As ob.gyns. face a growing number of shoulder dystocia cases, also escalating are medical malpractice lawsuits that claim physicians are to blame for related injuries.
"Because there is an increasing incidence of obesity in the United States, as well as women entering pregnancy at high risk or already having diabetes, the risks of dystocia are rising," said Dr. Robert H. Debbs, director of the Pennsylvania Hospital Maternal Fetal Medicine, Philadelphia. "The trends appear to be suits now being filed not for failing to perform C [cesarean] sections, but for how the dystocia was handled; i.e., was it anticipated? Were the proper maneuvers done? Is there evidence of excessive force used? And was the ‘team’ responsive to the situation?"
Dr. Robert H. Debbs
Adding to legal risks is the difficulty of predicting shoulder dystocia, noted Dr. Debbs. A 2012 study in Archives of Gynecology and Obstetrics that analyzed 234 shoulder dystocia cases found only mode of delivery and birth weight were independent risk factors of the condition. The U.K. researchers concluded that exact birth weight and delivery mode is difficult to foretell, and therefore, occurrence of shoulder dystocia is highly unpredictable (Arch. Gynecol. Obstet. 2012;285:291-5).
"It’s clear that we are neither able to predict with accuracy, nor prevent dystocia accurately in that most cases occur in normal-weight babies, and only 25% of patients have risk factors," said Dr. Debbs, who recently spoke on the subject at the American Conference Institute obstetric claims forum in Philadelphia. "Performing elective cesarean sections for suspected large babies has not reduced significantly the number of dystocias, and we would have to perform close to 300 cesarean-sections to prevent one permanent nerve injury to a child, a number that places women at risk of future pregnancy complications in addition to morbidity and even mortality from surgery," according to Dr. Debbs.
Despite the literature, many plaintiffs’ attorneys argue the mere presence of a brachial plexus injury in a newborn indicates the physician pulled too hard or in the wrong direction, said Dr. Michael G. Ross, chair of the obstetrics and gynecology department for Harbor-UCLA Medical Center, Torrance, Calif.
"That’s simply not true," he said in an interview. "It’s the forces of the contraction, the forces of maternal pushing. It’s the baby’s movement down the birth canal," that causes the injuries.
To avoid litigation, ob.gyns. should be aware of American Congress of Obstetricians and Gynecologists guidelines pertaining to shoulder dystocia and ensure that the risks of dystocia and brachial plexus injuries are discussed with patients, Dr. Ross said.
Additionally, physicians and health care team members should attend a dystocia drill every 1-2 years and make sure their institution has designated appropriate staff to respond during dystocia events, Dr. Debbs said. Documentation of dystocia incidents and conversations with families after the fact also are crucial.
"Always sit down with patient and family and discuss what happened and how it was remedied in detail," he said. "Many lawsuits are filed after families feel no one spoke with them and explained things."