Compound presentation, obese mother, bad outcome

Facts

A 26-year-old woman vaginally delivered a 9 lb, 1 oz baby in October 2009. Her history included 1 prior uncomplicated vaginal delivery of a baby with a birth weight of 7 lb, 6 oz. The prenatal period for the 2009 pregnancy was uneventful with a total of 14 office visits, at first monthly, then bi-weekly in September, and weekly by October. While there was a family history of diabetes noted and a couple of instances of elevated glucose levels during the summer, a fasting glucose test in August was within normal limits.

The mother presented to the hospital in labor in the early morning on October 27, 2009. Her prepregnancy weight was noted to be 225 lb and she was 5 ft 6 in tall. She was at 39 weeks + 6 days, and according to sonogram, this was her due date. She came with contractions, mild abdominal pain, and no unexpected complaints. The notes reflect a 30-lb weight gain during pregnancy and that the woman was initially found to be 4 cm dilated, 60% eff aced and station +3.

By 7 am, she had dilated only to 5 cm. Her membranes were artificially ruptured and her pelvis was listed as “probably clinically adequate.” Oxytocin was stopped at roughly 9 am, when an epidural catheter was placed.

Between 9 and 10 am, the patient became fully dilated. Up until that time, the notes reflect reassuring fetal heart rate (FHR) tracings. At 10:15, a nurse wrote: “Difficulty noted following delivery of infant’s head. Drs. A, B and Mid-Wife C were in attendance. The patient was put in position and McRobert’s maneuver was used along with suprapubic pressure being applied. Pediatricians were called.”

Dr A performed the delivery and Dr B applied suprapubic pressure. The child’s Apgar scores were 7 and 8. Dr D saw the child for the first time in the nursery and diagnosed a fractured left humerus.

The delivery notes state, “There was moderate shoulder dystocia. The time between head delivery to complete delivery was one minute. The following was a sequence of maneuvers done to relieve the shoulder dystocia. Maneuver 1, posterior arm delivery, suprapubic pressure, delivery of the posterior arm. The placenta was thereafter delivered spontaneously and intact. The mother suffered no lacerations.”

Attending Dr A wrote: “I was scrubbed during the procedure. I was immediately available during the procedure. Patient became fully dilated at 10:00 a.m. and began to push. The head descended with 3 contractions and pushing, head was delivered indirect OA, the shoulder was slow to deliver, exam showed that the shoulders in transverse with compound presentation of the posterior arm. The posterior arm delivered and the interior shoulders followed. There was a popping sensation and pediatrics was immediately notified in responding. The baby’s APGAR (sic) was 7/8; the baby was taken to NICU for further evaluation. Total time from head to shoulders was less than one minute.”

The pediatricians reported that they were paged to a vaginal delivery of a term baby with shoulder dystocia with “difficult labor.” They wrote, “Reached after baby was born; one minute APGAR was 7 and at one minute was given by OB/Gyn. Noticed that baby had a low tone and was not moving both the hands and MORO was asymmetrical. OB/Gyn mentioned hearing a popping sound while delivering and explained situation to mother. Baby was pink and had a good heart rate and respiratory effort started developing few retractions and tachypnea and was transferred to NICU for respiratory distress. Mom was explained of the baby’s condition (sic).”

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The maternal plaintiff remained in the hospital until October 29, without complication, while the child stayed behind in the neonatal intensive care unit (NICU). The infant was ultimately transferred from the NICU. X-rays revealed a displaced fracture of the left humerus, with no fractures of the clavicle or the right humerus. Prior to discharge on November 12, 2009, the issue with the left humerus resolved with some compression dressings.

After discharge the child was treated at a hand therapy center for several months. While the patient had excellent triceps function and good hand function, he was unable to shoulder abduct, rotate the shoulder externally, or have any significant bicep function. Accordingly, on June 19, 2010, when he was 8½ months old, the infant underwent a spinal accessory nerve transfer. The infant tolerated the procedure well and was discharged the same day. Thereafter, he had occasional therapy.

