Shoulder Dystocia

Shoulder dystocia (SD) is a rare obstetrical emergency that requires prompt, knowledgeable and systematic management. Pregnant people that experience SD are at significant risk for a poor perinatal outcome despite a well-managed response. Reviews of medical legal claims shows that inadequate documentation of the delivery practitioner’s and team’s response to the emergency rather than response itself is often the driver behind out of court settlements and court awarded damages. 

Common Claim Findings

  • Delays in:
    • Identifying SD;
    • Calling for help where SD is encountered (e.g. the call for help occurring after a series of  more than one failed maneuvers);
    • Loss of situational awareness (e.g.,tunnel vision where the attending/delivering practitioner and/or team focusses on one aspect of care to the detriment of the pregnant person) during prolonged labours, unexpected situations and obstetrical emergencies;
    • Concerns surrounding SD maneuvers such as those implemented in an unprepared and/or panicked manner;
    • Excessive time spent on an ineffective maneuver before moving to the next; 
    • Lack of familiarity with recommended maneuvers;
    • Use of maternal pushing alone to resolve SD. 
  • Arterial and venous cord blood gases inconsistently obtained following SD.
  • Pathological placental evaluations inconsistently requested by attending practitioners following a SD (note: such evaluations can play a significant role in legal cases in helping to define the timing and etiology of cerebral palsy. For example, the evaluation may help disprove that the cerebral palsy was caused by an intrapartum asphyxial event vs. an intrinsic placental insufficiency).
  • Significant delays in charting and alteration of original health record following a SD.
  • Inconsistent of documentation of:
    • Delivering practitioner’s intrapartum consideration of risk factors (e.g., large for gestational age, gestational diabetes, post-dates pregnancy, prolonged second stage, oxytocin augmentation); 
    • Fetal surveillance during the second stage of labour;
    • Details surrounding the management of the SD. 

Case Study 1

A pregnant person received pharmaceutical augmentation for their labour due to lack of progress. A prolonged shoulder dystocia was encountered. Assistance was called four minutes after the dystocia was identified. The infant sustained permanent brain injury and brachial plexus injury. Expert review was not supportive of the delivering practitioner’s care and management, in particular the delay in identifying the SD despite repetitive ‘turtle sign’ episodes, delays calling for assistance once the dystocia was identified, and inadequate documentation of the management to respond to the SD. The delivering practitioner had documented the maneuvers used to facilitate the delivery, however the documentation failed to provide clear details with respect to the sequence, duration and frequency of the maneuvers throughout the obstetrical emergency.

Case Study 2

A pregnant person with a history of gestational diabetes required augmentation during labour due to a lack of progress. The person consented to a forceps delivery which took place in the OR. The attending practitioner notified the team of the ‘shoulder precaution’ and a pediatrician was in attendance. Once the head was delivered with forceps, a shoulder dystocia was encountered. A series of maneuvers were applied which ultimately delivered the shoulders. The infant was diagnosed with permanent brachial plexus injury. While expert review was critical of the inadequate documentation surrounding the specific sequence, duration and how many times each maneuver was attempted, they were supportive of the decision to call a shoulder precaution to alert the team before the attempted forceps delivery.

Mitigation Strategies

Reliable Care Processes

  • Adopt a team approach to SD where all members of the team share in:
    • Communicating ‘shoulder precaution’ (or similar) to the team (e.g., during interdisciplinary team huddles);
    • Immediately calling for help once SD is suspected or encountered;
    • Knowledge of the roles of each team member present and aware of the necessary maneuvers.
  • Consider developing processes to facilitate the processing of cord blood gases in the community birth setting.
  • Implement a standardized SD labour management protocol, algorithm and/or checklist to aid clinical decision making and to ensure a systematic and coordinated approach to maneuvers (e.g., early recognition, planned response and documentation; mnemonics) that includes (but is not limited to): 
    • Adopting a standardized definition for prolonged second stage of labour and SD;
    • Mentally preparing for and/or rehearsing of the maneuvers;
    • Ensuring availability of equipment for the out of hospital birth (e.g., a stool/chair or a slipper pan to assist with the performance of the maneuvers);
    • Providing anticipatory guidance to the laboring person once the dystocia is suspected or encountered (e.g., “I may ask you to stop pushing until your baby is repositioned”).
  • Adopt strategies to enhance situational awareness during labour and obstetrical emergencies (e.g., “PETT” mnemonic – proactively seek information related to the patient, environment, task and time, assess the information, think ahead and consider ‘what if’; the use of scoreboards and checklists, effective handoffs and structured communication practices such as SBAR).
  • Implement post-incident management processes (e.g., request arterial and blood cord gases analysis and pathological placental examination) in all birth locations for all shoulder dystocia deliveries. 
  • Conduct team debriefings following all SD births (e.g., what went well and should be recreated; what can be improved); offer support for the attending and delivering practitioners, other team members and learners.
  • Adopt a standardized policy on audio and visual recording of labours and deliveries; consider prohibiting the recording during obstetrical emergencies such as shoulder dystocia (e.g., may interfere with the emergency response or become evidence in legal case) without the consent (i.e. privacy issues) of the attending practitioners, students and hospital or midwife birth centre staff

Documentation

  • Adopt a standardized SD checklist, pre-populated template and/or dictation aid to trigger the systematic, chronological, comprehensive and timely recording of SD management, that includes (but is not limited to):
    • Exact time and how SD was encountered;
    • All personnel called to attend (name, time called and time arriving);
    • Maneuvers attempted and by whom;
    • Sequence, duration and number of times each maneuver 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 (Apgar scores, cord blood gas values (where available), weight, description of injuries and bruises), including whether a pediatrician or  neonatologist consult was requested (where available);
    • Maternal injuries (e.g., lacerations, postpartum hemorrhage);
    • Traction applied (e.g., routine axial, other, reason if not routine axial).

