Shoulder dystocia is a complication that arises when a baby delivering head first - ie. the normal way - gets stuck on the way out.
The usual sequence of events is that when the head is delivered, it is facing backwards, i.e. towards the back of the mother. The head once delivered then turns before the rest of the body comes out. This turning means that one shoulder has to dip lower than the other so making it easier for the baby to be delivered. If there is a problem in part of this sequence of events, then this can be catastrophic for the baby and cause significant harm to the mother.
The most common cause is that one of the shoulders cannot move, as it is either pressing on the behind section of the pubic bone (at the front), or is against the sacrum at the back of the pelvis. Figures quoted in the literature say that it happens in about 0.6% of deliveries.
The injuries to the mother include tears in the perineum or significant haemorrhage (which can even be life threatening).
For the baby, problems can arise owing to pressure on the arm meaning that there can be damage to the nerves of the arm, an Erb’s palsy being the form most frequent seen (described as the arm hanging down with the hand rotated, like a waiter putting his hand out behind him for a tip!).
If the umbilical cord is also compressed, there is a risk of intracranial bleeding that can be a cause of brain damage. This is fortunately an uncommon occurrence but can be devastating to the baby.
From the Royal College of Obstetrics and Gynaecology’s guidelines on this condition:
‘The NHSLA (NHS Litigation Authority) has reported that 46% of the injuries were associated with substandard care. However, they also emphasised that not all injuries are due to excess traction by healthcare professionals, and there is a significant body of evidence suggesting that maternal propulsive force may contribute to some of these injuries.’
The following are important when considering a possible case of clinical negligence.
When looking at the notes, the following should have been recorded:
- When the head was delivered and when the rest of the body was delivered
- What steps were taken to encourage the delivery, and when and in what order
- What were the findings of the examination of the mother, and estimated blood loss
- How was the baby – this should have included an assessment by a neonatologist
All maternity staff are required at least annually to take part in shoulder dystocia training- is this the case for the clinicians involved?
Were the attendants trained to look out for the features of shoulder dystocia - these include:
1) A failure for the delivered head to rotate (this aligns the head with the rest of the body during the final phases of the delivery process)
2) A delay/inability to deliver the shoulders- the shoulders are not coming down from the vagina
3) Difficulty in delivering the head
If shoulder dystocia is suspected, then help is required to manage both the mother and baby as indicated above.
This is an important and common area for claims, and expert medical opinion is needed at an early stage, as indicated by the fact that some birth injuries may occur due to the circumstances surrounding the delivery and are not due to negligence. Hence it is important to determine which claims do fulfil breach of duty and causation matters.
If you want further information about this particular topic, or wish to discuss the possibility of bringing a claim, please contact the Dutton Gregory Clinical Negligence Team.