Takeaway: Opportunities to mitigate risks present themselves throughout pregnancy, from prenatal care through labor and delivery, and then through the postpartum period. In spite of best efforts to anticipate and diminish risks, practitioners may encounter hard-to-predict, intrinsically high-liability events like shoulder dystocia. Still, practitioners who consistently and persistently seek opportunities to mitigate risks will find better outcomes for their patients, as well as reduced liability for themselves.
The Case: An expectant mother with morbid obesity, previous gestational diabetes, and a previous uncomplicated vaginal delivery of an infant over 9 pounds was followed by the same obstetrician she had seen during her prior pregnancy. At 23 weeks, the ultrasound showed the fetus in the 49th percentile for weight. There was no documentation regarding gestational diabetes and no further glucose testing after a glucose tolerance test of 140 mg/dL (normal is below 140 mg/dL). The obstetrician used Leopold’s maneuvers to determine the size of the infant but did not measure fundal heights. There were no other ultrasounds done during pregnancy.
At 39 weeks, the mother presented to labor and delivery following spontaneous rupture of membranes. The infant was born vaginally, but there was no documentation of shoulder dystocia in the obstetrician’s notes. However, the mother described two nurses standing on something and pushing on her abdomen to assist in getting the infant out (suprapubic pressure). Apgar scores were 7, then 8, and the infant’s weight was over 11 pounds. The infant was not moving one arm but had some movement of the hand. The infant was sent to the neonatal intensive care unit (NICU) with hypoglycemia, respiratory distress, and concern for sepsis. The infant was ultimately diagnosed with Erb’s palsy, muscle weakness in the arm or shoulders frequently related to a birth or later-in-life injury, and treated with a brace. The child did not require surgery, but did need extensive therapy, and still has some mobility issues in the shoulder.
Analysis: Experts were critical of the management of the pregnancy. Considering the mother’s morbid obesity and previous gestational diabetes, a consultation with a maternal fetal medicine specialist would have been beneficial. There was a failure to monitor for potential gestational diabetes during pregnancy. No ultrasound was done during the third trimester to assess the fetal size (although ultrasounds can be unreliable in morbidly obese patients). These failures led to insufficient awareness of the development of macrosomia and shoulder dystocia. The documentation was sparse.
This case example comes from a recent study analyzing The Doctors Company’s medical professional liability closed claims related to perinatal morbidity and mortality. Using an evidence-based taxonomy, the study included The Doctors Company’s relevant medical professional liability closed claims from the loss years of 2010 through 2023.
Consistent with this case, allegations of improper management of pregnancy featured prominently among the studied medical malpractice claims.
Tips for Malpractice Risk Reduction: Plan for Adverse Events to Prevent Adverse Outcomes
Allegations of improper management of a pregnancy were frequently driven by failure to order or delay in ordering a diagnostic test. Clinicians should be aware that in The Doctors Company’s study, ultrasounds were the most common diagnostic test delayed or not ordered.
Shoulder dystocia is a serious complication that is also unpredictable, and shoulder dystocia claims are difficult to defend. Healthcare teams can anticipate a need to:
- Act quickly in providing coordinated care the moment shoulder dystocia appears
- Thoroughly document all care provided related to shoulder dystocia
When anticipating a potential case of shoulder dystocia, healthcare practitioners can consult resources available in medical journals and medical professional societies, including the American Journal of Obstetrics and Gynecology (AJOG) and the American College of Obstetricians and Gynecologists (ACOG).
To prepare for shoulder dystocia cases, healthcare teams can engage in simulation drills that provide an opportunity for practitioners to improve their skills, including their assessment skills, their technical maneuver skills, and their teamwork and communication skills. Teams can also discover systems issues before they impede the response to an actual emergency. Where high-fidelity physical simulation would be cost prohibitive, virtual simulations offer benefits.
A Final Word: For more patient safety and risk mitigation strategies to help improve perinatal and obstetric care and patient outcomes, see “Perinatal Malpractice Claims: Communication and Technical Skills Limit Risks,” published by The Doctors Company.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider, considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.
Reference
1. Copyrighted by and used with permission of Candello, a division of The Risk Management Foundation of the Harvard Medical Institutions Incorporated, all rights reserved.