Shoulder Dystocia

Understanding Shoulder Dystocia: Risks, Response, and Medical Malpractice

Shoulder dystocia in the obstetrician’s delivery room requires immediate, precise intervention to prevent lifelong injury. When a medical provider fails to manage a shoulder dystocia according to the established standard of care, the result can be medical malpractice. It can be devastating for both the infant and the family.

The Anatomy of Birth and Shoulder Dystocia

To understand shoulder dystocia, one must understand the anatomy of the birth canal. During a normal delivery, the baby’s head emerges first. This is followed by a natural rotation that allows the shoulders to pass through the mother’s pelvic opening.

The maternal pelvis is a rigid bony structure. The narrowest part of this passage is the space behind the symphysis pubis (the pubic bone). In a case of shoulder dystocia, the medical provider delivers the baby’s head. However, the leading (anterior) shoulder becomes physically wedged behind the mother’s pubic bone. Less commonly, the trailing (posterior) shoulder can become stuck on the sacral promontory.

As the dystocia develops, a classic sign known as the “turtle sign” occurs. The baby’s head emerges but then pulls back tightly against the perineum, much like a turtle retracting into its shell. This happens because the shoulder anchors firmly against the pelvic bone, preventing the rest of the body from sliding out.

Causes and Risk Factors

While many cases occur in low-risk pregnancies, several factors significantly increase the likelihood of the shoulders becoming trapped:

• Fetal Macrosomia: A baby weighing more than 4,500 grams (roughly 9 lbs 15 oz) is at much higher risk.
• Maternal Diabetes: Gestational or pre-existing diabetes often leads to babies with larger chest and shoulder circumferences relative to their head size.
• Maternal Obesity: Excessive weight gain during pregnancy can narrow the functional space of the birth canal.
• Post-term Pregnancy: Pregnancies lasting beyond 42 weeks often result in larger infants.
• Operative Vaginal Delivery: The use of forceps or vacuum extractor to pull the head out can sometimes “impact” the shoulder more firmly against the bone.
• Previous History: A mother who has experienced shoulder dystocia in a prior birth is at a significantly higher risk for recurrence.

Diagnosis and Emergency Response

Shoulder dystocia is a clinical diagnosis. This means the delivering provider defines it based on observation during the second stage of labor. There is no ultrasound or blood test that diagnoses it in the moment. The provider must recognize the “turtle sign” and the failure of the shoulders to deliver.

Who Should Respond?

Because this is an obstetric emergency, it requires a coordinated team. This usually includes:

1. The Obstetrician (leading the maneuvers).
2. Labor and Delivery Nurses (to assist with positioning).
3. Anesthesiologist or other Anesthesia Providers (in case an emergency C-section or deep relaxation is needed).
4. Neonatologists or Pediatricians (to treat the baby immediately upon delivery).

How Should They Respond?

Standard medical protocol dictates a specific sequence of maneuvers designed to reposition the mother’s pelvis or the baby’s shoulders without causing trauma. The most common include:

• McRoberts Maneuver: Flexing the mother’s legs back toward her abdomen to open the pelvic angle.
• Suprapubic Pressure: A nurse applies pressure just above the pubic bone to “nudge” the baby’s shoulder downward.
• Internal Rotation (Wood’s Screw): The doctor reaches inside to rotate the baby’s body.
• Delivery of the Posterior Arm: Reaching in to pull the baby’s free arm out first, which reduces the width of the shoulders.

Crucially, the provider must avoid “fundal pressure” (pushing on the top of the uterus) or “excessive traction” (pulling hard on the baby’s head), as these actions are known to worsen the impaction and cause permanent nerve damage.

Potential Injuries and Complications – Shoulder Dystocia & Medical Malpractice

The most common and serious injury resulting from shoulder dystocia is Brachial Plexus Injury. The brachial plexus is a network of nerves (C5​ through T1​) that sends signals from the spinal cord to the shoulder, arm, and hand.

1. Erb’s Palsy: Damage to the upper nerves, resulting in a “waiter’s tip” paralysis where the arm hangs limp and rotated inward.
2. Klumpke’s Palsy: Damage to the lower nerves, affecting the hand and wrist.
3. HIE: Hypoxic Ischemic Encephalopathy: If the baby is stuck for too long, there can be umbilical cord compression, starving the brain of oxygen and leading to cerebral palsy (CP) or brain damage.
4. Fractures: Breaking the baby’s clavicle (collarbone) or humerus (upper arm).
5. Maternal Injury: Severe tearing (4th-degree lacerations) or uterine rupture.

Treatment and Prognosis

If an injury occurs, a multidisciplinary team of doctors and other medical providers is required for long-term care:

• Pediatric Neurologists: To assess nerve and brain function.
• Physical and Occupational Therapists: To maintain range of motion and prevent muscle atrophy in the affected arm.
• Orthopedic Surgeons or Neurosurgeons: In severe cases of nerve avulsion (tearing away from the spine), surgery or nerve grafts may be necessary.

Prognosis: Many brachial plexus injuries resolve on their own within 3 to 6 months. However, if the nerves are torn or stretched beyond their elastic limit, the child may suffer from permanent weakness, stunted limb growth, or total paralysis of the arm.

Shoulder Dystocia Medical Malpractice Claims

Not every case of shoulder dystocia is malpractice. However, legal claims are often brought when the “standard of care” is breached. Common grounds for a lawsuit include:

• Failure to Consent: If a doctor knew the baby was macrosomic (large) but failed to offer the mother the option of a C-section.
• Excessive Traction: The most common claim. If the provider panicked and pulled too hard on the baby’s head, causing the nerves to tear, they may be liable.
• Failure to Perform Maneuvers: If the provider used outdated methods or failed to perform the McRoberts maneuver or suprapubic pressure correctly.
• Improper Use of Delivery Tools: Inappropriately using a vacuum or forceps when a baby is already showing signs of being too large for the pelvis.
• Failure to Manage Gestational Diabetes: If the provider ignored high blood sugar levels, leading to an oversized baby.

In these cases, families may seek damages for medical expenses (past and future), specialized therapy, pain and suffering, and the loss of the child’s future earning capacity due to permanent physical disability. Shoulder dystocia remains a complex area of medical law.

If you have a potential shoulder dystocia medical malpractice case, then visit our free consultation page or video. Then contact the Kopec Law Firm at 800-604-0704 to speak directly with Attorney Mark Kopec. He is a top-rated Baltimore medical malpractice lawyer. The Kopec Law Firm is in Baltimore and pursues cases throughout Maryland and Washington, D.C.