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Shoulder Dystocia Solicitors - Compensation Claim - Medical Negligence


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If you or your child have suffered personal injury and you fear you may have been the victim of incompetence or negligence there is no time for delay. In order to know what options you have you should seek expert legal advice as soon as possible. Our medical negligence solicitors operate a service with no charge whereby you can meet us in person or chat over the telephone with one of our experts and obtain initial advice. If you subsequently decide to proceed no further then that is your right and you will not be charged for our shoulder dystocia solicitors initial advice.

The term 'dystocia' means difficult labour (childbirth). During labour, there are numerous factors that could be responsible for dystocia including in-coordinate uterine activity, abnormal foetal lie or presentation or absolute or relative cephalopelvic disproportion.

Foetal lie is defined as the relationship between the long axis of the foetus and the long axis of the maternal spine; a longitudinal lie is the normal. Dystocia is associated with abnormal foetal lie such as a transverse lie. Cephalopelvic disproportion is said to occur when there is a large foetal head in the presence of a much smaller maternal pelvis.

There are two specific types of dystocia - cervical dystocia and shoulder dystocia. Cervical dystocia is defined as difficulty in labour resulting from failure of the cervix to dilate. In the remaining part of this article, we'll focus on shoulder dystocia - associated risk factors as well as complications.

According to the Royal College of Obstetricians and Gynecologists, the incidence of dystocia in the United Kingdom is around 0.5% or 1 in 200.

Shoulder Dystocia Explained

Shoulder dystocia is a specific case of dystocia where there is a difficulty with delivery of the foetal shoulders. In passing through the pelvis, the foetal head and shoulders rotate to make use of the widest diameters of the maternal pelvis. After delivery of the head, restitution occurs and the shoulders rotate into the antero-posterior (AP) diameter of the pelvic outlet. However, if the shoulders have not entered the pelvic inlet, the anterior shoulder may become caught above the maternal pubic symphysis. Occasionally, both shoulders may remain above the pelvic brim. Shoulder dystocia is therefore, diagnosed during labour when the shoulder fails to be delivered shortly after the foetal head.

This issue may give rise to injury which may be the result of medical negligence. Our shoulder dystocia solicitors are on hand to offer advice at no cost and with no further obligation.

Shoulder Dystocia Complications

Shoulder dystocia is a foetal emergency because if poorly managed, it could lead to foetal death. Complications that could result from shoulder dystocia include:

    • Foetal Complications

          • Brachial plexus injuries - in an effort to deliver the baby, inappropriate traction may be applied, causing stretching of the brachial plexus causing nerve damage. The most common form of brachial plexus injury associated with shoulder dystocia is Erb's palsy. Klumpke's palsy could also occur. Fortunately, most brachial plexus birth injuries are transient. Most of such injuries resolve between 2 weeks and 12 months but up to 15% of injuries result in permanent damage.
          • Fractures - including fractures of the clavicle and the humerus (long bone of the arm).
          • Birth asphyxia.
          • Cerebral damage - vessels of the foetal neck become occluded upon delivery of the head. Prolonged occlusion of these vessels for a few minutes is likely to cause varying degrees of cerebral damage.
          • Foetal death - the occlusion of the vessels may be prolonged long enough to cause foetal death.
    • Maternal Complications

          • Postpartum hemorrhage.
          • Rectovaginal fistula.
          • Symphyseal separation or diathesis, with or without transient femoral neuropathy.
          • Third or fourth degree episiotomy or tear.
          • Uterine rupture.

Risk Factors

Risk factors associated with the development of shoulder dystocia during labour include:


    Large Foetus

    Small Maternal Pelvis

        Pelvimetry involves estimating the dimensions of a gynecoid (or female) pelvis. The normal pelvic inlet has an AP (antero-posterior) diameter of 11cm and a transverse diameter of 13.5cm; the mid pelvis has an AP diameter of 12cm and a transverse diameter of 12cm; and the pelvic outlet has an AP diameter of 13.5cm and a transverse diameter of 11cm. If for any reason the dimensions of a female pelvis fall below the above, the pelvis becomes less than ideal for childbirth and there is an increased risk of shoulder dystocia occurring during delivery even in the absence of macrosomia.

    Post Maturity

        It is necessary to distinguish between prolonged pregnancy and post maturity. Prolonged pregnancy is defined as pregnancy exceeding 42 completed weeks of gestation or pregnancy exceeding 14 days from the normal length of 280 days (note that the first day of a pregnancy is the first day of the last normal menstrual period). Post maturity is a syndrome associated with meconium stained liquor, oligohydramnios and observational loss of subcutaneous fat with dry, cracked skin of the baby following delivery. The syndrome of post maturity can occur in a pregnancy less than 42 completed weeks of gestation and diagnosis is best made after delivery.

        Post maturity is a factor that has been known to be associated with shoulder dystocia.

    Previous Shoulder Dystocia

        There is a risk of recurrence of shoulder dystocia in subsequent pregnancies although definite figures are not available.

