Mismanagement of Shoulder Dystocia

Shoulder dystocia (SD) is an obstetrical emergency that requires prompt, knowledgeable, and systematic management.  While there are a number of factors associated with the increased risk of SD, the factors lack sufficient sensitivity to enable the reliable and accurate prediction of SD; further, some SD occur in the absence of risk factors. A coordinated and prompt response that includes accurate documentation by the care team can minimize harm incidents (including but not limited to neonatal hypoxic-ischemic encephalopathy) and risks of legal action against the clinical team and most responsible practitioner (MRP).  Effective management of SD requires antenatal assessments by skilled professionals, intrapartum care pathways, and proactive clinical management. From a medical legal perspective, inadequate documentation of the team’s clinical response to the SD emergency is often the driver behind out-of-court settlements and court awarded damages.

Expected Outcomes

Adopt a standardized evidence-based SD labour management protocol to ensure a systematic and coordinated approach. 

Implement formal strategies to provide ongoing and targeted education and training to support the interdisciplinary team’s clinical knowledge, skills (technical and non-technical), and practical experience surrounding SD

Adopt standardized quality indicators to review and monitor the collaborative care process involving SD

Definitions and Acronyms

• BMI – body mass index
• Client – includes all persons who receive healthcare and related services including patients, residents and persons in-care
• MRP – most responsible practitioner, often a midwife, nurse practitioner or physician
• SD – shoulder dystocia
• Situational awareness – deliberate and active scanning and assessing of the situation to maintain a holistic understanding of the environment in which the team is functioning

Common Claims Themes and Contributing Factors 

Organization

• Limited opportunities for midwives, physicians, and teams to acquire and maintain skills and experience in responding to obstetrical emergencies, such as SD.
• Hierarchical culture that does not encourage a team approach to obstetrical emergencies.
• Perceived and actual tolerance of unprofessional, unsafe, and disruptive behaviours as well as inter-/intra-professional conflicts.
• Lack of standardized SD record / dictation aid to support consistent and comprehensive documentation following a SD.

Knowledge and Judgment

• Lack of awareness or compliance with the healthcare organization’s SD policies / practices.
• Failure to recognize and act on risk factors for SD in the antenatal period.
• Loss of situational awareness during prolonged labours, unexpected situations and SD.
• Failure to appreciate signs of SD during the second stage of labour and anticipate for the need to additional / specialist attendance at the birth.
• Lack of familiarity or experience with recommended maneuvers to resolve SD.
• Failure to execute recommended SD maneuvers in a timely and coordinated manner.
• Failure to conduct or request recommended cord blood gases and pathological analysis of placenta in response to high risk labours and births or obstetrical emergencies such as SD. 

Communication 

• Delays notifying the MRP or requesting an obstetrical consult or transfer of care in the presence of prolonged or prodromal labour.
• Failure to communicate SD risk factors to the pregnant person or team members.
• Delays or failure to call for help where SD is anticipated or encountered.

Documentation 

• Use of generalized statements in documentation e.g., “…several maneuvers attempted”.
• Significant delays in charting or alteration of original health record following a SD.
• Inconsistent documentation of:
  • Antenatal conversations, including (but not limited to) identified risk factors and vaginal birth versus elective Caesarean;
  • Fetal surveillance during the second stage of labour.
  • Management of the SD.

Mitigation Strategies

Care Processes

• Implement a standardized evidence-based SD labour management protocol to ensure a systematic and coordinated approach that includes (but not limited to) the need for a standardized assessment of individuals at risk for SD, early recognition, planned response, equipment, and documentation requirements / templates (Agency for Healthcare Research and Quality, 2018) (American College of Obstetricians and Gynecologists, 2017).
• Implement a current evidence-based protocol for antenatal planning (e.g., personnel, consults with specialist, and equipment that may be required for the birth), and intrapartum and postpartum monitoring for pregnant persons with high BMI (Hope & MacDonald, 2019) (Maxwell, et al., 2019).
• Implement a current evidence-based protocol for diabetes in pregnancy (i.e., pre-gestational diabetes mellitus and gestational diabetes mellitus pregnancies) (Kattini, Hummelen, & Kelly, 2020) (Kehler, MacDonald, & Meuser) (Berger, Gagnon, & Sermer, 2019) (Berger, Gagnon, & Sermer, 2019).
• Adopt a team approach to SD where all members of the care team are expected to:
  • Be knowledgeable of the roles of each team member present and the necessary maneuvers;
  • Communicate concerns surrounding risk factors and / or anticipated SD to the team where indicated (e.g., upon arrival at triage or admission to the unit, team huddles);
  • Immediately call for help once SD is suspected and / or encountered.
• Conduct a post incident management process for all births with challenging resuscitations or intubation that includes (but not limited to) requesting arterial and venous blood cord gases analysis and pathological placental examinations (Dore & Ehman, 2020).

Communication 

• Conduct debriefings (interdisciplinary team and family) and offer supports following all births involving SD. 

Documentation 

Strategies for Midwives and Physicians

• Adopt a standardized SD documentation record or dictation aid to support timely and reliable documentation of SD management for all birth locations (Horspool, n.d.) (Clinical Guidelines For Obstetrical Services, 2022) (Royal College of Obstetricians and Gynaecologists, 2012) (Darthmouth Health, n.d.).

