Case Study: Expert Witness for Injured Plaintiff, Baby M

Physician Failure #1 – a statement setting forth how and when Dr. X (plaintiff’s obstetrician) failed to document fetal weight and maternal pelvic size prior to delivery.

Dr. X failed to document fetal weight and maternal pelvic size on the mother’s admission in labor. The pregnant patient in this case was a known gestational diabetic. The standard of practice when admitting a patient to labor and delivery is to document a History and Physical. The document completed by Dr., the expert witness, stated: This was one of the worst H&Ps that I have reviewed in 25 years. The record lacked a chief complaint, no review of systems, no physical examination, assessment, plan, or diagnoses. When planning to induce a diabetic patient, a reasonable and prudent provider would document a physical exam and estimated fetal weight, particularly with a patient with gestational diabetes and who was at higher risk for macrosomia and shoulder dystocia. The last ultrasound, before the scheduled induction of labor, showed an abdominal circumference in the 98th percentile/35 cm; an indicator for macrosomia.

“Dr. X examined the patient in the clinic on three different occasions. The last two fundal height measurements were 2 cm ahead, suggesting a larger infant. An ultrasound was performed in the clinic before the patient’s admission for induction, but Dr. X. never reviewed the results. On admission, there was no documentation of maternal pelvic adequacy, as Dr. X had not reviewed the patient’s prenatal chart at the time of admission.”

Physician Failure #2 – a statement setting forth how and when Dr. X failed to avoid excessive lateral traction prior to attempting maneuvers known to safely deliver infants with shoulder dystocia.

“Dr. X used excessive lateral traction during the 30 seconds from the time of delivery of the head to the delivery of the body. Note that it may be intuitive to rush when you are confronted with a shoulder dystocia. Supported by the evidence-based literature, this is NOT the most effective way to get the baby delivered intact and uninjured. Suprapubic pressure maneuvers, which incorporate traction, should be ‘gentle’. Dr. X documented NO maneuvers used to avoid traction in the medical record. Typically, Ruben’s, Wood’s screw, and posterior arm maneuvers are used after gentle traction does not relieve the shoulder dystocia, before and during the McRoberts’ and suprapubic pressure maneuver. Additional maneuvers are standard of practice after the failure of gentle traction and McRoberts’. (*) There was no typed or written delivery note in the record, which is a deviation of the standard of practice in deliveries complicated by a) a diabetic mother and b) shoulder dystocia.”

“The details of the delivery note must be documented, given that a permanent brachial plexus injury occurred during a shoulder dystocia. Permanent brachial plexus palsies typically occur during shoulder dystocia. The mechanism of action for the injury is ‘excessive traction’ that is greater than the inherent strength of the fetal brachial plexus. Excessive lateral traction is a pulling force that bends the neck of the fetus by moving the ear toward the posterior shoulder, which opens the contralateral angle of the neck, increasing the strain on the brachial plexus, known as downward lateral bending. In this case, Dr. X did not describe the amount of traction used. The only mechanism of injury in this case, more likely than not and within a reasonable degree of medical certainty, was the use of excessive lateral traction during the time from delivery of the head to the delivery of the body.”

The literature supports the fact that if excessive lateral traction is avoided, permanent brachial plexus injuries can be avoided.

Physician failure # 3: Dr. X used only traction procedures. Downward lateral traction, McRoberts’ and Suprapubic pressure. All must be done together as one, avoiding excessive traction.

“The medical records indicate that the shoulder dystocia was relieved in 30 seconds. On the record, the time difference noted from head to delivery was “0”. As a clinician, this tells me that Dr. X acted in extreme haste. The first step in treating a suspected shoulder dystocia is to wait for the next contraction, which could take 2-3 minutes, and initiate pushing again, which usually will relieve the shoulder. The diagnosis is made when the head does not deliver with “gentle traction”. Dr. X should stop, call for help, and appropriately prepare for the McRoberts’ maneuver by lowering the head of the bed, placing a nurse on each leg, which are then flexed firmly toward the maternal chest. Application of suprapubic pressure is concurrent. This would take time if done with a calm, focused approach, avoiding excessive traction to deliver the baby. The provider has about 30 seconds to attempt each of the maneuvers before moving on to the next. The provider has about 5 minutes to accomplish these maneuvers to avoid asphyxial injury.”

Dr. Robert Allen did an engineering study of clinician-applied forces, demonstrating that a wide range of applied forces corresponds to varying degrees of difficulty. The results indicated that a clinician’s first reaction to a difficult delivery is to exert considerably larger forces than they usually would. The faster the force is applied to the head, the more vulnerable the newborn is to injury. Dr. Allen also examined clinician-applied loads for routine, difficult, and shoulder dystocia deliveries, noting that many clinicians do use more force, twisting, bending, and do so hastily. 1,2

1. Risk Factors for Shoulder Dystocia: An Engineering Study of Clinician-Applied Forces. Robert Allen, Phd, Jagadish Sorab, MS, and Bernard Gonkik, MD. Obstetrics and Gynecology 77:32, 1991. pp. 352-355.

2. Comparing clinician-applied loads for routine, difficult, and shoulder dystocia deliveries. Robert H. Allen, PhD., Brian R. Bankosky, MS, Clifford A. Butzin, PhD, and David A. Nagey, MD, PhD. American Journal of Obstet Gynecol, December 1994. pp. 1621-1626.

(*) What about the all fours maneuver? **Additional references to follow: Part 2

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