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
Other maneuvers
Two other maneuvers are occasionally used, though neither is considered mainstream.
Gaskin or “all fours” maneuver. This technique is frequently advocated by the midwife community.33 It involves moving the laboring woman from the standard lithotomy pushing position to her hands and knees to free the stuck anterior shoulder. However, many have questioned the practicality of turning a fatigued, laboring woman rapidly enough to deliver a baby within the 4 to 6 minutes available, particularly when an epidural has been given or other maneuvers have already used up much of the allotted time.
Zavanelli maneuver if all else fails. This maneuver should be attempted only when all other efforts have failed.34 It involves flexing the fetal head and attempting to push the baby’s head back into the vagina, followed by emergency cesarean section.
Although case reports have described successful use of this maneuver, there also have been reports of fetal death, fractured spines, and other severe fetal damage. Thus, this maneuver should be the absolute last resort in desperate emergencies.35
What not to do
Traction
Do not continue to apply traction to the fetal head if the shoulder does not come. Once shoulder dystocia is diagnosed, cease all attempts to deliver the baby by continued pulling. Carefully but expeditiously use the various maneuvers you were trained to do, applying moderate traction after each one to see if the shoulder has been freed.
Fundal pressure
Do not apply fundal pressure. It never helps resolve shoulder dystocia, but only further jams the stuck shoulder against the maternal pubic bone. It also can cause injury to the fetus or even rupture the uterus.
Fundal pressure is often cited in court as a definite standard of care violation.
Theory vs evidence
A 3-member team is adequate
Shoulder dystocia occurs unexpectedly. Once it does occur, the obstetrician has 4 to 6 minutes to resolve it before the threat of central neurologic damage to the baby becomes significant. Although it would be very helpful for additional personnel to be available, it is not always possible to assemble this team quickly enough.
In reality, the only personnel truly necessary to resolve a shoulder dystocia are:
- The delivering doctor or midwife
- A medically trained assistant familiar with McRoberts maneuver and suprapubic pressure
- Any other available person, including a family member, who can be drafted to help and instructed to participate in the McRoberts maneuver by flexing one of the mother’s thighs
Drills are not an absolute necessity
It is sometimes claimed that formal shoulder dystocia drills should be conducted in labor and delivery units at fixed intervals. Although this may be a useful and reasonable educational practice, it is more important that each individual on the labor and delivery team know what his or her role is during such an emergency. Whether this is achieved through a practice drill or didactic instruction does not matter.
In short, there is nothing about the concept of a drill that is “standard of care.” What is standard of care is that every team member knows what to do, how to do it, when to do it, and how to document it.
Episiotomy is often superfluous
Multiple studies have shown that episiotomy is not necessary to resolve shoulder dystocia, although many textbooks and other published protocols still recommend it.36 The obstructing factor in shoulder dystocia is not the soft tissue of the perineum but the symphysis pubis. The only time episiotomy helps is when more room is needed for the obstetrician’s hand to enter the posterior aspect of the vagina to perform a shoulder dystocia maneuver. If you can perform all necessary maneuvers without episiotomy, it is superfluous.
Document early and always
Because shoulder dystocia often leads to litigation, it is extremely important to document what happened during delivery as soon as feasible and in as much detail as possible. Standardized forms are now available. (FORM)
At minimum, you should record:
- how shoulder dystocia was diagnosed
- which shoulder was anterior and which was posterior
- quantification of the force applied initially and in subsequent traction attempts, using terms such as “mild,” “moderate,” or “significant”
- duration of attempts to resolve the dystocia
- maneuvers performed
- approximate length of time each maneuver was tried
- condition of the baby at delivery, including Apgar scores, a description of all injuries and bruises, and cord pH, if obtained
- time from delivery of the fetal head to delivery of the body
- documentation of the discussion with the patient following delivery
