SHOULDER DYSTOCIA: COMMON AREA OF PERINATAL LITIGATION

In this blog, I’ll be reviewing some causes of perinatal litigation, the importance of providing care according to current standards of care, ways to mitigate perinatal liability exposure, common allegations specific to alleged injuries resulting from shoulder dystocia, and current standards of care intended to decrease professional liability exposure, and reduce the risk of iatrogenic (relating to injury or illness caused by medical examination or treatment) maternal and neonatal injury.  

Causes of Perinatal Litigation:  Findings suggest that allegations against nurses, certified nurse midwives, physicians, and/or institutions often result from a lack of knowledge or commitment to practice in accordance to current standards, guidelines, and evidence.  In other instances, care is rendered according to personal experiences, preferences, and history of practice over a long period of time during which the provider has not experienced an adverse outcome.  Moving toward a science based clinical practice environment, rather than “that’s the way we’ve always done it” is a challenge to promoting safe care (AWHONN, 2014; AWHONN, 2021).  

Ways to Mitigate Perinatal Liability Exposure:  Certainly, all adverse events are not preventable, however, practices inconsistent with current standards of care offer opportunity for the plaintiff to demonstrate a breach of the standard of care (AWHONN, 2021).  One key way to reduce liability exposure is to provide care consistent with current standards of care.  

Shoulder dystocia is a common area of perinatal litigation with common allegations including:

• Failure to accurately predict the risk of shoulder dystocia
• Failure to diagnose labor abnormalities
• Failure to appropriately initiate shoulder dystocia corrective maneuvers
• Failure to prioritize delivery of posterior arm
• Failure to perform cesarean birth
• Application of forceps or vacuum at high station, or continued application without evidence of fetal descent, resulting in shoulder dystocia
• Application of fundal pressure during shoulder dystocia, further affecting the shoulder and delaying birth, thereby resulting in maternal-fetal injuries

Standards, Guidelines, Recommendations:

• Although there are a number of known risk factors, shoulder dystocia cannot be accurately predicted or prevented (ACOG, 2017)
• When shoulder dystocia is suspected, the McRoberts maneuver should be attempted first because it is a simple, logical, and effective technique (ACOG, 2017)
• In cases where the McRoberts maneuver and suprapubic pressure are unsuccessful, delivery of the posterior arm can be considered as the next maneuver to manage shoulder dystocia (ACOG, 2017, AWHONN, 2021)
• Simulation exercises and shoulder dystocia protocols are recommended to improve team communication and maneuver use because this may reduce the incidence of brachial plexus palsy associated with shoulder dystocia (ACOG, 2017)
• The Joint Commission’s Sentinel Event Alert, Preventing Infant Death and Injury during Delivery, recommends conducting periodic drills for obstetric emergencies such as shoulder dystocia (AWHONN, 2021)

P.S. Comment and share your experience with a shoulder dystocia litigation. What were the strengths and weaknesses of the case?

References

Simpson K.R. et al. (2021). AWHONN Perinatal Nursing, 5^th ed. Wolters Kluwer

Simpson K.R. & Creehan P.A. (2014). AWHONN Perinatal Nursing, 4^th ed. Wolters Kluwer, Lippincott

The American College of Obstetricians and Gynecologists. (2017). Shoulder dystocia [Clinical Practice Bulletin #178]

Joint Commission. (2004). Preventing infant death and injury during delivery. Sentinel Event Alert Issue 30