Shoulder dystocia: how can improvements in care help prevent devastating outcomes?
Shoulder dystocia is a time-critical obstetric emergency and can result in death or severe brain injury in babies, as well as injuries to mothers.
In February 2021, the Healthcare Safety Investigation Branch (HSIB) released a report on poor outcomes associated with larger babies and shoulder dystocia. Our medical negligence solicitors have reviewed this in the light of a response to the report by the Royal College of Obstetricians and Gynaecologists (RCOG).
What is shoulder dystocia and why can it be dangerous?
Shoulder dystocia is where a baby’s shoulders get stuck during birth and additional manoeuvres are required to free them. It occurs in less than 1% of births, and the majority of babies whose births are complicated by shoulder dystocia do not suffer from injuries or long-term complications. However, it is considered a medical emergency. It can result in injuries to the arm (including serious nerve injuries), severe brain injury or death of the baby. It can also result in bleeding and trauma to the mother.
How well the baby does after shoulder dystocia depends on the time between the delivery of the head and the body. It has been reported that, in cases where this interval is less than five minutes, there is a very low rate of brain injury. Unfortunately, the average head-to-body delivery interval in the babies investigated for the HSIB report was seven minutes. It is thought it is very likely this was associated with brain injury related to oxygen deprivation. In the majority of the cases reviewed where babies had suffered a severe brain injury as a result of oxygen deprivation, shoulder dystocia was the main contributory factor.
Shoulder dystocia and ‘larger’ babies
It is recognised in national clinical guidance that babies that are larger than average are at an increased risk of birth injury or death as a result of shoulder dystocia. It is a characteristic associated with a risk of shoulder dystocia, along with the mother suffering from gestational diabetes, a raised BMI and induction of labour. However, just because the baby is large (or indeed if any of these other characteristics are present), this does not mean shoulder dystocia can be predicted.
When investigating the issue, the HSIB defined ‘large’ as a baby who weighed 4000g (around 8lbs 13oz) or above. There is no standardised definition of ‘large’, and this was identified as a theme of the investigation and, as a result, an opportunity for clinical improvement.
The report says that, across England, the approach to managing larger babies varies. There is no specific guidance on how to manage the pregnancy once a baby is identified as larger. Pregnant women will have a type of ‘bump‘ measurement taken to assess their baby’s growth, which is then plotted on a chart. They may also have ultrasound scans if there are any concerns. This is the most accurate way of estimating the baby’s weight whilst in the womb. There was little consistency across maternity services as to how to identify a larger baby and how to manage the care of their mothers. There was also a wide variation in what action a hospital Trust would take: for example referring the mother on for a more accurate growth scan. This is a disheartening finding: access to a good standard of care and appropriate investigations should not be a postcode lottery.
Lack of informed consent
One very troubling finding was that in 10 cases from the HSIB cohort, there was no evidence of a discussion with the mother about the risks of shoulder dystocia. For example, one piece of advice mothers with a suspected larger baby should be given is to give birth in an obstetric-led unit (rather than midwifery-led or at home without support).
The report highlights the judgment from the landmark case of Montgomery v Lanarkshire Health Board (a 2015 judgment, although the relevant care was in 1999). This case involved a woman whose baby suffered from shoulder dystocia leading to hypoxic brain damage and cerebral palsy. She lived with Type 1 diabetes and had a small stature. She had expressed concerns about being able to deliver her baby safely. Her obstetrician made the decision not to discuss the risks of shoulder dystocia with her. Had she known, she would have opted to have a Caesarean section. The principle that arose from the ruling is that clinicians must take reasonable care to ensure that patients are aware of material risks: they must disclose to which a reasonable person in the patient’s position would attach significance.
What improvements can be made to avoid complications with shoulder dystocia?
This HSIB report shows that there needs to be better communication with mothers about the risks and benefits of vaginal delivery versus a C-section where a larger baby is suspected. Mothers should be central to decision making about their care and they cannot do that if they are not given all the relevant information at the right time. To read more about this, visit our blog on safer births, which focuses on promoting mothers’ decision making.
Although the outcome for the 31 babies mentioned in the report is deeply sad, the report is noted to represent a chance for national change. There is an opportunity to develop a consistent national approach to identifying larger babies to ensure all mothers and babies are cared for appropriately.
The Royal College of Obstetricians and Gynaecologists have agreed to use this HSIB report when updating their guidelines. It is reassuring that they have acknowledged the principle from the Montgomery judgment applies to all pregnancies: women should be appropriately counselled about risks and their options, and involved in their own care. We welcome their response and are encouraged when any medical institution accepts lessons learned and strives for positive change.
If you are concerned about a birth that has been affected by shoulder dystocia, our specialist medical negligence solicitors are here to listen and offer you advice. For a no-obligation initial chat, call us on 0117 325 2929 or fill out our online enquiry form.