What is Infant Shoulder Dystocia and How is it Caused?
Advances in technology have helped to eliminate many potential causes of injury to mothers and babies during the labor and delivery process. However, delivering a child can still present many medical challenges. This is true even for women who have made it through their entire pregnancy healthy and without any issues. One complication that medical advances have not eliminated does not arise until just seconds before the delivery is complete. This complication, named shoulder dystocia, is an obstetrical complication which is encountered after the baby’s head has already delivered. If shoulder dystocia occurs and is not properly managed by the delivering medical team, the infant can suffer severe and permanent injuries in those last seconds of delivery.
Doctors, midwives, and obstetrical nursing staff are all trained to perform a shoulder dystocia delivery in a manner that would best protect the baby from injury. However, for any number of reasons, there are times when medical mistakes are made when a shoulder dystocia arises. Medical error in a shoulder dystocia delivery can leave a child with permanent nerve and spinal cord injuries. If you believe your child has suffered injury as a result of a shoulder dystocia delivery you should consult the experienced birth injury attorneys at Raynes & Lawn to investigate the circumstances of the delivery and your child’s injury.
What Is Infant Shoulder Dystocia?
Dystocia literally means a difficult birth. Shoulder dystocia means a difficult birth caused by the baby’s shoulder. Shoulder dystocia occurs just before the baby is fully delivered. The baby’s head has exited the birth canal (come out of the vagina), but the baby’s shoulder gets caught behind the mother’s pubic bone near the end of the birth canal. With the shoulder stuck, the shoulders and the rest of the baby’s body do not deliver. After the baby’s head has come out, it may be pulled back into the birth canal because of tension from the stuck shoulder, which is described “turtling” or “turtle syndrome” referring to a turtle sticking its head in and out of its shell. With the baby’s head out, but the remainder of the body stuck in the birth canal near the outlet, the umbilical cord can be compressed which will compromise the baby’s oxygen supply. For this reason, shoulder dystocia is considered an obstetrical emergency. While an emergency, it is recognized that the healthcare provider has several minutes to relieve the dystocia before the baby will suffer injury from lack of oxygen.
Several different techniques or maneuvers have been designed to relieve the stuck or “impacted” shoulder and safely deliver the baby well within those time parameters. These techniques which are often used in combinations, are designed to do one of two things: change the angle of the mother’s birth canal and/or change the position of the baby’s shoulders. The angle of the birth canal is changed by adjusting the mother’s position on the bed and pulling her legs back to flex her pelvis at a different angle. One way to change the baby’s shoulder position entails a nurse or other healthcare provider literally pushing on the mother’s lower abdomen in the area of her pubic bone to try to push the baby’s shoulder under and passed the pubic bone. Other techniques involve the delivering doctor or midwife reaching it to sweep the baby’s shoulder free, rotating the baby’s shoulders, and delivering the bottom, not stuck, shoulder first to relieve the dystocia. Frequently, an incision into the mother’s perineum (known as an “episiotomy”) is also made, or extended, to increase the size of the vaginal opening to facilitate these maneuvers and the delivery.
Risk Factors for Infant Shoulder Dystocia
In most instances, there is no advanced warning that a delivery will be complicated by shoulder dystocia. However, there are certain conditions and findings that increase the likelihood that a shoulder dystocia may occur. Some of the more common risk factors include maternal diabetes, maternal obesity, and fetal macrosomia (baby large for gestational age). However, other risk factors can also increase the chance of shoulder dystocia, including:
- Shoulder dystocia delivery with past pregnancy
- Estimate fetal weight greater than 8 lbs. 13 oz. (4500 grams)
- Small or abnormal maternal pelvis
- Maternal obesity
- Maternal gestational diabetes
- Failure of labor to progress or arrest of descent
- Instrument-assisted (forceps or vacuum extractor) delivery
In most instances, shoulder dystocia is unpredictable, therefore, it is not common to perform a C-section delivery solely to avoid a potential shoulder dystocia. However, under some circumstances because of the pre-labor risk factors and/or because the labor is not properly progressing, the medical standard of care would require performing a C-section rather than a vaginal delivery. If the standards of care called for an operative delivery rather than a riskier vaginal delivery, and a C-section was not performed, the doctor may be held responsible for any injuries that occur during the vaginal delivery. Much more commonly however, a shoulder dystocia could not be reasonable expected, and the sole medical/legal issue is whether the dystocia was properly addressed when encountered.
Is Infant Shoulder Dystocia Preventable?
