Failure to manage shoulder dystocia
Presentation and physician action
On July 29, a 24-year-old pregnant woman came to her ob-gyn with reports of headache, elevated blood pressure, and concerns of pre-eclampsia.
A year earlier, the ob-gyn delivered the patient’s first child, who sustained mild shoulder dystocia during delivery. Since that time, the ob-gyn regularly advised the patient that any subsequent pregnancies should be delivered via cesarean delivery to minimize the risk of shoulder dystocia. He did not document any of these conversations.
The patient’s blood pressure was unstable, and a 24-hour urine test revealed less than 300 mg of protein. The ob-gyn decided to induce labor and estimated the fetal weight at approximately 8 pounds.
During labor, the ob-gyn encountered trouble with the baby’s right shoulder. He performed the McRoberts Maneuver, as well as suprapubic pressure. Upon delivery, the baby sustained severe shoulder dystocia and had a flaccid right arm.
Two weeks later, the mother brought the baby, a boy, to Neurologist A. The physician placed the baby’s right arm in a splint. Two weeks later, Neurologist A referred the baby to a brachial plexus clinic for further treatment. The parents never took the patient to the clinic.
Six weeks later, the mother returned the patient to Neurologist A. The baby’s wrist and fingers were flexed, and his shoulder was internally rotated. Neurologist A diagnosed him with Erb’s Palsy.
Neurologist A ordered early childhood intervention services and a second referral to the same brachial plexus clinic. On November 11, the parents took the patient to the clinic and he was seen by Neurologist B. The physician noted the patient had difficulty lifting his arm above his head, rotating his shoulder, and straightening his elbow. Decreased muscle strength was also noted.
On February 10, Neurologist B noted no improvement in the baby’s condition, so a Mod-Quad procedure was scheduled for June. The procedure was performed without complication.
During the final follow-up appointment with Neurologist B on September 14, it was determined that the baby needed more aggressive physical and occupational therapy.
At his last therapy session on May 24, the patient had only a limited ability to reach above his head with his left arm, and limited range of motion due to stiffness. He made progress in individual skills but struggled with higher-level skills.
Allegations
The baby’s parents filed a lawsuit against the ob-gyn. Allegations included:
- failure to provide adequate care during the prenatal, labor, and delivery periods;
- failure to properly estimate the fetal weight;
- failure to properly respond to shoulder dystocia; and
- negligence in allowing a vaginal delivery despite the patient’s prior delivery resulting in shoulder dystocia.
Legal implications
An ob-gyn consultant for the plaintiff stated that he believed the baby’s injury was due to poor prenatal planning and improper delivery technique, but attributed no specific technique to the brachial plexus injury. He stated that bruising on the patient’s left arm and the presence of caput succedaneum showed the defendant employed substandard delivery techniques. But the consultant did agree that these injuries are often sustained during normal, spontaneous vaginal deliveries.
Two ob-gyn consultants for the defense both criticized the defendant for not documenting the specifics of the patient’s counseling, including educating the patient about the advantages of cesarean delivery due to the previous shoulder dystocia. Both found the lack of documentation “concerning.”
The patient testified that the ob-gyn never discussed cesarean delivery with her, and that she wanted a vaginal delivery to avoid a scar from a cesarean delivery.
One of the defense consultants noted that the main factors to consider when looking for the recurrence of shoulder dystocia are a birth weight higher than the first baby, prolonged second-stage labor, and greater maternal weight gain. In this case, the maternal weight gain between the first and second pregnancies was almost the same, and fetal weights were the same. However, the second child weighed one pound more at birth.
Disposition
This case was settled on behalf of the ob-gyn.
Risk management considerations
The lack of documentation made this case difficult to defend. Patient assessments, patient discussions, test results, clinical decisions, and the reasoning behind those decisions should be completely and accurately documented in the medical record. Good documentation helps to establish credibility and helps to defend medical liability cases.
In addition, this patient’s delivery presented a stronger risk of shoulder dystocia than a more typical delivery. Shoulder dystocia usually occurs unexpectedly and cannot be predicted. However, risk factors do exist for this serious complication. Specifically, the risk of shoulder dystocia increases if the mother experienced it in previous deliveries.
The mother in this case had previously delivered a baby with mild shoulder dystocia. The ob-gyn should have taken greater care to discuss the risks and benefits of a cesarean delivery with the patient; created a delivery plan specific to this patient’s history and condition; and documented these conversations. If the patient was unwilling to follow clinical advice, then the physician should have documented the patient’s decision and reasoning for doing so.