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The greatest nightmare an obstetrician is likely to face is shoulder dystocia. At an otherwise normal delivery, just after the baby's head has emerged, the neck suddenly retracts back against the mother's perineum causing the baby's cheeks to puff out. The experienced obstetrician knows at this point that the baby's anterior shoulder is caught on the mother's pubic bone and that if he or she is unable to free up the shoulder within a few minutes the baby will suffer irreversible brain damage or death.
Shoulder dystocia occurs in approximately 0.5%-1.5% of all deliveries. Given that there are roughly 3 million babies born vaginally each year in the United States, this delivery complication will be experienced by roughly 15,000-45,000 women a year. The larger the baby, the more likely it is to occur. However, even with very large babies shoulder dystocia occurs only occasionally and sporadically. Therefore a physician never knows when it will be encountered.
The most common serious complication following a shoulder dystocia delivery is brachial plexus injury. This is when the nerves in a baby's neck--the brachial plexus--are temporarily or permanently damaged. The nerves of the brachial plexus control the function of the arm and hand. Injury to the upper part of the brachial plexus is called Erb palsy while injury to the lower nerves of the plexus is called Klumpke palsy. Both can cause significant, lifelong disability.
Because of the gravity and unexpectedness of shoulder dystocia it has long been a major area of obstetrical concern. Yet despite the hundreds of published studies about shoulder dystocia there are still multiple, important recurrent questions: Is shoulder dystocia predictable? Can it be prevented? Is there anything that can be done when it does occur to deliver the baby without brachial plexus nerve damage? If there is an injury, was it caused by mismanagement on the part of the clinician or was it an inevitable consequence of the shoulder dystocia?
The interest obstetricians have in these questions has been heightened in the last two decades by the increasing influence of medical-legal issues on the practice of medicine. As regards shoulder dystocia, it is frequently the case that when a brachial plexus injury occurs, an obstetrician will be charged with negligence. Such claims are now so frequent that law suits related to shoulder dystocia deliveries constitute the second largest category of indemnity payments in obstetrics, exceeded only by birth asphyxia. In their defense, physicians contend that shoulder dystocia is a totally unpredictable event and that even with perfect management brachial plexus injuries will occur. Where does the truth lie?
This web site represents an attempt to answer this and other questions about shoulder dystocia. By having thoroughly reviewed the published literature on shoulder dystocia and brachial plexus injury from 1965 to the present, it has been possible to frame comprehensive and consistent answers to the major questions that bedevil this area of obstetrics. It is the hope of the author that the information presented here about the cause, preventability, and culpability for shoulder dystocia and brachial plexus injuries will (1) aid in improving the care given to women and their babies and (2) will help to fairly adjudicate responsibility in medical liability cases in which a baby has been injured during a shoulder dystocia delivery.
Imortant new document
A recent report by the American College of Obstetricians and Gynecologist (2014) entitled Neonatal Brachial Plexus Palsy, written by a panel of the leading experts on shoulder dystocia and brachial plexus palsy from across the country, has added much specific information and informed opinion to the discussion of shoulder dystocia and brachial plexus palsy. This document can be ordered at acog.org.
2017 Henry Lerner