Jason Reese May 17, 2018
Synopsis
- Dystocia means “difficult birth” and is a type of obstruction during childbirth where the baby’s shoulders get caught after the head is delivered.
- Shoulder dystocia creates issues during the rest of labor, sometimes causing further health complications to both the mother and the child and is the primary factor associated with brachial plexus injury, such as Klumpke’s Palsy and Erb’s Palsy. Both have potentially serious consequences.
- Although shoulder dystocia can be prevented by performing preemptive cesarean delivery on high risk patients, the ability to identify the issue feels limited by most clinicians and their teams.
- Only a prompt diagnosis and swift management of shoulder dystocia when it occurs is the key to preventing permanent damage to both mother and child.
- Third stage labor and postpartum care must include conversations and sharing of documents providing an explanation of events to the parents of what had occurred during delivery.
Shoulder Dystocia at Birth Can Cause Future Health Complications to Mom and Baby
Shoulder dystocia is defined as a difficulty in birth that happens when the anterior shoulder of the baby gets stuck behind one of the mother’s pelvic bones during normal vaginal delivery. The Global Library of Women’s Medicine’s (GLOWM) review that doctors most often diagnose shoulder dystocia if 60 seconds pass after the head is delivered without the body of the baby following but risk factors (if present) should be recognized ahead of time and include throughout reviews of:
Mother’s Health and Previous Childbirth History
- History of shoulder dystocia or previous delivery of baby with brachial plexus injury (BPI)
- Maternal diabetes
- Maternal obesity
Antepartum factors
- Macrosomia (risk increases as fetal weight increases)
- Gestational diabetes
- Excessive weight gain
Intrapartum factors
- Clinical pelvimetry and estimated fetal weight concerning for Cephalopelvic disproportion (CPD)
- Protracted active phase dilatation
- Arrest of dilatation
- Prolonged deceleration phase
- Failed, protracted or arrested descent
- Long second stage
- Precipitate second stage
- Instrumental delivery
Once a clinician recognizes the event as shoulder dystocia and it has been diagnosed, they should advise the mother to avoid specific maneuvers more common for childbirth like pulling, pushing, panicking, or pivoting their body. Since these movements could endanger both mother and baby, the delivery room doctors could then adhere to more conservative approaches and tactics such as the McRoberts, Rubin, or Woods maneuver via the ALARMER protocol.
ALARMER Protocol Activated
Since doctors preach that there is an inability to predict the occurrence of shoulder dystocia, heath care providers should be prepared for shoulder dystocia at all deliveries. Most health systems will have a management protocol in place and well known to all caregivers. The ALARMER mnemonic supported by GLOWM is commonly used and has been developed to assist in the appropriate and consistent management of shoulder dystocia complications. The method looks like this:
- A Ask for help
- L Lift/hyperflex Legs
- A Anterior shoulder disimpaction
- R Rotation of the posterior shoulder
- M Manual removal posterior arm
- E Episiotomy
- R Roll over onto “all fours”
Living With Complications from Brachial Plexus
Shoulder dystocia can result in a number of birth injuries for the child. The biggest concerns are the impact on the nerves and on oxygen flow. When the shoulders are stuck, an immense amount of pressure is put on the baby’s nerves. The pressure then can lead to stretching of a group of nerves called the brachial plexus. Brachial plexus injury is diagnosed in up to 20 percent of newborns after shoulder dystocia. Injury is transient in most but can lead to serious permanent disability.
In very severe cases, the obstruction during delivery can cause the pH levels of the umbilical cord to drop. This will start to happen after five minutes of shoulder dystocia and has the ability to cut off oxygen to the brain, sometimes leading to infant death. It’s important to note that this only occurs in extremely rare cases.
Other complications of shoulder dystocia include:
Fetal and neonata
- Hypoxia or asphyxia and sequelae
- Birth injuries and fractures: clavicle, humerus
- Brachial plexus palsy
- Death
Maternal
- Postpartum hemorrhage
- Uterine atony
- Maternal lacerations
- Uterine rupture
- 3rd or 4th degree tears
According to ALARMER International, after shoulder dystocia is known and the infant is delivered, there is a significant risk of maternal injury and postpartum hemorrhage. It’s important the care a woman receives through the third stage of labor is actively managed. This means doctors, nurses and the current care staff should:
- Inspect for and repair tears or lacerations.
- Do cord blood gases, if this is the policy of the institution.
- Ensure appropriate neonatal resuscitation and assessment; document all actions taken to resuscitate the newborn.
- Examine the newborn for evidence of trauma. Document the occurrence of shoulder dystocia in the baby’s chart.
- Document Apgar scores and any bruising or injuries found on the initial newborn exam.
- Re-examine the baby within 24 hours or at any time after the birth if concerns develop.
Everything related to the care of the mother and child from her pre to post-natal care should have been documented and doctors should have described the maneuvers used, and the time between the birth of the head to completion of the birth in both the mother’s and the baby’s charts. Every mother should know what management steps were taken during the delivery process. Mother’s should also be advised that they are at risk for another shoulder dystocia for future pregnancies (15 percent recurrence after one dystocia and 30 percent after two shoulder dystocias).
Shoulder dystocia is one of the most feared complications of a normal vaginal delivery, even more frightening when the reality is that most doctors are not nearly as prepared for delivery room emergencies as we’d like them to be. If you think that you or your infant has suffered due to medical negligence before, during, or after delivery, then do not hesitate to contact one of our birth injury attorneys today.
We Can Handle Your Medical Malpractice Claim
Our attorneys hold the medical profession in high regard, but when a physician or medical staff does not perform up to professional standards, legal accountability becomes necessary. Labor and delivery complications related to shoulder dystocia may have had a chance to be prevented and in return, infant mortality risks or birth injury outcomes could have been greatly reduced. Our experienced team of personal injury lawyers can help you make up for your financial losses, however unique the legal aspects of your case may be, by bringing your claims to justice.
If you have a medical claim caused by a birth or delivery complication, contact the law firm of Wagner Reese by completing our online form, and one of our attorneys will review your information, and respond promptly. If you wish to speak with us today, please call .
