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A recognised complication

01 September 2010

Mrs F was a 38-year-old secretary who was pregnant for the first time. She had no significant past medical history of note. Her pregnancy had been uneventful, but a glucose tolerance test at 28 weeks confirmed that she had gestational diabetes and was treated appropriately. She went into labour spontaneously at 37 weeks. The first stage of the labour progressed well; however, the second stage of labour was prolonged.

The obstetrician, Dr R, documented that the baby’s head was engaged and not palpable abdominally. The baby was in the correct position and the case was deemed suitable for an assisted vaginal delivery. Dr R successfully delivered the baby’s head with a ventouse cup at 7.05am but noted that there was some difficulty in delivering the baby’s shoulders.

Emergency help was called and with Mrs F’s legs hyperflexed (McRoberts position) and an assistant applying supra-pubic pressure, Dr R delivered a live 3.7 kg female infant by 7.07am. Further documentation also noted that “excess lateral traction was avoided”.

The baby was fully alert at delivery, but was found to have weakness in the left upper limb. The paediatricians soon made a diagnosis of Erb’s palsy, although within 12 months this resolved completely with careful physiotherapy follow-up.

Mrs F made a claim, as she was advised that a Caesarean section would have prevented this complication.

Expert opinion agreed that Erb’s palsy can be caused by negligent management but, in this particular case, the management of pregnancy and delivery had been correct and there had not been a real indication for a Caesarean section at any point. A defence was lodged and the claim was then discontinued.

Learning points

  • Shoulder dystocia occurs when the anterior foetal shoulder becomes impacted in the maternal pelvis after the head has been delivered. Additional "manoeuvres” are required to deliver the baby.
  • This is an acute, life-threatening obstetric emergency and must be recognised and treated urgently to avoid significant morbidity and mortality. Brachial plexus injuries are responsible for a significant number of obstetric claims. Familiarity with this complication can assist the management. 
  • Shoulder dystocia is unpredictable and should be anticipated at all deliveries.
  • Good documentation was the strength of this particular case. Dr R had documented all his actions and times of his procedures and identified the areas of risk. 
  • As a minimum, the following must be documented by the lead professional involved in the delivery with times noted by a scribe as soon as the emergency is recognised: 
    • The time of the delivery of the head 
    • Which shoulder impacted – left or right 
    • Time help was called 
    • Who was called 
    • Time of arrival of various staff members including names and profession 
    • A record of all manoeuvres 
    • The order in which they were carried out 
    • How long was spent on each manoeuvre 
    • Time the baby was born 
    • Time interval between head and body delivery. 
  • All entries must be signed, with the staff member’s name and position printed clearly.

The RCOG (Royal College of Obstetricians and Gynaecologists) Guideline No. 42, Shoulder Dystocia (2005) provides an excellent appendix to allow this information to be recorded clearly.

References

  1. Athukorala C, Middleton P, Crowther, CA, Cochrane Database of Systematic Reviews 2006, Issue 4, Intrapartum interventions for preventing shoulder dystocia.
  2. Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) (1996) 5th Annual Report, Maternal and Child Health Consortium, London.
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