This case involves an infant born to a patient who received prenatal care and presented to the hospital at full term after spontaneous rupture of membranes. The patient was placed on fetal monitoring and later progressed to the pushing stage of labor. A delivery team that included a resident, certified nurse midwife, and medical student was present for delivery.
According to the delivery note, the fetal head delivered first, and a loose nuchal cord was identified and reduced without difficulty. After delivery of the head, the resident was unable to deliver the anterior shoulder despite maternal pushing and attempts at gentle downward traction. Shoulder dystocia was identified and announced, and additional help, including an attending physician, was called to the room. The patient was placed in McRoberts position, and suprapubic pressure was applied. Additional attempts at downward traction did not deliver the shoulder. The resident then attempted to deliver the posterior arm but was unsuccessful. The certified nurse midwife then delivered the posterior arm, which allowed the anterior shoulder and the remainder of the infant’s body to be delivered.
The infant was later diagnosed with right-sided Erb’s palsy. Imaging demonstrated injury involving the right C5 and C6 nerve roots extending into the upper trunk of the brachial plexus. The infant later underwent brachial plexus exploration with nerve transfer surgery and continues to have limited range of motion.
From a legal perspective, this case may turn on whether shoulder dystocia was managed in accordance with accepted obstetric and midwifery standards. The key issues may include the sequence and timing of delivery maneuvers, use of traction, escalation to additional providers, documentation of the dystocia event, and whether the infant’s brachial plexus injury was caused by excessive force, the underlying obstetric emergency, or another factor.
Questions to the OBGYN expert and their responses
How often do you encounter shoulder dystocia during deliveries?
Approximately every 6 months.
What is the standard of care once shoulder dystocia is encountered during delivery, and when is it appropriate to suggest a cesarean section?
If a shoulder dystocia is encountered, the first step is to identify the shoulder appropriately, instruct the mother to stop pushing, and then call for help or assistance. This assistance should include additional nursing, NICU, and anesthesia, as well as other OBGYNs or CNMs who may be available to assist. Next most commonly performed are McRoberts and suprapubic pressure, with communication to the L&D team regarding the baby's orientation so that suprapubic pressure can be applied in the correct location and with the correct orientation to the fetal anterior shoulder. The next commonly performed maneuvers are rotational maneuvers, including the Woods screw maneuver and the Rubin maneuver. The first rotates the shoulders in a counterclockwise fashion, while the second rotates them in a clockwise fashion. Next, or sometimes before, the rotational maneuvers (there is no correct order in terms of rotational versus posterior arm) is delivery of the posterior arm. Another maneuver is the Gaskin position on all 4's. Lastly, there are more deleterious maneuvers such as breaking the infant's clavicle or humerus. Lastly, there are maneuvers of last resort, such as abdominal rescue and the Zanvanelli maneuver.
About the expert
This expert has extensive experience in the obstetrics and gynecology field. She earned her BA in English at Reed College and her MD at the University of South Dakota School of Medicine. She then completed her internship at the University of Hawaii and her residency at the University of California at Los Angeles. Today, this expert is board-certified in obstetrics & gynecology and is an active member of the American College of Obstetricians and Gynecologists and the Society of Ob Hospitalists. Previously, she served as medical director of business development at the OB Hospitalist Group, then she was the co-founder of OB Best Practice LLC, and as an associate physician at Kaiser Permanente. Currently, this expert is an assistant professor of the ObGyn department at a private research university in New York.
E-1065731
Specialties:
Questions to the Nursing expert and their responses
Have you encountered a shoulder dystocia before?
Yes, I have encountered at least 20 shoulder dystocias, having delivered over 2,000 babies.
Do you know the appropriate interventions to take during a delivery complicated by a shoulder dystocia
Yes, there are assessments which should be done to evaluate for increased risk of shoulder dystocia, signs within the labor that a shoulder dystocia may be more likely, and signs right before delivery that should begin alerting the provider that a shoulder dystocia may be imminent. It is important that the proper sequence of maneuvers are performed as well as gentle axial (not downward) traction, to decrease the risk of nerve damage.
About the expert
This expert has over 10 years of experience in the field of nursing, specializing in midwife nursing. She earned her BA in community studies from the University of California Santa Cruz and her MS in nursing from the University of California, San Francisco. Today, she is a licensed registered nurse, nurse practitioner, and nurse midwife in the state of California. She remains active in her field as a member of several professional organizations, such as the American College of Nurse-Midwives and the California Nurse-Midwives Association. This expert previously was the founder of Nature Nurture Birth, where she served as a birth and postpartum doula, providing newborn care education, along with advocacy, pain management techniques, and collaborative care with healthcare providers. She later served as the lead nurse-midwife director at the OB Hospitalist Group. Currently, she is a nurse midwife for a medical group and volunteer clinical faculty at a university in California.
E-1010848
Specialties:
Questions to the OBGYN expert and their responses
What treatment standards exist when shoulder dystocia is noted during delivery, and traditional measures to deliver the shoulder fail?
There is guidance as to the maneuvers to do as well as as what to do when those maneuvers fail, but it should be noted that when the maneuvers fail there is almost universally bad outcomes.
About the expert
This expert has over a decade of experience in the field of obstetrics and gynecology, specializing in maternal-fetal medicine. He obtained his BA in history from Yeshiva University before completing his MD at the SUNY Downstate Medical Center. This expert has also completed additional OBGYN and maternal-fetal medicine education at North Shore University Hospital and New York University. In addition, this expert completed a residency in obstetrics and gynecology at Mount Sinai South Nassau. Today, this expert is board certified in obstetrics and gynecology with a subspecialty in maternal-fetal medicine. He also stays very active in his field as a member of the International Society of Ultrasound in Obstetrics and Gynecology, the American Institute of Ultrasound in Medicine, the Society for Maternal-Fetal Medicine, and the American College of Obstetrics and Gynecology.
E-721159
Specialties:
