A Review of the Evidence Based Literature in Shoulder Dystocia Litigation 1980’s – 2000’s Part 1

A. Cohen B, et.al. Sonographic Prediction of Shoulder Dystocia in Infants of Diabetic Mothers. Obstet Gynecol 1996: 88:10-13. [AD-BPD cut-off 2.6 cm; infants of diabetic mothers 10x as likely to weigh more than 4500 gms; incidence of SD in diabetics 3-9%; current practice favors advising abdominal delivery for fetuses believed to exceed 4000 gms.

B. Spellacy WN et al. Macrosomia-Maternal Characteristics and Infant Complications. Obstet Gynecol 66:158, 1985. [The high risk group triad included obsesity, diabetes, and post dates, and had a macrosomia frequency of 5-14%. Macrosomic infants delivered by cesarean section had fewer birth injuries . . . would seem prudent to scan all women in labor who have diabetes to determine an estimated fetal weight. Error rate 10%]

C. Elliott JP et al. Ultrasonic prediction of Fetal Macrosomia in Diabetic Patients. Obstet Gynecol 60;159, 1982. [In this study, cesarean section for all fetuses with a chest-biparietal diameter of 1.4 cm or greater would reduce the incidence of traumatic morbidity from 27% to 9%.]

D. Acker, DB et al. Risk Factors for Shoulder Dystocia. Obstet gynecol 66:762, 1985. [Cesarean section is recommended for diabetic gravidas whose estimated fetal weight is 4000 gm. The two factor combination of diabetes and fetal weight 4000 gm provided best predictability of SD . . .54.7%.

E. Langer, O. et al. Shoulder dystocia: should the fetus weighing greater than or equal to 4000 gm be delivered by cesarean section? Am J Obstet Gynecol 1991; 175:831-7. [Eight percent of shoulder dystocia occurred in the diabetic group when fetal weight was greater than or equal to 4250 gm. . .Elective cesarean section is strongly recommended for diabetics with fetal weights greater that 4250 g.]

F. Benedetti TJ et al. Shoulder Dystocia. A Complication of Fetal Macrosomia and Prolonged Second Stage of Labor With Midpelvic Delivery. Obstet Gynecol 52;526. 1978. [Risk factors known to be associated with shoulder dystocia include maternal obesity (>180 lbs), previous infants weighing greater than 4000 g , maternal diabetes and fetal macrosomia > 4000g.

G. Acker DB et al. Risk Factors for Erb’s-Duchenne Palsy. Obstet Gynecol 71:389, 1988. [One of six infants of diabetic gravidas who sustained a should dystocia experienced an Erb-Duchenne Palsy. Erb-Duchenne and Klumpke palsies, the traumatic neuropathies caused by mechanical disruption of the brachial plexis nerve roots, are serious complications of birth. For cephalic presentation fetuses, traction and lateral flexion to resolve a shoulder dystocia is causative.]

H. Acker DB. A Shoulder Dystocia Intervention Form. Obstet Gynecol 78:150, 1991. [The absence of a detailed note describing the maneuvers used to resolve shoulder dystocia often results in an inconsistent and counterproductive representation of the facts. Such a note should include exact times of events, a description of the maneuvers used, and an estimation of the traction forces exerted.]

I. Gonen R. et al. Is Macrosomia Predictable, and Are Shoulder Dystocia and Birth Trauma Preventable? Obstet Gynecol 1996; 88:526-9. [Our departmental policy is to consider cesarean delivery when the fetal weight is estimated to exceed 4000 grams for diabetic women.

J. ACOG Practice Bulletin Number 30, September 2001. Gestational Diabetes. [Patients with only one abnormal value have been demonstrated to manifest increased risk for macrosomic infants.]

K. Neiger R. et al. Are current ACOG Glucose Enhanced Test Criteria Sensitive Enough? Obstet Gynecol 78: 1117, 1991. [The ACOG GTT criteria may fail to detect a proportion of women with GDM whose carbohydrate metbolism abnormality is severe enough to require insulin therapy. Uses 95mg/dl for FBS, and 180,155,140 mg/dl for 1,2, and 3 hour values respectively].

L. ACOG Practice Bulletin Number 40, November 2002. Shoulder Dystocia. [Shoulder dystocia is most often unpredictable and unpreventable. Although fetal macrosomia and maternal diabetes increase the risk of shoulder dystocia...the presence of both predicts 55% of cases of shoulder dystocia.]

M. Acker, DB et al. Risk Factors for Shoulder Dystocia. Obstet Gynecol 66: 762, 1985. [is control of the diabetes has not been adequate, however, and the estimated fetal weight exceeds 4000 gm as determined by accurate ultrasonographic measurements, a cesarean section would be appropriate and prudent, as suggested by Gabbe. . . Nonetheless, a large fetus (4000+ gm) in a diabetic predicted 73.3% of shoulder dystocia among diabeticsl l l The two-factor combination of diabetes and/or fetal weight provided the best predictability. . .and were capable of detecting 54.7% of shoulder dystocia.]

N. ACOG Practice Patterns Number 7, October 1997. Shoulder Dystocia. [macrosomia and maternal diabetes are the two risk factors most strongly associated with shoulder dystocia. . . a planned cesarean delivery may be reasonable. . .ultrasonography could correctly identify macrosomia 60% of the time and 88% in one study.

O. Baskett TF et al. Perinatal Implications of Shoulder Dystocia. Obstet gynecol 1995;86:14-17. [Strong downward traction on the head is associated with the greatest degree of neonatal trauma (43%) whereas McRoberts maneuver has the least. . .strong downward traction and other methods; McR, Woods, or post arm, are associated with next greatest degree of trauma (39%). McR alone had no BPI. Plan for management of shoulder dystocia must be logical and the sequence used must be documented carefully in the chart ].

P. Nocon JJ et al. Shoulder Dystocia; an analysis of risks and obstetrics maneuvers. Am J Obstet Gynecol 1993; 178:1732-7. [The occurrence of shoulder dystocia increased in direct relationship to the birth weight and become significant in newborns over 4000 gms (p<0.01). Diabetes and midforceps delivery become significant factors only in the presence of a large fetus.]

Q. Acker DB et al. Risk Factors for Erb’s-Duchenne Palsy. Obstet Gynecol 71:389, 1988.

R. ACOG Practice Bulletin Number 22, November 2000. Fetal Macrosomia. “The term fetal macrosomia implies growth beyond a certain weight, usually 4000 g or 4500 g, regardless of the gestational age. . . The most serious complication of fetal macrosomia is shoulder dystocia. . . When birth weight exceeds 4500 g, however, the risk of shoulder dystocia is increased with rates reported from 9.2% to 24%. . .First, clinicians tend to under-report the occurrence of shoulder dystocia. Second, the incidence of shoulder dystocia and the likelihood of subsequent fetal injury vary depending on the criteria used to render a diagnosis of dystocia. . .Maternal obesity increases the risk of fetal macrosomia, most agree that maternal obesity plays a greater role. . . There is little doubt that birth weight, in general, increases with maternal body mass index (BMI). Almost all authors report that obese women are more likely than women of normal weight to have large infants. . .The risk of newborn macrosomia associated with excessive maternal weight gain is greater for obese women than those that are not obese. Methods used to predict birth weight include assessment of maternal risk factors, clinical examination, and ultrasound measurements of the fetus. . .Case controlled studies demonstrate that the risk of brachial plexus injury among infants delivered vaginally is increased 18-21 fold when birth weights exceed 4500 gms. . .However, persistent injury may be more common with birth weights greater than 4500 g. . .First, the risk of birth trauma associated with vaginal delivery increases with birth weight. Second, cesarean delivery reduces, but does not eliminate, the risk of birth trauma and brachial plexus injury associated with fetal macrosomia. The protective effect of cesarean delivery is large.”

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