In 2012, a Virginia woman began receiving prenatal care for her seventh pregnancy, during which she was diagnosed with Type II diabetes and obesity. Given her history of large infants she was admitted to the hospital at 37 weeks’ gestation for induction of labor. During the delivery, shoulder dystocia was encountered. The baby weighed 9 lb 10 oz at birth and her right arm was noted to be limp. She was diagnosed with a brachial plexus injury which involved C5, C6, C7, and C8 nerve roots and muscles. The injuries were evident from magnetic resonance imaging, which showed at least 2 nerve root avulsions, and by direct visualization by the surgeon who performed an extensive nerve graft to try to restore some function to the baby’s right arm. Although the baby’s right arm function and range of motion has improved, she has not recovered normal function of the injured nerves nor the muscles they innervate.
The woman sued those involved with the delivery, claiming that during the course of her care, the history, physical examinations, and tests showed she had an increased risk for encountering shoulder dystocia during a vaginal delivery. The patient’s experts opined that the obstetrician was required under the standard of care to obtain informed consent from the patient prior to proceeding with a vaginal delivery, which he did not do. It was also the experts’ opinion that as a part of obtaining informed consent, a discussion was required regarding the risk of shoulder dystocia, the risk of injury to the baby’s brachial plexus nerves if shoulder dystocia were encountered, and the option of a cesarean section. The patient’s expert testified that the standard of care required a physician delivering a baby to use no more than gentle traction in the face of a shoulder dystocia, only when the obstetrician believes that a maneuver has released the shoulder. If any resistance during use of gentle traction is encountered, this would indicate that the shoulder dystocia still exists, so traction must immediately cease and new maneuvers be employed to free the shoulder. It was his opinion that the obstetrician deviated from the standard of care by applying more than gentle traction to the fetal head when the shoulder was still impacted and asserting the severe permanent injury to the right brachial plexus resulted from the excessive lateral traction used, and that the injury would not have occurred had a cesarean delivery been performed. The infant’s experts opined that her injury was permanent, regardless of intervention and therapy.
During deposition, the obstetrician testified that he suspected fetal macrosomia, however, he did not discuss his suspicion with the patient. The labor and delivery nurse testified that prior to the delivery, the obstetrician told her he was expecting a large baby, and that they might encounter a shoulder dystocia. He also testified that he applied traction on the fetal head three times: once after McRoberts, once after suprapubic pressure, and once after delivery of the posterior arm. He dictated in his delivery notes, “We had to be careful to avoid excessive traction forces.” He also claimed that shoulder dystocia was an unpredictable and unpreventable obstetrical emergency and that standard obstetric maneuvers were employed. Further, he argued that the injury was caused by the maternal forces of labor before the obstetrician ever touched the fetal head. The patient’s experts responded that this mechanism of maternal forces injuring the brachial plexus nerve is just an unproven hypothesis.
Verdict: The case settled for $950,000.
Analysis: In malpractice cases that involve a brachial plexus injury from a shoulder dystocia encountered during delivery, the claim is always made that the person delivering the infant used excessive traction, as this connects a person to the injury. While the defense often offers the explanation that the brachial plexus became injured upon delivery of the head with the shoulder stuck behind the symphysis, even with no traction on the head, it is not always successful in defending the case. It is imperative that the person delivering the infant stop any traction once the shoulder dystocia is encountered and not apply anymore traction until one or more appropriate maneuvers are performed. This also needs to be documented in the chart in the delivery note at the time of delivery, and many institutions use a check list-based approach to assure that no critical information is left out. This should be done anytime there is an extra maneuver performed to deliver the shoulder, even if injury is not apparent at the time.