Shoulder Dystocia Management and Medical Negligence: What You Need to Know

Rebecca Beesley

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By Claire Levene

Solicitor | Medical Negligence

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Shoulder Dystocia and Its Risks

Shoulder dystocia is one of the most challenging and potentially dangerous obstetric emergencies that can occur during childbirth. It arises when the baby’s shoulder becomes impacted behind the mother’s pubic bone, preventing the baby from being delivered after the head has emerged. This condition requires swift, skilled intervention to prevent severe complications for both the mother and the newborn.

However, when shoulder dystocia is not managed correctly, it can lead to devastating consequences. This blog covers how negligence may arise in the management of shoulder dystocia, and the potential impact of this on mother and baby.

What Causes Shoulder Dystocia During Childbirth?

Shoulder dystocia occurs when, after the baby’s head is delivered, the anterior shoulder becomes stuck behind the mother’s pubic bone. This situation can cause the baby’s shoulders to become wedged in the birth canal, preventing rest of the baby’s body from being delivered.

Shoulder dystocia is considered an obstetric emergency and requires immediate intervention. If managed correctly, the vast majority of cases can result in the safe delivery of both mother and child. However, when care is delayed or mishandled, it can lead to serious complications, including:

• Brachial plexus injuries: Damage to the nerves in the shoulder, which can result in permanent arm or hand dysfunction. This is also sometimes called Erb’s Palsy.
• Fractures: Clavicle or collarbone fractures may occur as the baby’s shoulder is forcibly manoeuvred.
• Hypoxia and brain injury: Prolonged pressure on the umbilical cord or delayed delivery can result in oxygen deprivation, leading to baby suffering brain damage.
• Maternal complications: These include uterine rupture, haemorrhage, and injury to the pelvic organs including tears affecting continence and toileting.

Clinical Negligence in Shoulder Dystocia Management

Royal College of Obstetricians and Gynaecologists (RCOG) has published guidelines regarding the management of shoulder dystocia. Negligence may arise if these guidelines are not adhered to, leading to avoidable complications.

Substandard management of shoulder dystocia is preventable with appropriate training, awareness, and timely intervention. Examples of mismanagement of shoulder dystocia that commonly arise in clinical negligence claims include:

1. Failure to consider maternal history, foetal size and mode of delivery.

Clinicians should give careful consideration to a woman’s previous medical history including whether there has been any past history of shoulder dystocia in previous deliveries, build and pelvic size, birth weight of previous children, whether there were any particular difficulties with previous deliveries, estimated birth weight to determine the risk of proceeding with a vaginal delivery or recommending a Caesarean section.

2. Delayed Recognition of Shoulder Dystocia

A common source of negligence is the failure to immediately recognise the signs of shoulder dystocia. The situation becomes critical once the baby’s head has emerged, and any delay in identifying the need for intervention can result in severe outcomes. Some signs that may indicate shoulder dystocia include:

• Failure of the head to deliver quickly after the emergence of the crown.
• The “turtle sign”: The baby’s head retracts back towards the perineum after emerging, indicating difficulty with shoulder delivery.

Failure to recognise these early signs can lead to delayed action and an increased risk of neonatal injury.

3. Improper Use of Obstetric Manoeuvres

When shoulder dystocia occurs, specific obstetric manoeuvres must be performed to free the impacted shoulder. These include:

• McRoberts manoeuvre: Involves flexing the mother’s legs towards her chest to increase the pelvic opening.
• Suprapubic pressure: Applying pressure just above the pubic bone to help dislodge the shoulder.
• Wood’s screw manoeuvre: Rotating the baby’s shoulder to allow for easier delivery.

Clinical negligence can occur if these techniques are not performed correctly or if the healthcare team does not follow them in the appropriate sequence. Overlooking a critical step or using excessive force can exacerbate the problem and lead to injury, such as brachial plexus nerve damage, or fractures.

4. Failure to Call for Assistance

Shoulder dystocia is a high-risk emergency that often requires the coordinated efforts of a skilled team. This team should ideally include obstetricians, midwives, neonatologists, and anaesthetists. Negligence can arise if a clinician fails to call for additional help in a timely manner or fails to escalate the situation appropriately.

Consequences of Clinical Negligence

The consequences of clinical negligence in the management of shoulder dystocia can be devastating for both mother and child. Some of the potential outcomes include:

• For the Newborn:
  • Brachial Plexus Injury: One of the most common consequences of shoulder dystocia is damage to the brachial plexus nerves, which control arm movement. This can result in conditions such as Erb’s palsy or Klumpke’s palsy, which may require long-term therapy and in some cases, surgery.
  • Fractures: The most common fracture resulting from shoulder dystocia is a clavicle fracture, though other fractures can occur as well.
  • Hypoxic Ischemic Encephalopathy (HIE): If the baby is deprived of oxygen for an extended period, it can lead to severe brain damage.
• For the Mother:
  • Postpartum Haemorrhage: Trauma to the birth canal or excessive pulling during delivery can result in significant bleeding.
  • Uterine or Pelvic Injury: If the delivery is mishandled, uterine tears or injury to the pelvic organs can occur.
  • Emotional and Psychological Impact: The trauma associated with a difficult delivery can result in long-term emotional distress for the mother, including anxiety, PTSD, or postnatal depression.

Bringing a Legal Claim

Although shoulder dystocia is a rare complication, when it does arise it can lead to devastating results.  Substandard management can result in serious and permanent harm to both mother and/or baby. When medical negligence occurs it is appropriate and reasonable to make a claim for damages to compensate you or your child for the harm suffered and to ensure that your/their needs and losses arising as a result of the negligence are met for life.

There are very strict time limits for bringing clinical negligence claims. Claims for children must be issued at Court before the child’s 21^st birthday. Claims for adults must be issued at Court within 3 years of the date on which the negligence occurred or the date upon which the adult became aware that they had suffered an injury due to medical negligence. It is possible for both mother and child to suffer injuries as a result of the same negligent treatment.

We recognise and understand that it can be very difficult to talk about a traumatic delivery but we would always recommend that you contact us to discuss your or your child’s potential claim early, as soon as you feel able to. One of our specialist team would be happy to speak with you and see if we can assist.