In most cases, infant shoulder dystocia is not preventable. However, the physician must be aware of the risk factors for shoulder dystocia for each mother and each pregnancy. In some instances when the risk for shoulder dystocia is very high, an elective C-section should be scheduled to avoid the labor process entirely. In all instances however, once a shoulder dystocia is encountered, the physician or midwife must use the above described techniques to reduce the risk of injury to the baby.
Shoulder Dystocia and Brachial Plexus Injury
Shoulder dystocia can lead to injuries to the baby even under the best of circumstances. For instance, if the standard maneuvers have not relieved the shoulder dystocia within the several minutes the baby will be at greater risk for brain injury or death from a lack of oxygen, and the doctor or midwife will need to exert force and literally break the baby’s collarbone to deliver the baby. However, that is truly the exception. Under almost all circumstances nothing more than gentle traction can be used to release the impacted shoulder to deliver the baby. It’s been said that the amount of force or “traction” on the baby in a shoulder dystocia delivery should be no more than used in an “normal” delivery. Excessive pulling, twisting or tugging on the baby’s head or neck can cause serious and permanent injury to the baby’s spinal cord, cervical nerve roots and/or nerves branching off the spinal cord in the neck. That grouping, or bundle, of nerves coming off the spinal cord in the neck and branching down the arms is known as the “brachial plexus”. Each of the delivery maneuvers and techniques described above are designed to relieve the trapped shoulder in a manner that does not cause undue pressure, twisting or stretch to the baby’s head and neck and these brachial plexus nerves.
Physicians and midwives are trained to never simply pull or twist the baby’s head to relieve the shoulder dystocia. Obstetrical personnel are also taught to never press down on the upper part of the mother’s abdomen (the fundus) when faced with a shoulder dystocia as that would only serve to further impact the shoulder behind the pubic bone. Unfortunately, when a shoulder dystocia is encountered oftentimes the delivering healthcare providers forget their training, or unnecessarily panic, and they twist, pull or otherwise use force to try to deliver the baby. When the head is pulled or twisted while the shoulder is stuck in place, the nerves coming off the spinal cord in the neck are being stretched and oftentimes completely torn causing significant injury to the child. Depending on the extent and location of the force, the child’s injuries could range from a temporary loss of sensation to permanent, lifetime paralysis of his or her arm.
What Is Brachial Plexus Palsy
The brachial plexus is the group of nerves that branch off the spinal cord in the area of the neck and extend down through the arm. These nerves control the strength, movement, and feeling in the arm, wrist, and hand. Injury to the nerves in the brachial plexus may cause a brachial plexus palsy. Erb’s Palsy is the name given to the palsy that results from injury to the upper nerves within the brachial plexus bundle. Damage to the nerves that make up the lower branches of the brachial plexus bundle is known as Klumpke’s Palsy. Children who have sustained serious injury to the entire brachial plexus are said to have suffered a total or global palsy.
Improper shoulder dystocia delivery can cause a range of injuries in a child depending upon the extent of the damage to the nerves. Some children will suffer a temporary or transient injury that will resolve over time with little or no care or intervention. Other children may require weeks, months, or years of therapy; others may need surgery. Some children will regain full use and sensation of their arm and hand, others tragically are left with a completely paralyzed arm. The extent or nature of the injury to the nerves will affect recovery and prognosis. The most severe injury would result in damage to the baby’s spinal cord itself. An avulsion injury is the term used when the nerve root is torn from its attachment to the spinal cord. A nerve rupture is disruption of all or some of the fibers on the nerve which can take place anywhere along the nerve. A stretch injury involves damage to the nerve but not to the point of tear or rupture. Neuropraxia is the term for a lesion which (most often temporarily) interferes with the passage of signals along the nerve. Neuroma is a build-up of scar tissue along a previously injured nerve which can cause pain and interfere with sensation and function.
Possible Maternal Complications
Along with injuries to the baby, there can be complications to the mother from a shoulder dystocia delivery. Symphyseal separation is a dislocation of the pubic bone which can cause permanent nerve damage in the Mother’s leg. Third- and fourth-degree lacerations can extend into the mother’s rectum or anus causing extended complications and disability.
Legal Help for Shoulder Dystocia Injury
If you or your child have experienced injuries related to a shoulder dystocia delivery you should consult with a lawyer to investigate the circumstances of the delivery to protect you and your child’s rights. While injuries can sometimes occur with proper care, oftentimes the injury was caused by improper obstetrical care by the doctor, midwife and/ or obstetrical nursing team. If your healthcare provider made mistakes that led to your child suffering a brachial plexus palsy or other birth injury, they may be held liable for your child’s pain, disability, and related medical costs.
The birth injury team at Raynes & Lawn is ready to help with your case. If you are interested in scheduling a consultation, please feel free to fill out the contact form.
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