Documentation and Risk Management for Shoulder Dystocia Claims

Shoulder dystocia is a relatively uncommon birthing complication that occurs when either one or both of a baby’s shoulders gets stuck in a mother’s pelvis during labor. Despite shoulder dystocia’s relatively low rate of occurrence (0.2-3.0%) and the fact that a majority of babies in these cases are born safely, shoulder dystocia is still a leading cause of litigation in obstetrics and is considered an emergency.

Shoulder dystocia is most commonly diagnosed as failure to deliver the fetal shoulders with gentle downward traction on the fetal head, according to the American College of Obstetricians and Gynecologists (ACOG), and delivery requires additional obstetric maneuvers.

Even though there are known risk factors, ACOG advises that shoulder dystocia is neither predictable nor preventable. Although the baby’s weight and the mother’s preexisting conditions (such as diabetes) are thought to be shoulder dystocia risk factors, studies have shown that the risk factors are poor predictors of this complication. While the risk of shoulder dystocia in second delivery can be higher, a previous incidence of shoulder dystocia in no way guarantees a repeat occurrence.

A well-educated and prepared team is the best defense against lawsuits, regardless of a deviation from the standard of care. Ensuring a fair and just end result requires clinicians to know what a shoulder dystocia is, understand why and how this complication can happen, be prepared to manage this medical emergency in the event it occurs, and ensure that the medical record accurately reflects what occurred. All those providing care must know how to work as a team, including optimizing communication among internal team members and with the mother and family.

Given that the complications of shoulder dystocia can lead to lawsuits and can occur even under the best care, it is important for every member of a healthcare practice to be well-trained in shoulder dystocia documentation and treatment. Proactive risk management and thorough documentation are the best forms of protection when it comes to minimizing the occurrence of shoulder dystocia lawsuits.

What Are the Complications of Shoulder Dystocia?

Mothers and babies can experience a number of complications as a result of shoulder dystocia. Brachial plexus injury (BPI) occurs in 2.3-16.0% of shoulder dystocia cases and is considered the most common shoulder dystocia complication for infants. BPI is the result of damage to the brachial plexus nerves—the nerves that run from the spinal cord down into the arm—and can lead to weakness or paralysis in the shoulder or arm. Although it is typically associated with shoulder dystocia, BPI also occurs in deliveries where shoulder dystocia is not a factor, such as with a precipitous delivery.

Other possible fetal complications of shoulder dystocia include fractures of the fetal clavicle and humerus and, in rare cases, asphyxia (a lack of oxygen in the body that can lead to brain injury or death). Fortunately, death is extremely rare and is reported in only 0.4% of cases of shoulder dystocia. For mothers experiencing the complications of shoulder dystocia, risk factors include tearing of the perineum (the area between the vagina and the rectum), postpartum hemorrhage (PPH), and uterine rupture.

While the severity of these complications varies from case to case, it’s important to note that the majority of mothers and babies recover from shoulder dystocia.

How Is Shoulder Dystocia Treated?

To treat shoulder dystocia, the baby’s shoulder must be released from where it is trapped in the pelvis. Providers may direct nurses to perform what are called primary maneuvers (e.g., McRoberts and suprapubic pressure). Providers themselves may conduct a series of maneuvers called secondary maneuvers (e.g., Rubin maneuver and posterior arm rotation). These maneuvers typically will release the shoulder and help the baby pass through the birth canal more easily.

Which maneuvers and techniques a clinician uses—and in what order—will depend on the baby’s position as well as the clinician’s experience and how they were trained. Following are the most common techniques used in shoulder dystocia treatment.

Primary Maneuvers

• McRoberts Maneuver: During this maneuver, the mother pulls her legs toward her stomach to flatten and rotate her pelvis, helping the baby’s shoulder release.
• Suprapubic Pressure: A clinician can encourage the baby’s shoulder to rotate by putting pressure on the mother’s pelvis with their fist.

Secondary Maneuvers

• Episiotomy: An episiotomy is an incision in the perineum. While this won’t solve the problem of shoulder dystocia entirely, it can create more space for the physician to conduct the maneuvers needed to move the baby through the birth canal. However, episiotomies come with risks, including maternal posterior perineal trauma.
• Rubin Maneuver: During the Rubin Maneuver, the clinician inserts their fingers into the vaginal canal to try to rotate the baby’s shoulder.
• Gaskin Maneuver: Some obstetrics teams may position the mother on her hands and knees, leveraging the power of gravity to help release the baby’s posterior arm from the birth canal. By releasing the baby’s arm, the clinician provides the baby’s shoulders with more space to pass through the canal.

If all those maneuvers fail to deliver the baby, the physician may elect a last-resort maneuver, such as an intentional clavicle fracture, a symphysiotomy, or the Zavanelli maneuver.

In the rare cases in which the likelihood of shoulder dystocia can be predicted, some mothers may decide to schedule a C-section rather than attempt a vaginal birth. This typically occurs if the fetus weighs 11 pounds or more or if the mother has diabetes and the baby weighs at least nine pounds, 15 ounces.

What Should Be Documented After Shoulder Dystocia?

Given the risk of litigation and how much variability there is in shoulder dystocia treatment, it is vital that every technique and procedure used is documented in great detail. Using a comprehensive checklist for shoulder dystocia documentation is designed to protect medical personnel from litigation. All reports should be written in a timely manner with enough detail and clarity that anyone—whether a medical professional or a courtroom attendee—can understand them.

An exhaustive shoulder dystocia report will include:

• When and how the shoulder dystocia was diagnosed, as well as the position of the baby’s head upon diagnosis.
• All the healthcare professionals attending the delivery, including doctors, nurses, and any other personnel (anesthesiologists, pediatric clinicians, etc.) that were called in to assist.
• Details on all the procedures and maneuvers employed, the order in which they were employed, the result obtained from each, and the reasons they were used. It is also best to include either the actual or estimated time between the initiation of each maneuver and the initiation of the subsequent maneuver. This is considered the “action plan” and is one of the most important elements to document.
• The time of delivery of the head.
• The time between the diagnosis of shoulder dystocia and the baby’s delivery.
• Impressions of the newborn upon delivery, including Apgar scores, birth weight, and the presence or absence of a nuchal cord, meconium staining, or intrapartum injury. It’s also important to include details about the placenta.
• A formal newborn assessment, including noting pulses, affected arm weaknesses, and reflexes.
• Any requests made to the pediatrician or neonatologist to check the newborn’s clavicle, humerus, shoulder, etc.
• Notes on the mother’s condition immediately following delivery, including all relevant findings of the postpartum exam and any actions taken on behalf of the mother’s wellbeing such as blood transfusions or pain relief measures.
• Documentation that the mother was informed of the occurrence of shoulder dystocia and the potential sequelae. The report must also state that the mother was given time to ask questions and express her concerns. A detailed list of those questions, concerns, or requests should be included.

Keep Patients and Practitioners Safe

Shoulder dystocia is a challenging medical emergency and is unpredictable and unpreventable. This is a delivery presentation that affects women and infants across the globe. It is also a leading cause of litigation in obstetrics, underscoring the importance of high-quality team (physicians and nurses) training in the identification, management, treatment, and documentation of the shoulder dystocia event. With the right training, the quality of care increases, delivery risks are reduced, and healthcare teams and systems are better protected.

Relias offers advanced training and educational courses that provide all obstetrics employees with in-depth information pertaining to shoulder dystocia treatment and documentation. With Relias, patients and practitioners alike are protected.