the child
following a shoulder dystocia. Plaintiff’s counsel will call expert witnesses to testify brachial
plexus injuries that follow shoulder dystocia are caused by excessive traction used by the
obstetrician in attempting to deliver the baby.
11
ACOG Practice Bulletin, Clinical Management Guidelines for Obstetricians-Gynecologists, Number 40,
November 2002.
12
Id.
7
Many children who have suffered brachial plexus injuries are treated at Texas Children’s
Hospital in Houston, Texas. The pediatric neurosurgeons or plastic surgeons who treat and
perform surgery on the injured child will provide favorable causation testimony to the plaintiff.
The group of physicians at Texas Children’s Hospital have written papers on management of
obstetrical brachial plexus injuries. One paper states: “In a review of our center’s experience
and of the literature available, we believe that traction is the predominant force creating these
devastating injuries. The pathogenesis of the injury … is excessive lateral traction on the head of
the infant away from the shoulder during labor.”13
Going further, the paper is critical of
obstetrical literature that suggests an alternative cause of obstetrical brachial plexus injuries other
than excessive traction following the shoulder dystocia. Such obstetrical literature points to
brachial plexus injuries as being associated with high intrauterine forces, not traction injuries.
Some obstetrical literature studies have shown brachial plexus injuries where delivery was made
by cesarean section. The physicians at Texas Children’s Hospital in their paper are critical of the
obstetrical literature. Specifically, their article states: “Although the above-mentioned studies
from the obstetrical literature may help to explain certain cases in which brachial plexus lesions
occurred in the absence of lateral neck traction, we believe that in the great majority of lesions,
lateral traction during birth is the culprit.”14
DEFENDING THE CLAIM OF EXCESSIVE TRACTION DEPENDS UPON THE FACTS OF THE CASE
If the charting was poor and no documentation was made of the use of any of the recommended
maneuvers used to relieve shoulder dystocia, the defense will be extremely difficult. With little
or sparse documentation of what happened at the time of delivery, plaintiff’s counsel can make
Shenaq S., “Current Management of Obstetrical Brachial Plexus Injuries at Texas Children’s Hospital Brachial
Plexus Center and Baylor College of Medicine. Seminars in Plastic Surgery,” Volume 19, Number 1. 2005: 46
14
Id.
13
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the easy argument that the obstetrician pulled too hard on the baby’s head in attempting the
delivery, causing a brachial plexus injury. In defending these claims, one should expect the
mother or family members inside the delivery room to testify delivery room nurses were pushing
on the uppermost portion of the mother’s belly or fundus. Fundal pressure is contraindicated
when shoulder dystocia is discovered. Hopefully, the nurses and obstetrician will document
supra pubic pressure was ordered and applied.
Assuming the delivery is well-documented, a good way to defend these cases is to show a very
orderly progression of actions once the shoulder dystocia was documented. Hopefully, the
documentation will show the maneuvers employed by the obstetrician necessary to free the
impacted shoulder and deliver the baby.
The obstetrician will testify he or she used the
necessary amount of traction to deliver the baby but not excessive force. The obstetrician should
testify he or she used the same amount of force or pressure as used in all deliveries. The infant
must be delivered as expeditiously as possible. The jury must understand the obstetrician goes
through his or her progression of maneuvers in attempting to deliver the baby, but the baby must
be delivered in a timely fashion or potentially suffer catastrophic brain injury or death. These
cases are defended by showing the obstetrician performed the maneuvers required to deliver the
baby in an orderly and timely fashion. However, it is important to show to the jury obstetrical
literature providing evidence that permanent brachial plexus injuries occur where no shoulder
dystocia is involved and in situations where delivery was accomplished by cesarean section.
There is logic in plaintiff’s argument that brachial plexus injuries following shoulder dystocia
result from traction on the fetal head that is applied in the opposite direction of the impacted
shoulder. Given that the shoulder does not move and force is applied to the fetal head in the
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opposite direction of the impacted shoulder, it makes anatomical sense that injury to the brachial
plexus could result as the nerve roots are stretched or avulsed.
The standard of care in a delivery complicated with shoulder dystocia is to follow the
recommended maneuvers to effectuate the delivery. Compliance with the standard of care does
not equate to a delivery without injury. Brachial plexus injuries, even permanent ones, can occur
even when the obstetrician handles the complicated delivery within the standard of care.
CONCLUSION
These cases can be difficult to defend in that the jury will tend to be sympathetic to a young child
who has little to no use of an arm. As to causation, it makes logical sense that a brachial plexus
injury occurs because the shoulder is stuck and does not move and traction or pressure is placed
on the head in the opposite direction in an attempt to deliver the baby resulting in stretching or
tearing of the nerve or nerve roots. Nevertheless, these cases can be successfully defended if the
medical record sets out an orderly rendition of what happened in the delivery room and the
obstetrician performed the maneuvers required to effectuate delivery.
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