Peter S. Bernstein, MD, MPH

Disclosures

October 12, 2004

One of the most common lawsuits brought against obstetricians for medical malpractice involves shoulder dystocias and brachial plexus injuries. Shoulder dystocias constitute real medical emergencies that every obstetrician needs to be prepared to handle, as the vast majority of them are unpredictable. Furthermore, shoulder injuries cannot necessarily be prevented even when they are handled properly. Providers' fear of encountering shoulder dystocias has unfortunately resulted in their performing many cesarean deliveries unnecessarily in order to avoid a small risk of a shoulder dystocia, exposing the mother and the newborn to other, more likely risks.

Even if we perform cesarean sections on all women having risk factors for shoulder dystocias during their deliveries, we would still encounter a large number of totally unexpected shoulder dystocias. Therefore, it is important for all obstetric care providers to know the maneuvers to perform when these difficult situations occur. The point of this essay, however, is not to go over these maneuvers but to consider some of the other aspects of care and documentation that will help obstetric providers to care for their patients and protect themselves from liability should an untoward outcome occur that results in a lawsuit.

Here is a hypothetical case that demonstrates some of these points: A 25-year-old woman presents for care with her first pregnancy. She is obese and has a strong family history of type 2 diabetes mellitus. Her obesity and family history are risk factors for delivering a macrosomic infant at term.

Thus, at the time of the first prenatal visit, it is important for her prenatal provider to document a plan to address these risk factors that includes an early screen for diabetes, nutrition counseling, and counseling about appropriate weight gain, for example.. Complete documentation of this plan helps to ensure that no element is overlooked at subsequent visits.

This particular patient had an early screen for diabetes that was negative and a dating ultrasound, because it was difficult to judge the size of her uterus in light of her obesity. She had a normal level 2 ultrasound; but at 26 weeks, she had a positive screen for gestational diabetes (her glucose level 1 hour after a 50-g oral dose of glucose was 170 mg/dL). Her subsequent 3-hour glucose tolerance test (GTT) was negative for gestational diabetes. A positive screen for diabetes is another risk factor for a macrosomic newborn at term, even in the setting of a negative diagnostic test for gestational diabetes. Again, it is important that a note be written in the chart that acknowledges this risk and documents a plan.

In this case, the plan was to repeat the 3-hour GTT 4 weeks later and to obtain an ultrasound for fetal growth at approximately 32 weeks of gestation, as it was difficult to accurately determine the patient's fundal heights. The repeat GTT done at 30 weeks of gestation was again negative, but the 1-hour value was slightly above its cutoff. The ultrasound for fetal growth at 32 weeks revealed a fetal weight estimated to be at the 75th percentile, although the abdominal circumference was just above the 90th percentile for the fetus's gestational age.

Understanding the limitations of tests and documenting that understanding in your assessment and plan buttresses your position. In this case, although the ultrasound does not indicate a macrosomic fetus, the enlarged abdominal circumference in the setting of a single elevated value on the 3-hour GTT increases the risk of some underlying glucose intolerance in this patient and increased chance of dystocia at the time of labor and delivery. Placing this patient on a suitable diabetic diet may be an acceptable intervention at this point, along with planning for another ultrasound at approximately 38 weeks of gestation.

In our case, the patient presents to labor and delivery in active labor at 38 weeks of gestation before she is able to have her repeat ultrasound. The patient's primary provider is not on call that night -- her partner is.

Communication between providers is a key element to reducing untoward outcomes. With most providers working as part of groups, not ensuring that a complete record of a patient's care is available to the delivering provider places that provider and the group at substantial risk. In this not unusual example, the doctor on call has not cared for this patient over the course of her pregnancy and therefore would be at a significant disadvantage in terms of planning for the management of her labor and delivery if a complete copy of the prenatal record is not available at the time of this patient's admission in labor.

In this case, the patient has gained 45 pounds over the course of her pregnancy (an excessive amount given that she started the pregnancy significantly overweight), and her fundal height at the last prenatal visit was 41 cm. Still she is in active labor with her cervix dilated 5 cm and the fetal vertex at -1 station, with almost no molding or caput.

