Although the course of her second pregnancy had been uncomplicated, Mrs P, a 32-year old teacher, had some anxieties about labour. In her first pregnancy there had been suggestions of gestational diabetes but a glucose tolerance test was not done, and she had a normal delivery of a healthy baby girl weighing 4000g.
This time, she felt the baby was bigger than her first and relatives had commented on the size of her abdomen. Fundal height measurements taken in the third trimester were on the 90th centile.
Two days after the estimated due date, Mrs P was admitted to the delivery suite in spontaneous labour. On palpating the abdomen the admitting midwife remarked that this was a big baby. Mrs P had strong, regular uterine contractions and progressed from 3cm cervical dilatation on admission to 9cm six hours later. It took three more hours before the cervix was fully dilated.
Progress was also slow in the second stage of labour and Dr A, locum consultant, was called after Mrs P had been pushing for 45 minutes. Having assessed the pelvis, he proceeded to ventouse delivery of the baby. The head was delivered easily, but it immediately retracted, with the baby’s chin abutting on the perineum (the “turtle sign”). Dr A applied traction to deliver the rest of the baby but this was unsuccessful and it became clear that there was shoulder dystocia.
Dr A cut an episiotomy, then applied further traction but could not deliver the shoulders. A click was heard as he tried unsuccessfully to deliver the posterior arm. Meanwhile the midwife tried to assist by applying fundal pressure but this was not successful. Mrs P’s legs were then removed from the stirrups and McRoberts manoeuvre was applied. This was successful in disimpacting the anterior shoulder and the baby boy G was delivered. G had Apgar scores of 6 and 9 at one and five minutes respectively, and weighed 4300 g. He had a fracture of the left humerus and was found to have a brachial plexus injury of the right side involving C5, C6 and C7 nerve roots (Erb’s palsy). Mrs P suffered a third degree perineal tear, postpartum haemorrhage and symphysis pubis dysfunction. She suffered post-traumatic stress disorder because of the delivery.
The expert witnesses were critical of the management of shoulder dystocia. Once the turtle neck sign was observed, any lateral traction on the baby’s head carried the risk of causing brachial plexus injury and should have been avoided. The hospital had a protocol for the management of shoulder dystocia which outlined the type and sequence of manoeuvres that should be employed. Dr A knew of this protocol but had not read it.
The application of fundal, rather than suprapubic, pressure could not be supported by a reasonable body of medical opinion. Indeed, this practice was considered to be potentially dangerous, as it pushes the impacted shoulder against the pubic bone and could cause uterine rupture.
Expert opinion was also critical of the technique employed by Dr A in an attempt to deliver the posterior arm.
The case was settled for a substantial sum.
- When working as a locum, or in any post, familiarise yourself with the protocols that are in place. If you don’t follow the local protocol then you must be able to show that this departure was based on good clinical grounds, valid evidence, and safe practice.
- An important aspect of the management of shoulder dystocia is contemporaneous documentation, and the hospital’s protocol stated that the type, duration and sequence of manoeuvres used in managing each case should be documented. Although Dr A wrote an operation note for the ventouse delivery, these details regarding the management of shoulder dystocia were not documented.
- Events in previous pregnancies should be taken into account in performing a risk assessment in the index pregnancy.
- Although shoulder dystocia is largely an unpredictable emergency, there were risk factors in this case which made the diagnosis foreseeable: a suggestion of possible impaired glucose tolerance, macrosomia, prolonged labour and mid-cavity instrumental delivery. These should have alerted the staff to anticipate shoulder dystocia and rehearse the shoulder dystocia drill. If shoulder dystocia is appropriately managed, it is more likely than not that the outcome for the baby will be good.
- Consider the entire clinical picture when contemplating an intervention. In this case the slow progress towards end of the first stage of labour, taken with the past obstetric history and macrosomia, should have rung alarm bells.
- Simulation training (“fire drills”) for uncommon emergencies help to hone skills in readiness for actual cases.