Physical examinations were performed by pediatric rehabilitation and sports medicine specialists on October 8, 2011, who confirmed a moderate-to-severe Erb’s injury. The rehab doctor noted that the child’s fine motor skills are delayed on the injured arm. The child reaches left preferentially and does not effectively reach, grasp, or shake with the right arm. While the child can open and close the right hand and move his fingers and thumb, the right grasp is weaker than the left. Additionally, the child is unable to bring his right hand to his mouth independently without the left arm assisting.

NEXT: Allegations and discovery

Allegations

The plaintiff alleged that given the fetal size and weight, earlier caesarean delivery was warranted and that improper management of shoulder dystocia and compound presentation of the posterior arm resulted in right Erb’s palsy, scapular winging, and decreased movement and function of the right extremity.

Discovery

Pediatric records from March 2014 confirmed that the child had decreased motion of the shoulder and elbow of the right arm as well as weak grip strength. The plaintiff said that during the delivery, an unidentified female doctor pulled on the baby while a second healthcare worker placed her hand under her breast, at the top of her stomach, and pushed down at the same time. She doesn’t remember how long this went on, but remembers being told that the child was stuck and that the doctor was pulling “very very hard.” The witness testified she did not recall being moved or rotated in any way. After the child was “pulled out” she recalled being told that the arms were not working well and the child was immediately whisked away.

Despite strong testimony from the delivering doctor, Dr A, Dr B, who assisted in the delivery, was easily rattled, and gave some poor testimony, in essence contradicting Dr A and indicating that the head was out of the vagina for a minute prior to delivery. She also called into question Dr A’s assertion of a compound presentation. She confirmed, however, that fundal pressure was not used. Dr B also asserted that artificial rupture of membranes could precipitate transverse lie, a statement our expert could not support.

The most significant aspect of this case for our expert was the fact that it was a compound presentation. She explained that a predelivery ultrasound would not have indicated the compound presentation. She indicated that once the child begins to descend, the extremity could come alongside the fetal head. Thus the plaintiff’s claim regarding the inappropriate use of oxytocin is negated because the situation does not present itself until the baby’s descent.

To refute any claims regarding an inadequate pelvis, the expert pointed out that the head delivered and the rest of the body delivered within a minute. Thus there was no “hanging up” of the baby. The expert also pointed out that because this was a big patient with a significant amount of soft tissue, there was still some pliability. The expert also pointed out that an episiotomy would have been inappropriate.

The expert was satisfied with the documentation and choice of maneuvers. The expert also indicated that the witnesses should be clear regarding the issue of applying suprapubic pressure as opposed to fundal pressure. Due to the mother’s body habitus they had to move her pannus out of the way, which could also lead the mother to misinterpret exactly where the hands were placed.

The expert indicated that the estimated fetal weight was 8 lb, 8 oz, which would be small enough to get through this adequate pelvis. The fact that the child was ultimately 4135 grams still did not concern her as this was still a small-enough baby to be delivered vaginally.

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However, the expert believed that the nurse-midwife’s care prior to the delivery was problematic. Specifically, the nurse-midwife either started the delivery or was present for the delivery of the head. During that time, it is more likely than not that some traction was placed on the head, bringing about the injury. The reason was based upon the compound presentation followed by the quick delivery by Dr A. There was no real opportunity for Dr A to cause the injury.

Resolution

Permanent brachial plexus injury cases are generally difficult to defend as they invariably involve assertions of excessive traction as the motivating force behind unresolved nerve injury. Here, where we encountered the additional hurdle of questionable timing of delivery after presentation of the fetal head, along with hesitant, contradictory testimony from the resident as to the presentation encountered, maneuvers applied, and the timing of events at issue, we decided to resolve the case prior to trial rather than risk it being priced by a jury.