Additional Considerations

Examples of elements to address within the standardized SD documentation record or dictation aid (hospital and community birth locations):

• Exact time and how SD was encountered;
• All personnel called / paged to attend (name, time called, and time arriving);
• Maneuvers attempted and by whom;
• Sequence, duration, and number of times each maneuver was attempted;
• Which fetal shoulder was anterior and which was posterior;
• Position of the fetal head at delivery;
• Exact delivery time for head and body;
• Assessment of the infant (e.g., Apgar scores, cord blood gases, weight, description of injuries and bruising, whether a pediatric consult was requested);
• Assessment of the postpartum person (e.g., injuries, lacerations, hemorrhage).

• Ensure complete and timely antenatal care management plans for pregnant persons with risk factors, incorporating pertinent information such as evaluations / interventions recommended, performed, and / or declined (e.g., glucose tolerance), nutritional counselling, referrals, consults and recommendations, and antenatal discussion of SD management. 

Team Training and Education

• Implement formal strategies to support and enhance the team’s clinical knowledge, skills (technical and non-technical), and practical experience surrounding SD, including (but not limited to) scheduled interprofessional and cross-department skill drills and simulations (Agency for Healthcare Research and Quality, 2018).
• Ensure the scheduled interprofessional and cross-departmental team training and education strategies consider or involve: 
  • Practitioners bias and assumptions towards pregnant persons with a high BMI (Hope & MacDonald, 2019) (Maxwell, et al., 2019);
  • Team and practitioner situational awareness (‘helicopter view’) and human factors;
  • Program areas or sites with limited practical experience with obstetrical emergencies such as low birth volume sites, rural sites and midwifery led birth centres;
  • Unregulated care providers (where utilized), locums, travel, agency, contracted care providers in addition to regulated health providers.

Monitoring and Measurement

• Adopt a standardized, interdisciplinary, collaborative, and evidence-based protocol for conducting quality of care reviews involving SD resulting in client harm or death; incorporate system thinking and human factors concepts into the review process (Society of Obstetricians and Gynaecologists of Canada, 2021) (Machen, 2023). 
• Adopt standardized quality indicators for SD (Calder, et al., 2019) (Coroneos, et al., 2016).
• Incorporate learning from local, provincial, and national SD-related safety reviews and data into local protocols as well as staff and client education and training (Agency for Healthcare Research and Quality, 2018). 

References

• Agency for Healthcare Research and Quality. (2018). Labor and Delivery Unit Safety: Shoulder Dystocia. Retrieved from https://www.ahrq.gov/hai/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool-shoulder-dystocia.html
• American College of Obstetricians and Gynecologists. (2017). Shoulder dystocia. Practice Bulletin, 178.
• Berger, H., Gagnon, R., & Sermer, M. (2019, 12). Guideline No. 393-Diabetes in Pregnancy. 
• Calder, L., Bowman, C., Yang, Q., Gondocz, T., Young, C., Zhang, C., . . . Lefebvre, G. (2019). A Quality Indicator Framework for High-Risk Areas in Obstetrical Care. Unpublished manuscript.
• Clinical Guidelines For Obstetrical Services. (2022). Appendix A: Sample documentation of delivery with shoulder dystocia. Retrieved from Harvard University: https://www.rmf.harvard.edu/-/media/Files/_Global/KC/PDFs/Guidelines/CRICO-OB-consent-App-A.pdf
• Coroneos, C., Voineskos, S., Coroneos, M., Alolabi, N., Goekjian, S., Willoughby, L., . . . Brouwers, M. (2016, 2). Obstetrical brachial plexus injury: burden in a publicly funded, universal healthcare system. 
• Darthmouth Health. (n.d.). Sample delivery note: Shoulder dystocia. Retrieved from https://www.dartmouth-hitchcock.org/health-care-professionals/sample-delivery-note-shoulder-dystocia
• Dore, S., & Ehman, W. (2020, 3). No. 396-Fetal Health Surveillance: Intrapartum Consensus Guideline. 
• Hope, N., & MacDonald, T. (2019). Clinical practice guideline No.12: The management of high or low body mass index during pregnancy 2019 update. Association of Ontario Midwives.
• Horspool, D. (n.d.). Operation: Shoulder dystocia. Retrieved from OBGYNTools: http://obgyntools.com/dictations/dictation-shoulderdystocia.html
• Kattini, R., Hummelen, R., & Kelly, L. (2020, 11). Early Gestational Diabetes Mellitus Screening With Glycated Hemoglobin: A Systematic Review. 
• Kehler, S., MacDonald, T., & Meuser, A. (n.d.). Gestational diabetes mellitus: A review for midwives. Association of Ontario Midwives.
• Machen, S. (2023, 5). Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report. BMJ Open Quality, 12(2), e002020.
• Maxwell, C., Gaudet, L., Cassir, G., Nowik, C., McLeod, N., Jacob, C.-É., & Walker, M. (2019, 11). Guideline No. 392-Pregnancy and Maternal Obesity Part 2: Team Planning for Delivery and Postpartum Care. 
• Royal College of Obstetricians and Gynaecologists. (2012). RCOG green-top guideline No. 42: Shoulder dystocia. RCOG.
• Society of Obstetricians and Gynaecologists of Canada. (2021). Maternal mortality review committees guide.