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Inside the brachial plexus injury case: improper handling of shoulder dystocia during birth can result in permanent injury to the baby. Understanding why this complication occurs and what doctors should do about it will help you litigate these complex cases successfully.

Article Excerpt
Because brachial plexus injuries (BPI) to an infant can result from breaches of the standard of care during childbirth, plaintiff lawyers pursuing medical negligence claims in birth injury cases need to know how BPI arise. Although most BPI are transient, resolving within six months, about 10 percent are permanent and devastating.

Such injuries are most often caused when a health care practitioner exerts excessive force during delivery in an inappropriate response to shoulder dystocia, which is a failure of the baby's shoulders to readily follow his or her head during a vaginal delivery. Thus, the starting point of most BPI cases is determining the presence of shoulder dystocia and showing how its improper management causes BPI.

The brachial plexus is a network of nerves that emanate from the upper spine and travel through the neck, shoulder, and arm to the hand. Damage to these nerves may cause simple loss of sensation over portions of the affected arm or complete paralysis of the affected arm, shoulder, and hand.

There are four types of brachial plexus injury, the most severe of which is avulsion, when the nerve roots are torn out of the spine. Rupture occurs when the nerve is torn but remains attached to the spine; neuroma, when the torn nerve heals improperly with formation of scar tissue; and neuropraxia, when the nerve is stretched but not torn.

Shoulder dystocia occurs either when the baby's anterior shoulder is trapped behind the mother's pubic bone (the most common presentation) or when the baby's posterior shoulder becomes trapped in the hollow of the mother's tailbone. To dislodge the baby's shoulders, practitioners can use the following maneuvers, listed in order from most to least commonly used; each should be documented in the medical record, along with the outcomes:

* McRoberts maneuver--the mother's legs are hyperflexed back on her abdomen to increase the space between the pubic bone and sacrum, which should allow the baby's shoulder to drop below the pubic bone.

* Suprapubic pressure--the practitioner applies downward pressure at a 45-degree angle in an attempt to rotate and push the entrapped shoulder below the pubic bone. This is acceptable practice when performed low on a mother's abdomen; fundal pressure, performed high up on the abdomen, is contraindicated.

* Woods/Rubens maneuver--the practitioner places a hand internally against the baby's anterior or posterior shoulder and rotates the baby.

* Posterior arm sweep--the practitioner reaches in and pulls the baby's posterior arm out and the shoulder after, thereby releasing the anterior shoulder.

* Episiotomy. It is controversial whether this procedure helps or not. (1)

* Zavenelli maneuver--a rarely used technique in which the practitioner pushes the baby's head back into the vagina and performs an emergency cesarean section.

* Symphysectomy--another rarely used technique in which the practitioner surgically divides the mother's pubic bone in half to release the baby's shoulder.

The standard of care requires the practitioner to know how each of these techniques is performed and when to use it. When shoulder dystocia occurs, the patient's medical records should document exactly which maneuvers were used and the result.

Risk factors

A number of factors place a baby at risk of shoulder dystocia during labor and delivery: (2)

* fetal macrosomia, or an excessively large baby

* maternal diabetes, which may be preexisting or may be acquired during pregnancy

* maternal obesity, determined by the mother's body mass index

* a history of prior vaginal deliveries

* postterm gestation

* history of delivery of a macrosomic infant

* history of shoulder dystocia

* induction of labor

* precipitous second stage of labor, from...