Shoulder Dystocia: The Importance of Documentation in the Medical Record

All events that are associated with a shoulder dystocia must be carefully recorded in the medical record. Appropriate documentation allows an accurate record of what happened during the delivery, especially for attorneys and experts to review retrospecitvely, but also for reviewing your own experience. Your perspective will be important for educational, billing, or risk management purposes.

Most notations in the medical record, in cases of shoulder dystocia, deal specifically with what happened during the delivery. However, this may be insufficient. The delivery summary should begin with a summary of the patient's prenatal care up to the hospital admission. There should be careful documentation of any obsetrical or prenatal factors that are associated with risk of shoulder dystocia.

If specific risks for shoulder dystocia arise during the course of labor, documentation must include a list and assessment of each one, and how this knowledge was incorporated in the care provided during labor and delivery. If, during the course of labor, acute issues arise which suggest potential dificulty during delivery, these concerns need to be recorded, including provider considerations and preparations for them. In addition, all discussions with the mother regarding potential risks should be recorded.1

Again, the patient's past obstetrical history, along with prenatal, labor, and delivery events should be documented. Discussions regarding risks during a vaginal delivery, as well as alternative suggestions or options, must be recorded in the medical record. If the patient decides to proceed with a vaginal delivery, in the face of potential risks for shoulder dystocia, the mother must be briefed on what may occur, who will be summoned, and how the delivery might proceed. It is probably wise to have a witness present during this discussion. If your patient refuses an option for cesarean delivery, this dicussion should also be carefully documented.2

Newborn barachial plexis injuries (BPI) are among the most common claims against obstetrical care providers. Malpractice settlement costs may be higher for BPI cases than other obstetrical negligence suits, averaging more than $500,000 according to various medical liability carriers.*

Liability complaints include: failure to identify or consider obesity, weight gain, or post-dates, and failure to test for and manage diabetes. Allegations may also include failure to assess or document estimates of fetal weight. Third trimester utrasounds in high risk patients may be helpful. Plaintiffs may claim that the mother was not told of her option for cesarean delivery prior to labor and informed consent was not obtained.

Allegations of mismanagement of shoulder dystocia may include poorly executed maneuvers to free the impacted shoulder or failue to have the appropriate, trained and experienced individuals present at the time of delivery. Again, when shoulder dystocia occurs, documentation of labor and delivery events must be thorough. It is important that providers are familiar, and document, all details of the delivery to include the mother's participation in decision-making. With regard to decisions for cesarean section vs. vaginal delivery, the physician and/or midwife should not decide, on their own, the benefits to mother and baby. Remember, in your careful documentation, that informed consent is obtained from the mother, not given to her.

In defining the standard of care in the management of Shoulder Dystocia and Brachial Plexus Injury, it is described as that which a reasonable physician or CNM/CM would do in the same or similar circumstances in the management of shoulder dystocia. It is an unanticipated and unpredictable event, in many cases, and requires the participation of midwives, obstetricians, nurses (OB and NICU), anesthesiologists, and neonatologists. All participants should rehearse their specific roles in this emergency. In your institution, you should expect mandatory SD drills at reasonable intervals.4

Case Study: 1**

COMPLAINT AND JURY DEMAND

Plaintiffs, Susie Smith, individually, and on behalf of and as parent and natural guardian of B.S., a minor, by and through their undersigned attorneys sue the Defendants, and as grounds, therefore allege as follows:

1. Plaintiffs claim damages from Defendants in a sum far in excess of Fifteen Thousand ($15,000) Dollars.

2. At all times material hereto, Defendant John Doe, M.D., was a duly licensed physician in the State of Confusion.

3. At all times material hereto Dr. Lesley Newby, was a duly licensed physician in the State of Confusion.

4. At all times, hereto, Marion Blue, CNM, APRN ("Midwife Blue") was a duly licensed Certified Nurse-Midwife and an Advanced Prractice Registered Nurse in the State of Confusion. At all times, Midwife Blue undertook the care and treatment of Plaintiffs.

5. Upon information and belief, without the benefit of all of the necessary medical records pertaining to the Plaintiffs care and treatment, Plaintiffs allege that the minor, B.S. (Baby Smith), suffered a brachial plexus injury at or about the time that she was delivered vaginally by Midwife Blue. Plaintiffs allege that once the complication of shoulder dystocia occurred, the emergency was not handled competently. Furthermore, Plaintiffs allege that B.S. should have been delivered via cesarian section at the time Plaintiff Smith was admitted.

6. Apparently, shoulder dystocia was encountered approximately 4 minutes before delivery. Dr. Newby was called to the bedside to assist Midwife Blue. At this point, McRoberts positioning had been initiated. Dr. Newby then documented in the record that she performed Rubins maneuver, followed by Woods maneuver, followed by posterior Axilla reduction, followed, again, by posterior arm maneuver. Plaintiff Smith was, later, diagnosed with a fourth degree perineal laceration.

7. At the time of delivery, Plaintiff Smith was 5 ft. 2 in. tall and weiged 250 lbs. Because Plaintiff Smith was obese at the time of delivery, there is a strong probability that a vaginal delivery should not have been ordered or attempted, in which case a Cesarean section should have been planned at the time of admission.

8. As a direct and proximate cause of the negligence of defendants, Plaintiff B.S. suffered permanent injuries to her arm and hand.

9. a. Dr. John Doe was negligent in failing to recognize that shoulder dystocia was likely to occur because Plaintiff Smith was obese.

b. Dr. Doe was negligent in failing to supervise the labor and delivery process, including the supervision of Defendant Midwife, Marion Blue.

c. Dr. Doe was negligent in delegating his responsibilities for the said patients to Dr. Newby, a first year resident, and/or Midwife Blue, who seemed to be managing the labor and delivery without appropriate supervision.

d. Midwife Blue was negligent in failing to contact Dr. Newby before the baby's head had delivered. Midwife Blue should have rquested Dr. Newby’s presence at the bedside to manage the labor and delivery of Plaintiff Smith.

WHEREFORE, Plaintiffs demand judgment against Marion Blue, CNM, APRN for damages and costs of this action. Further, Plaintiffs demand trial by jury on all issues triable as of right by jury.

This is a train-wreck complaint and jury demand, crafted by a lawfirm that was not accustomed to medical malpractice litigation. It was filed before all of the medical records could be reviewed.

While, Dr. Newby and CNM Blue were also named in the lawsuit, I present the midwife's complaint as an example of a pleading that was incompetent for many reasons, including mischaracterization of what a certified nurse-midwife is licensed to do when managing a delivery.

This lawsuit persisted for years and, eventually, settled. Apparently, the original filing law firm had to bring on a medical malpractice firm that could make proper factual and legal sense of the original complaint, once all of the medical records were obtained.

Sloppy approaches to medical/midwifery litigation are not the norm, but they are filed more frequently than they should be . Unfortunately, even with competent trial attorneys, malpractice cases can drag on for five years or more.

* Excluding cases of Hypoxic Ischemic Encephalopathy, which often involve verdicts and settlements amounting to millions of dollars.

** Names of Plaintiffs and Defendants have been omitted or changed, along with several identifying locations set forth in the Complaint.

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1. O'Leary, JA: SHoulder Dystocia and Birth Injury. Shifrin, BS and Cohen, WB. The Maternal Fetal Medicine Viewpoint: Causation and Litigation. p.237.

2. Ibid at 241.

3. Ibid at 243.

4. Ibid at 238-239.

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https://www.midwivesontrial.com

Common Legal Claims Against Certified Nurse-Midwives and Certified Midwives

Common Legal Claims Against Midwives, cont.

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