It may be entirely appropriate to allow this patient to undergo labor and attempt a vaginal delivery. Whatever the provider caring for this patient in labor chooses as a plan, it is important that a careful admission note be written. The note should indicate that the provider has reviewed the patient's past obstetric and medical history, as well as her prenatal course. It should acknowledge any problems or risk factors noted during the course of the pregnancy to date, and it should clearly outline the plan of management. It should also document that the plan of management has been discussed with the patient. Important items not to be forgotten in the admission note for this patient would include estimation of the current fetal weight and the adequacy of the patient's pelvis, and a detailed plan of management for her labor and delivery.

In this fictitious example, the physician documents all of the above and plans for a trial of labor. For this patient, a trial of labor is appropriate -- provided the reasoning of the physician's plan is well documented. In this case, it would include the following information: the reassuring status of the fetus; the normal progression of labor; the fact that the patient did not have gestational diabetes; that the estimated fetal weight was not excessive; on exam her pelvis seemed adequate for delivery of the fetus; and that the plan of management might change if the labor did not progress adequately.

Documentation of a plan to observe "shoulder precautions" is also appropriate. These may include but are not limited to ensuring adequate intravenous access should emergency medications need to be given, notification of pediatric and anesthesiology staff at the time of delivery, preparation to perform standard maneuvers if a shoulder dystocia is encountered, and ensuring that there is appropriate obstetric staff support available to assist at the time of delivery.

In this case, the patient's labor progressed as expected. But if it had not, documented plans can always be amended as the clinical situation changes. If this patient had not progressed adequately in the presence of adequate contractions as judged clinically or objectively with the use of an intrauterine pressure catheter, a cesarean delivery might be appropriate. If the contraction pattern was inadequate, the use of oxytocin augmentation might be appropriate. Either way, documentation should demonstrate the provider's reasoning. If oxytocin is going to be used, the note should include evaluation of fetal well-being, evidence to support an inadequate contraction pattern, an estimate of fetal weight, assessment of maternal pain control, and documentation of the adequacy of the maternal pelvis.

Returning again to this case, even though the care was entirely appropriate, a shoulder dystocia was encountered. The delivering physician was prepared, in that there was appropriate support from the labor and delivery staff. The usual maneuvers were performed and the baby delivered. A detailed delivery note is critical in this situation.

Documentation of the delivery is central to reducing liability. An accurate and honest delivery note should be written by the attending physician. If house staff were involved, they should also write a delivery note and indicate how they were supervised by an attending physician. The delivery note should include the following elements:

  1. Position of the fetal head at delivery

  2. Which shoulder was the anterior shoulder

  3. Time of delivery of the fetal head

  4. Time of delivery of the fetal body

  5. Staff present (eg, nursing, obstetrics, pediatrics, anesthesia)

  6. Maneuvers used to achieve the delivery

  7. Newborn weight and Apgar scores

  8. Cord blood gases

  9. Any deficit in motion of the extremities and which extremity(ies)

  10. Disposition of the newborn

  11. Any maternal injuries (eg, 4th degree laceration, postpartum hemorrhage)

All of this information is important. For example, sometimes injuries occur in the posterior shoulder, which suggests that they did not occur during the actual delivery but before the delivery of the fetal head. Normal Apgar scores or cord pHs greater than 7.0 would suggest that if the newborn or child develops some sort of central nervous system injury, it is not the result of hypoxia during the delivery.

Fortunately, shoulder dystocias are rare events and seldom result in permanent injury to the newborn. Unfortunately, they usually are not predictable events, and performing more cesarean deliveries will not have a substantial impact on their occurrence (as they can occur at cesarean deliveries, a large number of cesareans would need to be performed to prevent a single shoulder dystocia, and as many as 50% of shoulder dystocias occur in patients without risk factors). Also, unfortunately, our medical-legal system operates in a way that it tries to assign blame in order for financial assistance to be given to the unfortunate newborn who may be affected by this complication. Given these circumstances, providers need to do their best to provide thoughtful and complete care to their patients and to document all aspects of that care.

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