Common Legal Claims Against Midwives, cont.

Shoulder Dystocia: What Not to Do: Pre-trial Report of Plaintiff's Expert Witness

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During the course of a vaginal birth, a baby's shoulder can become lodged under the mother's pubic bone, preventing the body of the baby to proceed down the birth canal for delivery. When this occurs, it is referred to as shoulder dystocia. For management, no health provider, nurse, or relative should be directed to press down on the fundus (top) of the uterus. This is ineffective and dangerous. Fundal pressure in a shoulder dystocia emergency is always the worst choice of remedies and it may compound the stress and stretch on the nerve fibers in a baby's neck. Damage to the delicate nerve fibers can cause permanent paralysis to a baby's arm and hand.

When a pulling force is applied to an infant's neck during delivery, the nerve bundle which proceeds from the spinal cord can be bruised, stetched, or torn (avulsed). The nerve bundle is known as the brachial plexus.The severity of the injury to an infant's arm will depend on the stretching force exerted on these delicate nerves. If the nerves are minimally stretched during delivery, the infant may recover from the trauma, regaining full use of its arm or hand. It may take a full year for a brachial plexus stretch injury to fully recover. However, in the case of severe bruising, stretching and tearing, injuries to the baby are likely to be permanent. Naturally, this injury is devastating due to the lifelong effects of the birth injury (Erb's Palsy).

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Excessive lateral traction on the fetal neck falls well below the standard of care for nurse-midwives and obstetricians. It has been a recognized and reported injury for over a hundred years. In order to avoid brachial plexux injuries as a result of shoulder dystocia and crude attempts to relieve it, there are several established maneuvers that have been used by obstetricians and midwives to competently deliver infants with shoulder dystocia. One technique is the McRoberts manuever, often tried first, when shoulder dystocia is recognized. If the mother is supine a nurse, or other attendant, is asked to pull the mother's knees back so that they rest against her chest. This maneuver increases the pelvic diameter which may allow the baby's shoulder to pass under the pubic bone. If nurses do not execute McRobert's competently, at the onset of this emergency, it will not accomplish its purpose to open the diameter of the pelvis.

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Conflicting documentation exists regarding what was actually done in this case. The dictated note does not mention use of the McRoberts maneuver, but nearly everything else was. Standard of care would require that McRoberts be used, along with suprapubic pressure. Suprapubic pressure requires that the assistant places their fist directly over the pubic bone and applies significant pressure, which may dislodge the impacted shoulder and will rotate the baby's shoulders to an oblique position in the pelvis instead of direct anterior-posterior. There was, also, no notation in the record that this maneuver was attempted.

With the posterior arm maneuver, after adequate room is made by episiotomy, the doctor or midwife, reaches posteriorly into the vagina, locates the arm, flexes it at the elbow, sweeps it across the baby's chest, and delivers it first. This maneuver will disengage the anterior shoulder, rotating the baby and allowing delivery of the rest of the body. In this case, delivery of the posterior arm was documented in the shoulder dystocia form but not in the physician's dictated note.

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Once again, fundal pressure is a technique where someone pushes down at the top of the uterus, forcing the already impacted shoulder further into the pubic bone. This causes further damage and makes it difficult for sucessful use of the other disimpaction techniques. It should never be done, especially during a delivery complicated by shoulder dystocia.

Summary:

More likely than not, within a reasonable degree of medical certainty, the breaches in the standard of care, noted above, were the proximate cause of the permanent brachial plexus injury suffered by the infant.

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