    Prolonged Second Stage Of Labour

        Labour occurs in three stages - stage one begins with painful, regular and progressive uterine contractions and ends with cervical effacement and dilation up to 10cm; stage two ends with the delivery of the foetus and stage three ends with delivery of the placenta.

        Failure of the foetal head to descend during the second stage of labour; and a lengthy second stage of labour are associated with shoulder dystocia.

    Assisted Vaginal Delivery

        Shoulder dystocia has been found to be more common in instrumental deliveries than in spontaneous vaginal deliveries.

    Medical Protocols

    This condition is an emergency and the best strategy is to have in place a defined shoulder dystocia protocol to help health care professionals cope with the condition. The HELPERR mnemonic is one of such clinical tools.

      H - Call for help

        This refers to activating the pre-arranged protocol or requesting the appropriate personnel to respond with necessary equipment to the labour and delivery unit.

      E - Evaluate for episiotomy

        Episiotomy should be considered throughout the management of shoulder dystocia but is necessary only to make more room if rotation manoeuvres are required. Shoulder dystocia is a bony impaction, so episiotomy alone will not release the shoulder. Because most cases of shoulder dystocia can be relieved with the McRoberts manoeuvre and suprapubic pressure, many women can be spared a surgical incision.

      L - Legs (the McRoberts manoeuvre)

        This procedure involves flexing and abducting the maternal hips, positioning the maternal thighs up onto the maternal abdomen. This position flattens the sacral promontory and results in cephalad rotation of the pubic symphysis. Nurses and family members present at the delivery can provide assistance for this manoeuvre.

      P - Suprapubic pressure

        The hand of an assistant should be placed suprapubically over the foetal anterior shoulder applying pressure in a cardiopulmonary resuscitation style with a downward and lateral motion on the posterior aspect of the foetal shoulder. This manoeuvre should be attempted while continuing downward traction. When this manoeuvres is successful, the foetus should be delivered with normal traction.

      E - Enter manoeuvre (internal rotation)

        These manoeuvres attempt to manipulate the fetus to rotate the anterior shoulder into an oblique plane and under the maternal symphysis. These manoeuvres can be difficult to perform when the anterior shoulder is wedged beneath the symphysis. At times, it is necessary to push the foetus up into the pelvis slightly to accomplish the manoeuvres. The manoeuvres include the Rubin II, the Woods corkscrew and the Reverse Woods corkscrew manoeuvres.

      R - Remove the posterior arm

        Removing the posterior arm from the birth canal also shortens the bisacromial diameter, allowing the foetus to drop into the sacral hollow, freeing the impaction. The elbow then should be flexed and the forearm delivered in a sweeping motion over the fetal anterior chest wall. Grasping and pulling directly on the foetal arm may fracture the humerus.

      R - Roll the patient

        The patient rolls from her existing position to the all-fours position. Often, the shoulder will dislodge during the act of turning, so that this movement alone may be sufficient to dislodge the impaction. In addition, once the position change is completed, gravitational forces may aid in the disimpaction of the foetal shoulders.

    Last Resort Protocols

    If the manoeuvres described in the HELPERR shoulder dystocia protocol mnemonic are unsuccessful, several techniques have been described as 'last-resort' manoeuvres. They include �

      Deliberate clavicle fracture

        Direct upward pressure on the mid-portion of the foetal clavicle; reduces the shoulder-to-shoulder distance.

      Zavanelli manoeuvre

        Cephalic replacement followed by cesarean delivery; involves rotating the foetal head into a direct occiput anterior position, then flexing and pushing the vertex back into the birth canal while holding continuous upward pressure until cesarean delivery is accomplished. An operating team, anesthesiologist, and physicians capable of performing a cesarean delivery must be present, and this manoeuvre should never be attempted if a nuchal cord previously has been clamped out and cut.

      General anesthesia

        Musculoskeletal or uterine relaxation with halothane or another general anesthetic may bring about enough uterine relaxation to affect delivery. Oral or intravenous nitroglycerin may be used as an alternative to general anesthesia.

      Abdominal surgery with hysterotomy

        General anesthesia is induced and cesarean incision is performed, after which the surgeon rotates the infant transabdominally through the hysterectomy incision, allowing the shoulder to rotate, much like a Woods corkscrew manoeuvre. Vaginal extraction is then accomplished by another physician.

      Symphysiotomy

        Intentional division of the fibrous cartilage of the pubic symphysis under local anesthesia has been used more widely in developing countries. It should be used only when all other manoeuvres have failed and capability of cesarean delivery is unavailable.

    Documentation & Evidence

    Following the successful delivery of the baby after inplementation of a shoulder dystocia protocol, proper documentation is necessary for two reasons. The first is because the documentation would prove useful in developing better techniques to deal with the condition; secondly because shoulder dystocia is an important reason for initiating medico-legal action.

        • Fully document events in terms of description and sequence of manoeuvres including times from delivery of head to complete delivery.
        • Who was called to help and record time.
        • Take paired cord samples and record pH levels.
        • Baby is assessed by staff grade pediatrician.
        • Complete audit form and clinical incidence form.
        • Details of information given to parents.


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The author of the substantive medical writing on this website is Dr. Christine Traxler MD whose biography can be read here