Shoulder dystocia: What is the legal standard of care?
It’s your job to educate the jury that, even in the best of hands, permanent brachial plexus injuries can occur
IN THIS ARTICLE
When is cesarean section warranted?
In deciding the answer to this question, the obstetrician must consider that cesarean section is not without its own risks: excessive bleeding, infection, injury to bowel or bladder, deep venous thrombosis, and the need for hysterectomy.
These adverse events occur much more frequently than does permanent brachial plexus injury.26 And the risks are higher yet for the very same patients at greatest risk for shoulder dystocia—diabetic and obese women.
Prevent “I didn’t know” accusations
This is the point at which the patient’s input becomes vital. It is important to convey to her in readily understandable terms the risks—to both her and her child—of cesarean section versus attempted vaginal delivery. Plaintiff attorneys often claim that, had their client known there was a 1 in 450 chance of her baby having a permanent injury, she would have opted for cesarean section. The truth of this claim is, of course, open to question. However, from a medicolegal perspective, it is extremely important that the woman be informed of the degree of risk to herself and her baby so that her decision is truly informed—even if it is not the choice the obstetrician would have made.
The consensus in surgery is that the patient should be informed when the threshold of risk for an adverse event reaches 1% or higher. Although it is an informal teaching, this threshold is documented in the medical literature.27
The option of cesarean section should be discussed and possibly recommended for all women whose infants are estimated to weigh more than 5,000 g in the absence of diabetes and 4,500 g or more in women with diabetes.
Often a mother will voice concern about whether she will be able to deliver her baby safely vaginally. She may feel that her infant is too big, that she is too small, or that her obesity will make her delivery more difficult. Do not blithely ignore such concerns or provide blanket reassurances that everything will be OK.
Instead, review with her any risk factors she may have for shoulder dystocia and discuss the specific odds of injury to her baby should dystocia arise. Then discuss the risks to her and the discomfort she will experience if she elects a cesarean section.
Patients have a right to know the risks
Although it is appropriate to be reassuring when there are no significant risk factors, patients deserve to know what risks they run and to have these risks put into perspective. For example, if the mother has diabetes and her baby is estimated to weigh over 4,500 g, the risk of permanent brachial plexus injury approaches 1 in 450. The same is true if she is nondiabetic but has an estimated fetal weight of 5,000 g or more.
In high-risk cases such as these, you should discuss the risks with the patient and have her participate in the decisionmaking. You should also clearly document this discussion in the medical record.
Labor management
Prolonged second stage and instrumental delivery
Although the literature is not clear on this point, there is a trend toward increased rates of shoulder dystocia with a prolonged second stage of labor2,3,28 and with instrumental deliveries.6,12,29,30 Most experts believe this trend merely reflects the fact that bigger babies—the known major risk factor for shoulder dystocia—encounter these sorts of labor problems more frequently than do smaller babies. Whatever the reason, it warrants attention. An obstetrician’s care of any laboring woman should follow standard practices regarding arrest of labor and descent or a prolonged second stage.
Plaintiffs are quick to condemn vacuum and forceps
The same applies to intervention with forceps or vacuum. Only in women at highest risk for shoulder dystocia—those with diabetes or with suspected macrosomic fetuses—should standard management be modified.
Given the potential for shoulder dystocia in such high-risk circumstances, not to mention our inability to predict dystocia, prudence dictates that we avoid aggressive management and the use of forceps or vacuum in these cases.
These practices are often condemned in court by plaintiff lawyers and their expert witnesses.
Oxytocin is OK
In cases of arrest of labor and descent, the use of oxytocin is appropriate. A laboring woman should be given adequate time to deliver on her own, especially if a regional anesthetic has been used.
…but prepare to act quickly. In high-risk cases, be prepared to move more quickly than normal to cesarean section.
Is your team prepared? 4 standards of care
Although it is true that an obstetrician must be prepared for the possibility of shoulder dystocia in any delivery, to act as though it will occur in all deliveries is simply not reasonable, given that the rate of dystocia is 0.5% to 1.5%, or 1 in 67 to 200 deliveries.12,21,25,29
