One common type of obstetric malpractice case involves a delivery complication known as shoulder dystocia, in which one of the baby’s shoulders (usually the front or anterior shoulder) gets stuck behind the mother’s bone. The common scenario is that the baby’s head delivers and then pulls back toward the mother’s body–the so-called “turtle sign.” Shoulder dystocia is an obstetric emergency, because the baby is stuck and won’t deliver without special obstetric maneuvers, but isn’t getting adequate oxygen because the umbilical cord is compressed by the baby’s body. If the shoulder dystocia is not resolved quickly, brain damage or even death can result.
But freeing the trapped shoulder has its own risks. If the obstetrician pulls too hard on the baby’s head, injury to the brachial plexus nerves in the shoulder may result. Also known as Erb's Palsy, this damage may heal over time, or, if the nerves are torn or avulsed, it may be permanent. Depending on the extent and level of the damage, a child with Erb's Palsy may have little or no use of his wrist, arm, and/or shoulder.
There are two ways to prevent Erb's Palsy: by delivering the baby by Cesarean section before the shoulder dystocia occurs, or by using obstetric techniques that free the shoulder without traumatizing the brachial plexus nerves. Either a doctor’s failure to recognize the risk of shoulder dystocia or the failure to use the proper techniques may form the basis of a malpractice claim.
For years, doctors have attempted to defend these cases by claiming that shoulder dystocia is unpreventable and unpredictable. More recently, obstetricians have created a body of literature to help in their defense, claiming that Erb's palsy injuries aren’t caused by traction, but are due to the forces of the uterus expelling the baby down the birth canal. Both of these defenses are rebuttable with scientifically based medical literature.
While it’s impossible to “predict” in any given mother whether there will be shoulder dystocia, there are a number of factors that can dramatically increase the risk, sometimes to the point where a Cesarean section is advisable. These include pre-labor factors such as the mother’s height and weight, the baby’s estimated weight, maternal diabetes, and a history of prior shoulder dystocias. There are also risk factors that arise during labor, such as induction with Pitocin or a delivery that is either prolonged or precipitous (too long or too short). One company claims to have created an algorithm that will enable doctors to assess the risk accurately so that it can be discussed with their patients.
Some “women’s rights” groups decry the notion of “prophylactic” Cesarean sections, done to prevent shoulder dystocia in high-risk situations. Their members fill internet bulletin boards and chat rooms with diatribes about the “myth” of the big baby, and of obstetricians who perform unnecessary Cesareans, or “cause” shoulder dystocia by inducing labor.
Yet just like the obstetricians who exclude women from the decision-making process, these supposed patient advocates do expectant mothers a great disservice. Since there is no way to predict exactly which high-risk mothers will have shoulder dystocia, each woman must make her own choice, after careful discussion with her health care providers. Some women prefer to attempt a vaginal delivery, while others choose the operative route to avoid the risk of a child with a devastating injury. And the calculus can change during labor if additional risk factors develop. What seemed safe enough at the outset may become more dangerous with the passage of time.
It is also regrettable that the medical profession has chosen to devote so much time and money to creating defenses to shoulder dystocia cases, rather than to educating providers and counseling mothers so that they can work together to make the best choice for each individual. Proper education, risk assessment, and decision-making would reduce both the number of injured babies and the number of malpractice claims.