Shoulder Dystocia Presentation November 19-20, 2009

Shoulder Dystocia Presentation

November 19-20, 2009

Shoulder Dystocia

• The words “Shoulder Dystocia” were first used in 1902 by Fieux.

Shoulder Dystocia Overview

• Unpredictable

• Ultrasound Very Unreliable

• Estimated Fetal Weight Unreliable

• Risk Factors Unreliable

• Labor Factors Unreliable

Shoulder Dystocia Overview

• Delivery Factors Unreliable

• Patient Observations Unreliable

• Nursing Observations Unreliable

• Traction Estimates Unreliable

• Clinical Pelvemetry Unreliable

• Physician Very Reliable

History of Traction

• 1730 Smellie• 1851 Danyau• 1878 Speilberg• 1905 Clark• 1920 Taylor• 1925 Sever

• 1926 Williams• 1930 Jepson• 1939 Koff• 1943 Woods

Defense History of Non-Traction

• 1980 Koenigsberger (later refuted by Gonik 1998)

• 1985 Dunn & Engle (a chronic congenital injury)

• 1992 Jennett• 1995 Nocon• 1995 Hankins

• 1997 Ouzounian• 1997 Gherman• 1997 Gilbert• 1998 Gherman• 1999 Ouzounian• 2000 Sandmire• 2001 Gonik

U.S. is the Home of Intrauterine Caused Brachial Plexus Injuries

The Gonik Epiphany

• 1998 B.P.I. – result from traction• 2000 – not clearly elucidated• 1998 B.P.I. – avoid traction• 2000 – force limits not recognizable• 1998 B.P.I. – occurs from excessive force• 2000 – greatly debated

Precis – 6th Edition, Vol. 6 1998 & 2000

Authoritative Textbooks

• Neurology• Pediatrics• Pediatric Neurology• Orthopedics• Pediatric Orthopedics• Neurosurgery• Pediatric Neurosurgery• ALL SAY TRACTION!

John P. Laurent, M.D.Texas Children’s Hospital

• 4,000 permanent brachial plexus injuries

• 2 from cesarean sections

• Both had cephalic replacement after failed vaginal maneuvers

• See Laurent deposition testimony

Intrauterine Injury, Laurent, M.D.

• “I do not believe that.”• “Baby floating in water = no fixed point.”• “Ultrasounds show limb movement.”• “No doubt it is excessive traction.”• “No excessive traction = no injury.”

November 13, 2000

Uterine Forces

• 1) Relatively uniform

• 2) 50 to 75 MM of HG

• 3) Why are injuries so variable?

Labor

• Uterine contractions are uniform and symmetrical.

• How can the injury be so focal, local, and asymmetrical?

EFM

• No evidence of fetal pain.• (a) accelerations• (b) tachycardia• Hyperstimulation• Tetanic contractions• Sustained contractions = tetany• NO B.P.I.!!!• ACOG = Amalgamated Coalition of OB-GYN

Defense “Expert” Opinion

• “We are beginning to understand that it occurs for reasons we don’t know about.”

January 26, 2004

1973 – Brachial plexus paralysis is caused by damage to nerve fibers consequent to excessive lateral traction of the neck during delivery. Am J Obstet Gynecol, Gordon, et al.

1986 - Injuries to the brachial plexus occur when there is a strong lateral traction on the head and neck or a downward traction on the shoulders. . . Obstet Gynecol, McFarland, et al.

1992 – Injuries to the brachial plexus occur when there is a strong lateral traction on the brachial plexus that may cause stretching, tearing, or avulsion of the nerve roots C5-T1. Shoulder Dystocia and Birth Injury, O’Leary.

1992 – Nor can brachial plexus impairment with diagnosed shoulder dystocia be taken as prima facie evidence that the two are causally related in all such instances. Am J Obstet Gynecol, Jennett, et al.

1995 – Thus there is a strong suggestion that some brachial plexus injuries may be completely unrelated to manipulations performed at the time of delivery. In these cases it is most likely that maternal expulsive forces of delivery may be partly or totally responsible for posterior or anterior arm injuries. For example, the posterior shoulder may become temporarily lodged behind the sacral promontory, yet delivery of the head results from maternal expulsive efforts or use of instruments. Am J Perinatol, Hankins, et al.

