A Delicate Balancing Act: Delivering an Infant With Shoulder Dystocia

April 13, 2012

The thought of a baby getting stuck during delivery naturally brings extreme fear to the mother and her family, and high stress for the doctor and medical staff. On rare occasions, after the baby's head has emerged from the birth canal, one or both of his or her shoulders becomes wedged behind the mother's pelvic bones, bringing the delivery to a frightening standstill.

Physically, the shoulders normally rotate during delivery to pass the pelvic bones at a certain complementary angle and place. When the shoulders are too big or the mother's pelvic area is too narrow for the appropriate rotation to take place, shoulder dystocia can occur.

Although certain factors like high birth weight, previous dystocia in the mother, pregnancy-induced diabetes, maternal obesity, maternal pelvic malformation, overdue birth, and use or forceps or vacuum can be associated with shoulder dystocia, it also occurs with no apparent risk factors present, making it sometimes difficult to forecast.

Certain medical practices and specialized training may help to lower the incidence of shoulder dystocia, however, including careful management of gestational diabetes to control the baby's weight gain.

Shoulder dystocia is a medical emergency, and the attending physician and staff have a complicated series of decisions and medical interventions to consider under intense time pressure. According to Medscape, a maximum of only six minutes should elapse between delivery of the head and the rest of the body.

The bottom line: successful outcome without birth injury when shoulder dystocia presents itself during a birth requires great skill, keen judgment and the ability to stay calm on the part of the doctor and medical staff.

Medical research and experience have shown that to resolve dystocia, the shoulders must fit through the pelvis, so a series of maneuvers have been developed to either move the position of the mother, or of the baby, in order to reposition the physical relationship between the shoulders and the pelvic bones in such a way that the baby can keep moving through the canal to birth. The successful physician must learn to quickly discern which maneuvers to try and in what order.

Repositioning maneuvers almost always can resolve the shoulder dystocia and retrigger active birth movement. For example, a highly touted position change for the mother that may result in dystocia resolution is to turn her over onto all fours. For the baby, the doctor has various twisting and pressure methods to try, as well as delivering the posterior arm.

Some of the ways to help bring about a successful birth despite dystocia include:
- Avoidance of applying fundal (abdominal) pressure to try to push the baby out
- Avoidance of strong traction or pulling of the baby from the birth canal
- Immediate request for additional medical personnel, including a specialist to attend to the baby after birth
- Protection of the baby's head from overrotation
- Appointment of a timekeeper to remind the doctor at intervals how much time has passed since delivery of the head
- Simulated, rehearsed shoulder dystocia deliveries by medical teams

If the dystocia is not safely resolved, both the baby and the mother are in danger of injury, including:

For the baby:
- Brachial plexus injury: temporary or permanent harm to the nerves running through the affected shoulder down the arm
- Fracture of the collar bone or arm
- Oxygen deprivation from umbilical cord compression causing brain injury, disabilities or death

For the mother:
- Serious lacerations
- Hemorrhage
- Fistula
- Uterine rupture
- Fecal incontinence

If the prescribed repositioning maneuvers do not work, next steps are to undertake drastic steps to deliver the baby quickly like intention fracturing of the infant's collar bone, cesarean section while repositioning the baby for alternative removal, anesthesia to relax the mother's uterus, or abdominal surgery through which one doctor rotates the baby through the incision so another physician can deliver him or her vaginally.

In such a complex situation, mistakes can be made by doctors and medical personnel, even with experience and training. Legal remedies are available for mothers and babies injured through medical malpractice or physician negligence. An experienced personal injury attorney can advise those harmed by improperly handled shoulder dystocia.

Article provided by Seigel Capozzi Law Firm LLC
Visit us at www.seigellawfirm.com