Shoulder Dystocia

Shoulder dystocia occurs where there is difficulty delivering a baby’s shoulder. During vaginal birth, a baby’s shoulder may become lodged behind the mother’s pubic bone.

This is an emergency because the baby’s head is outside of the birth canal, but its neck has not emerged. The mother’s contractions then put pressure on the baby’s neck and body, which can be fatal.  The obstetrical team must carefully keep track of the time from the beginning of the emergency. This is because when the shoulder becomes stuck it can trap the baby’s head and put pressure on the umbilical cord, which restricts oxygen and blood flow to the baby. It is therefore important in most shoulder dystocia emergencies, that the baby is delivered within five minutes or less.

As soon as it is apparent that the baby’s shoulder is stuck, the delivery team must work quickly to deliver the baby to prevent brain injury or death. Obstetricians are trained to perform the following procedures in this order:

1. McRoberts manoeuvre the mother’s legs are bent up toward her chest, this widens the pelvis and flattens the spine of the lower back. If the baby’s shoulder does not dislodge, the medical team should move to the next procedure.
2. Suprapubic Pressure: Pressure is put on the mother’s stomach at a forty-five degree angle to rotate and push the trapped shoulder below the mother’s pubic bone.  The pressure should be applied to the lower abdomen only
3. Wood’s Screw manoeuvre: The obstetrician puts his hand inside the birth canal, next to the baby’s shoulder and rotates the baby to dislodge the shoulder
4. Episiotomy: An episiotomy is a surgical cut to the area between the vagina and the anus.  The theory is that it gives the baby more room for delivery
5. Zavenelli manoeuvre: This is rarely used, and requires the obstetrician to push the baby back into the vagina, and deliver the baby by emergency cesarean section
6. Symphsectomy:  Also rarely used, the symphsectomy surgically cuts the mother’s pubic bone to allow room for the baby’s shoulder to come through

Injuries Caused by Shoulder Dystocia

The only actual injuries that can be caused by shoulder dystocia alone are hypoxic brain injury or death.  Any other injury the baby sustains is caused by the obstetrician’s attempts to free the shoulder, either by excessive pulling or twisting of the baby.  In these circumstances the following injuries may result:

• Brachial plexus nerve injuries, such as Erb’s palsy and Klumpke’s palsy
• A fracture of the bone that connects the shoulder to the elbow (the humerus)
• A fracture of the collar bone (the clavicle)

Medical Negligence Causing Shoulder Dystocia Injuries

Birth injuries caused by shoulder dystocia are among the most preventable, especially if the procedures listed above are undertaken in an appropriate and timely manner. Negligent doctors often claim that due to shoulder dystocia causing a medical emergency, any injuries caused by excessive pulling and twisting of the baby are unavoidable. Whilst shoulder dystocia is technically an obstetric emergency, the possible injuries are entirely foreseeable, which means some are preventable. This is particularly so where shoulder dystocia risk factors have been flagged up. Such risk factors include:

• Fetal macrosomia i.e. the baby is larger than 4,000 grams or 8.13 pounds
• Maternal diabetes/gestational diabetes
• The mother has had previous births that have been complicated by shoulder dystocia
• Maternal obesity
• The pregnancy has lasted longer than 42 weeks
• There has been a prolonged second stage of labour
• There has been an assisted delivery with the use of either forceps or ventrous.