Presentation
A 24-year-old pregnant woman began prenatal care with her ob-gyn at approximately 24 weeks into her pregnancy.
The ob-gyn provided care for the patient throughout the prenatal course, which was reported as relatively unremarkable. The results of an ultrasound early in the third trimester were within normal limits, and the size of the fetus was consistent with the stated gestational age. At 37 weeks, the patient began her maternity leave.
Physician action
At 39 weeks, the patient was admitted to the hospital to induce labor. Cervical ripening with dinoprostone before an oxytocin injection induction was planned for the following day. At the time of admission, the fetus was at a -3 station. The patient went into spontaneous labor during the night and began dilating before the oxytocin injection was administered.
In the first hours of labor, the patient made rapid progress, dilating from 4 cm to 7 cm and progressing to -1 station. The patient was given an injection of oxytocin. Dilatation progressed to 9.5 cm with a vertex presentation. Two hours later, dilatation remained at 9.5 cm and now 0 station.
According to labor and delivery notes, the patient's cervix was fully dilated and the infant was delivered vaginally with the aid of a second-degree midline episiotomy. At delivery, shoulder dystocia was noted. The physician used the McRobert’s Maneuver and suprapubic pressure along with “slow, steady, downward pressure and rotation of the shoulders” to reduce the impacted shoulder and bring about completion of the delivery. The infant weighed 9 pounds, 3 ounces or 4,175 grams. The patient and infant were discharged from the hospital two days later. The infant soon began physical therapy.
Allegations
The plaintiff alleged that the ob-gyn failed to meet the standard of care related to:
- Timely medical decision-making in correlation between a large for gestation age infant (weighing greater than 4,000 grams) and maternal pelvic size with associated risks of vaginal delivery;
- Recognition of prolonged first and/or second stage labor as a risk factor associated with shoulder dystocia;
- The diagnosis and treatment of shoulder dystocia, proceeding to an emergent cesarean delivery;
- Informed consent regarding shoulder dystocia and delivery options and the related foreseeable risks associated with each option; and
- Employing evidence based interventions and/ or maneuvers needed to deliver a fetus with shoulder dystocia.
Legal implications
The ob-gyn's documentation was described as inadequate regarding the positioning and rotation of the infant’s shoulder, which created some difficulty in explaining events of the delivery.
Plaintiff's experts were critical of the ob-gyn's clinical decision-making, which they claimed resulted in injury to the infant. Other experts pointed out that most cases of shoulder dystocia are unpredictable and that the events in this case are common in deliveries not complicated by shoulder dystocia. The physician’s choice to employ the McRobert’s Maneuver and suprapubic pressure, along with the episiotomy, are the most commonly used methods in this situation. However, the lack of documentation describing the amount of traction used while applying these maneuvers was considered a weakness.
Disposition
The case was settled on behalf of the ob-gyn.
Risk management considerations
Assessing risk factors for each patient is beneficial when developing a birth plan. The occurrence of shoulder dystocia reported in the literature varies. The World Health Organization reports the occurrence between 0.6% and 1.4% for infants with a birth weight between 2500 grams and 4000 grams. The rate is significantly higher for birth weights greater than 4000 grams, ranging between 5% to 9%. (1)
Complete and accurate documentation of all deliveries becomes especially important when unexpected complications occur. Documenting assessments, discussions with patients (including informed consent discussions), clinical decision-making and interventions will avoid the necessity of later having to rely on memory. In defending medical liability cases or Texas Medical Board complaints, thorough documentation helps establish credibility.
One risk management method is to stay current on recommendations for the assessment, management, and interventions associated with frequently occurring complications. According to the American Congress of Obstetricians and Gynecologists (ACOG), “Shoulder dystocia cannot be predicted or prevented because accurate methods for identifying which fetuses will experience this complication do not exist.”2 However, in the 2013 publication (which postdates this case) Optimizing Protocols in Obstetrics, Managing Shoulder Dystocia, ACOG identifies risk factors associated with shoulder dystocia (found in the table below) and key elements for management of this complication when it arises. (2)
Sources
1. Intrapartum Interventions for Preventing Shoulder Dystocia. Available at http://apps.who.int/rhl/pregnancy_childbirth/ childbirth/2nd_stage/cd005543_melob/en/.
2. Optimizing Protocols in Obstetrics, Managing Shoulder Dystocia. Available at https://www.acog.org/~/media/Districts/District%20II/PDFs/Optimizing_Protocols_In_OB_HTN_ Series_3.pdf.