Strategies specific to midwives, obstetricians and family practitioners 

  • Ensure complete and timely antenatal care management plans for pregnant persons with risk factors, incorporating pertinent information such as:
    • Evaluations and interventions recommended, performed and/or declined, in particular glucose tolerance, nutritional counselling, referrals, consults and recommendations;
    • Antenatal discussion of SD management, to prepare the pregnant person for the kinds of requests that might be made at the end of second stage (e.g., to change position).
  • Ensure complete and timely maternal labour records for all labouring persons, in particular those with a prolonged labour and/or undergoing IV oxytocin augmentation of labour or assisted vaginal delivery (vacuum or forceps).

Education

  • Implement formal multifaceted strategies to support and enhance team members clinical knowledge, skills and communication surrounding recognition and response to shoulder dystocia (e.g., participation in MOREob, problem based interdisciplinary, in-situ simulations and emergency skills drills; sharing of learnings and trends from periodic chart audits and extracts, analysis of reported incidents, and medical-legal matters).

Monitoring and Measurement

  • Implement formal strategies to monitor and measure the effectiveness and efficiency of, and adherence to, shoulder dystocia labour management protocol, algorithm and/or checklist(s), including (but not limited to):
    • Adoption of formal process, outcome and balancing indicators associated with shoulder dystocia (e.g., % augmented pregnant persons with SD; % of urgent or emergent C-Section arising SDs following failed assisted vaginal deliveries; compliance with the shoulder dystocia checklist/pre-populated/dictation);
    • Learnings from near-miss and harm incidents (e.g. chart audits/trigger tools, incident reports, team debriefs, critical incident and quality of care committee reviews, data from provincial birth and perinatal registries as well as maternal and perinatal networks, medical legal claims).

Reference

  • HIROC claims.
  • Anderson J. (2012). Complications of labor and delivery: Shoulder dystocia. Prim Care. 39(1):135–44
  • Association of Ontario Midwives. (2010). Management of uncomplicated pregnancy beyond 41+0 weeks’ gestation. Clinical Practice Guideline.
  • Association of Ontario Midwives. (2014). The management of women with a high or low body mass index. Clinical Practice Guideline.
  • Association of Ontario midwives. (2014). Emergency skills workshop manual.
  • Canadian Medical Protective Association. (2016). Safe care in obstetrics: Keys to effective interprofessional care. Safety of care.
  • Chauhan S, Laye M, Lutgendorf M, et al. (2014). A multicenter assessment of 1,177 cases of shoulder dystocia: Lessons learned. Am J Perinatol. 31(5):401–406. 
  • Clark S, Belfort M, Dildy G, et al. (2008). Reducing obstetric litigation through alterations in practice patterns. Obstet Gynecol. 112(6):1279-1283.
  • CRICO. (2017). OB guideline 24: Management of shoulder dystocia.
  • Crofts J, Lenguerrand E, Bentham G, et al. (2016). Prevention of brachial plexus injury - 12 years of shoulder dystocia training: An interrupted time-series study. BJOG. 123(1):111–118. 
  • Deering S, Tobler K, Cypher R. (2010). Improvement in documentation using an electronic checklist for shoulder dystocia deliveries. Obstet Gynecol. 116(1):63-66. 
  • Edozien L. (2015). Situational awareness and its application in the delivery suite. Obstet Gynecol. 125(1):65-69.
  • ECRI Institute. (2009). Obstetrical liability. Healthcare Risk, Quality, & Safety Guidance – Guidance.
  • Fansen A, van de Ven J, Merien A, et al. (2012). Effect of obstetric team training on team performance and medical technical skills: A randomized controlled trial. BJOG. 119:1387-1393.
  • Graves C, Smallwood G, Bressman P, et al. (2012). The initiation of simulation training at a large community hospital. Proc Obstet Gynecol. 2(3):1-12. 
  • Grobman W, Miller D, Burke C, et al. (2011) Outcomes associated with introduction of a shoulder dystocia protocol. Am J Obstet Gynecol; 205(6):513–517. 
  • Grunebaum A, Chervenak F, Skupski D. (2011). Effect of comprehensive obstetric patient safety program on compensation payments and sentinel events. Am J Obstet Gynecol. 204(2):97-105.
  • Inglis S, Feier N, Chetiyaar J, et al. (2011). Effects of shoulder dystocia training on the incidence of brachial plexus injury. Am J Obstet Gynecol. 204(4):322.e1-6. 
  • Lefebvre G, Calder LA, De Gorter et al., (2019). Recommendations from a national panel on quality improvement in obstetrics. Journal of Obstetrics and Gynaecology. 41(5): 653-659.
  • Lerner H. (2007). Three typical claims in shoulder dystocia lawsuits. CRICO/RMF Forum. 
  • Perinatal Services of British Columbia. (2011). Obstetrical emergencies — shoulder dystocia. [Decision Support Tool 8B]. 
  • Poot E, de Bruijne M, Wouters M, et al. (2014). Exploring perinatal shift-to-shift handover communication and process: An observational study. J Eval Clin Pract. 20(2):166-175.
  • Royal College of Obstetricians and Gynaecologists. (2012). Shoulder dystocia.
  • Royal College of Obstetricians and Gynaecologists. (2013). Information for you.
  • Thanh N X, Jacobs P, Wanke M I, et al. (2010) Outcomes of the introduction of the MOREOB continuing education program in Alberta. J Obstet Gynaecol Can. 32:749-755.
  • Van de Ven J, van Deursen F, van Runnard Heimel P, et al. (2015). Effectiveness of team training on managing shoulder dystocia: A retrospective study. J Matern Fetal Neonatal Med. 29(19):1-5.