“Shoulder dystocia: What is the legal standard of care?” by Henry M. Lerner, MD
I have 3 questions for Dr. Lerner. First, he cited a recommendation from the American College of Obstetricians and Gynecologists (ACOG) on the estimated fetal weight at which to offer cesarean delivery. That recommendation was graded by ACOG as level C: consensus or expert opinion. Should we inform our patients that our recommendation regarding cesare-an delivery for certain estimated fetal weights is based on opinion only, or even on level B evidence, defined as “limited or inconsistent scientific evidence”? According to a recent overview of practice bulletins,1 60% of the recommendations in the ACOG shoulder dystocia bulletin were level C, 40% were level B, and none were level A.
Second, Dr. Lerner stated: “Routine or ‘moderate’ traction is used in most deliveries. The birth attendant almost always depresses the fetal head and applies a moderate amount of traction.” He also observed: “The only time traction is unnecessary is when the expulsive forces of the mother are so strong or uncontrolled that she pushes the baby out entirely on her own.”
The word “most” implies a majority. In my experience—and, I trust, the experience of generations of women delivering babies without obstetrical attendants—the vast majority of babies do not need any type of traction. I teach medical students and residents that their role in vaginal delivery is to “assist” the birth, and to be prepared to address problems if they occur. How are babies born without attendants applying traction?
Third, Dr. Lerner noted that a recent case report by Allen and Gurewitsch2 “settled” the question as to whether brachial plexus injury can follow a “traction-free” delivery. As noted in the reference, the injury described by Allen and Gurewitsch was “temporary.” A subsequent paper by Gurewitsch, Allen, and others3 demonstrated that the vast majority of permanent injuries are traction-related. Are they implying that temporary injuries equal permanent injuries?
Russel D. Jelsema, MD
Grand Rapids, Mich
Dr. Lerner responds: Don’t argue for firm data and then fail to provide it
While I respect Dr. Jelsema’s right to comment on my article, I find his remarks inappropriate, inconsistent, and, in one case, plainly wrong.
In his first point, Dr. Jelsema takes ACOG to task because its recommendation is based primarily on level C evidence. He wants to know if patients are advised that the recommendation is based on consensus and expert opinion. Dr. Jelsema also seems to criticize ACOG recommendations based on level B evidence.
Is Dr. Jelsema really proposing that physicians should never advise patients about any matters unless they have been settled by randomized, double-blinded, controlled studies? If all issues in medicine had been settled by this sort of evidence, that position might make sense. But in the real world that is far from the case—as Dr. Jelsema surely knows.
He next argues about whether birth attendants almost always depress the fetal head and apply traction during delivery. His evidence? It comes solely from his own experience and what he teaches his students and residents. He quotes no studies or reports. This certainly does not comport with the standard of evidence he is advocating in the first point of his letter.
Most seriously, Dr. Jelsema’s claim that the paper by Gurewitsch, Allen, and others demonstrates that “the vast majority of permanent injuries are traction-related” is absolutely false. The article does nothing of the kind. In fact, it demonstrates only that brachial plexus injuries that result from deliveries involving shoulder dystocia are different and have different risk factors than those that occur when no shoulder dystocia is recorded. Nothing in the article links traction disorders to permanent brachial plexus injuries.