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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 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 one half of one percent of all deliveries. Given
that there are 4 million babies born each year in the United
States, this delivery complication will be experienced by
roughly 20,000 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
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 still are
multiple, important unanswered questions:
Is shoulder dystocia predictable?
Can it be prevented?
Is there anything that can be done
when it does occur to prevent brachial plexus nerve damage?
If there is an injury, was it caused
by mismanagement on the part of the physician while
attempting to resolve the shoulder dystocia 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 result in the second largest category of
indemnity payments in obstetrics, exceeded only by birth
In their defense, physicians contend
that shoulder dystocia is a totally unpredictable event and
that even with perfect management brachial plexus injuries
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 adjudicate responsibility in
medical liability cases in which a baby has been injured
during a shoulder dystocia delivery.
2006 Henry Lerner