1997 – In the cases with permanent Erb palsy in the posterior shoulder of the deliverying infant, we hypotesize that the injury was not a product of traction applied at delivery but rather preceded expulsion of the fetal head. Obstet Gynecol, Ouzounian, et al.

1998 – Recent literature supports the hypothesis that some cases of brachial plexus palsy may have an intrauterine origin. Am J Obstet Gynecol, Gherman.

1999 – The brachial plexus is subject to injury when excessive downward traction and lateral extension of the fetal head and neck occur in the attempt to delivery the anterior shoulder; however, there are exceptions to that cause of brachial plexus injury . . . Brachial plexus palsy may involve the arm that was in the posterior pelvis at the time of delivery. Maternal-Fetal Medicine, Creasy.

2000 – Recent reports have documented cases of brachial plexus injury in the neonate unrelated to recognized birth trauma. As Jennett and Tarby pointed out, “[t]o maintain a posteriori that brachial plexus impairment in itself is evidence that such (extreme lateral traction] pressure must have been used is unteneble.” Am J Obstet Gynecol, Gonik, et al.

2001 - Jennett and associates and Gherman and colleagues have presented evidence that brachial plexus injuries may precede the delivery itself and may occur even prior to labor. Williams Obstetrics.

2003 – Current expert opinion evidence supports the notion that forces of labor constitute the major cause of shoulder dystocia with the potential result of a brachial plexus injury. Therefore, the belief that all brachial plexus injuries result from inappropriate maneuvers at delivery has no scientific foundation. Prolog Obstetrics, American College of Obstetricians and Gynecologists.

2004 - In considering the etiology of these injuries [brachial palsy], one should remember that a significant number of cases of brachial palsy (often bilateral and in association with other nerve palsies) occur in utero and in the absence of birth trauma. Maternal-Fetal Medicine, Creasy.

2005 – The fact that almost half of the brachial plexus injuries occur without any difficulty during delivery of the shoulders, suggests that the injury does occur in-utero, atraumatically. Am J Obstet Gynecol, Chauhan, et al.

2005 – The propulsive efforts of normal delivery may cause brachial nerve stretching and damage. Williams Obstetrics.

Deposition Testimony• Q Okay. We'll talk about that in a littlebit. You've delivered lectures to physicians andadjusters for insurance companies telling them how themedical records should be written to best defend thephysician, haven't you?

• A That's a -- only a partially true statement.By writing a good medical record, it helps with thedefense, but a good medical record is a good thing in andof itself. So in the talks I've given to risk managementgroups, I talk about what I feel would be a better ormore ideal medical record than is generally the standardof care in the community. That is a good thing to do formedical care. It has the side benefit of making casesmore defensible because there's more information in them.

Deposition of Henry Lerner, M.D., May 7, 2008

Deposition Testimony

• Q You've actually told them what should be inthe record to make it more defensible or easier foryou to defend, haven't you?

• A Sure, on the basis of being told byplaintiff attorneys what various doctors werenegligent for not having put in the record.

Deposition of Henry Lerner, M.D., May 7, 2008


• Q (By Mr. Puga) Okay. Dr. Lerner, on what datedid you submit your article, "Permanent Brachial PlexusInjury Following Vaginal Delivery Without PhysicianTraction or Shoulder Dystocia," that's been marked asExhibit 4? On what date was that case report submitted tothe American Journal of Obstetrics and Gynecology?

• A I submitted it on or about June 11, 2007.

Deposition of Henry Lerner, M.D., June 5, 2008.


• Q (By Mr. Puga) All right. I just asked you afew minutes ago the question, and it's your testimony thaton at least two occasions of thoroughly and carefullyreviewing these records that you missed on one of therecords a note that there was a left Erb's palsy due tomild shoulder dystocia at delivery. You said missed interms of not remembering seeing it, yes. Explain what youmean by that answer.

• A I do not recall seeing it in either review.



• Q Would you agree with me that if youhad seen it, it would be importantinformation for both your opinions as anexpert witness and to be included in the casereport?

• A No.


Documents

Shoulder Dystocia Presentation November 19-20, 2009