The AVMA Medical and Legal Journal

1

• The AVMA Medical and Legal Journal
• Incorporating
• Healthcare Law Digest

2
BRACHIAL PLEXUS INJURY AT BIRTH
RISK
CLINICAL
AVMA Conference July 12th 2002

• A TRACTION INJURY

Roger V Clements EditorClinical Risk
3
The Brachial Plexus
4
BRACHIAL PLEXUS INJURY AT BIRTH
RISK
CLINICAL
AVMA Conference July 12th 2002

• A TRACTION INJURY
• always?

Roger V Clements EditorClinical Risk
5
BRACHIAL PLEXUS INJURY AT BIRTH
RISK
CLINICAL
AVMA Conference July 12th 2002

• A TRACTION INJURY
• almost always

Roger V Clements EditorClinical Risk
6
BRACHIAL PLEXUS INJURY AT BIRTH
RISK
CLINICAL
AVMA Conference July 12th 2002

• Vaginal delivery
• cephalic presentation
• complicated by shoulder dystocia
• breech delivery employing the
• Mauriceau-Smellie-Veit manoeuvre

Roger V Clements EditorClinical Risk
7
The Mauriceau-Smellie-Veit Manoeuvre
8
BRACHIAL PLEXUS INJURY AT BIRTH
RISK
CLINICAL
AVMA Conference July 12th 2002

• Caesarean delivery
• cephalic presentation - a large baby and an
  inadequate incision
• breech delivery - a tiny preterm baby through an
  injudicious lower segment incision

Roger V Clements EditorClinical Risk
9
SHOULDER DYSTOCIA
RISK
CLINICAL
AVMA Conference July 12th 2002

• Incidence 1.02
• (range 0.1 - 2)
• (underourished Chinese - overweight Americans)

Roger V Clements EditorClinical Risk
10
SHOULDER DYSTOCIA
RISK
CLINICAL
AVMA Conference July 12th 2002

• Definition
• when the standard delivery procedures of gentle
  downward traction of the fetal head and moderate
  fundal pressure fail to accomplish delivery
• (OLeary)

Roger V Clements EditorClinical Risk
11
SHOULDER DYSTOCIA
RISK
CLINICAL
AVMA Conference July 12th 2002

• Classification
• OLearyAccording to treatment employed
• Gibb 3 degrees of difficulty
• 1. A little bit of difficulty with the shoulders
• 2. Unilateral
• 3. Bilateral

Roger V Clements EditorClinical Risk
12
Bilateral
Unilateral
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SHOULDER DYSTOCIA
RISK
CLINICAL
AVMA Conference July 12th 2002

• Unilateral usually deliverable with adequate
  technique
• Bilateral undeliverable vaginally

Roger V Clements EditorClinical Risk
14
SHOULDER DYSTOCIA
RISK
CLINICAL
AVMA Conference July 12th 2002

• What if not relieved?
• Asphyxia
• brain damage
• death

Roger V Clements EditorClinical Risk
15
SHOULDER DYSTOCIA
RISK
CLINICAL
AVMA Conference July 12th 2002

• Management at Delivery
• McRoberts position/all fours
• Suprapubic Pressure
• Woods/Rubin Screw
• Deliver Posterior Arm
• Zavanelli Manoevre

Roger V Clements EditorClinical Risk
16
McRoberts Position
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Suprapubic Pressure - Single-handed
18
The Woods Screw Manoeuvre in All-Fours
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Delivery of the posterior arm 1
20
Delivery of the posterior arm 2
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Delivery of the posterior arm 3
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Delivery of the posterior arm 4
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SHOULDER DYSTOCIA
RISK
CLINICAL
AVMA Conference July 12th 2002

• Management at Delivery
• What not to do-
• firm traction
• repeated traction
• fundal pressure

Roger V Clements EditorClinical Risk
24
BRACHIAL PLEXUS INJURY AT BIRTH
RISK
CLINICAL
AVMA Conference July 12th 2002

• A TRACTION INJURY
• almost always

Roger V Clements EditorClinical Risk
25
BRACHIAL PLEXUS INJURY AT BIRTH
RISK
CLINICAL
AVMA Conference July 12th 2002

• A TRACTION INJURY
• but not quite always

Roger V Clements EditorClinical Risk
26
BRACHIAL PLEXUS INJURY WITHOUT SHOULDER DYSTOCIA
RISK
CLINICAL
AVMA Conference July 12th 2002

• Anecdotal reports from 5 US centers of OBPI
  without recorded shoulder dystocia
• Phoenix, Arizona
• Green Bay, Wisconsin
• Salt Lake City, Utah
• Iowa City, Iowa
• Los Angeles, California

Roger V Clements EditorClinical Risk
27
BRACHIAL PLEXUS INJURY WITHOUT SHOULDER DYSTOCIA
RISK
CLINICAL
AVMA Conference July 12th 2002

• Phoenix, Arizona
• Intra-uterine maladaptation
• incontrovertible evidence
• intrauterine pressures
• uterine anomalies
• Jennett R J, Tarby T J Kreinick M A Brachial
  Plexus Palsy An old problem revisited. Am J Obst
  Gynecol 1992 16616733-7

Roger V Clements EditorClinical Risk
28
BRACHIAL PLEXUS INJURY WITHOUT SHOULDER DYSTOCIA
RISK
CLINICAL
AVMA Conference July 12th 2002

• Green Bay, Wisconsin
• Propulsive theory
• strong retraction forces of the fetal head
  betweencontractions after pushingstretching of
  the nerves occurs because of the disproportionate
  descent of the head before complete delivery
• Sandmire H F DeMott RK Erbs palsy Concepts
  of Causation. Obstetrics and Gynaecology
  200095941-942

Roger V Clements EditorClinical Risk
29
BRACHIAL PLEXUS INJURY WITHOUT SHOULDER DYSTOCIA
RISK
CLINICAL
AVMA Conference July 12th 2002

• Salt Lake City, Utah
• Propulsive theory
• Observation of OBPI to the posterior shoulder
• Hankins G D V Clark S L Brachial Plexus
  Palsy involving the posterior shoulder at
  spontaneous vaginal delivery American J
  Perinatolgy 19951244-45

Roger V Clements EditorClinical Risk
30
BRACHIAL PLEXUS INJURY WITHOUT SHOULDER DYSTOCIA
RISK
CLINICAL
AVMA Conference July 12th 2002

• Los Angeles, California
• Propulsive theory
• Four cases that occurred in the absence of
  shoulder dystocia...and four cases .. in the
  posterior arm of infants with anterior shoulder
  dystocia
• Ouzounian J G, Korst LM and Phelan J P Permanent
  Erbs palsy a traction-related injury?
  Obstetrics and Gynaecology 1997 89139-141

Roger V Clements EditorClinical Risk
31
BRACHIAL PLEXUS INJURY WITHOUT SHOULDER DYSTOCIA
RISK
CLINICAL
AVMA Conference July 12th 2002

• Iowa City, Iowa
• Completely idiopathic
• The forces of labor, maternal pelvic anatomy,
  and fetal position interact in such a way as to
  make certain fetuses more vulnerable..
• Peleg D, Hasnin J Shalev E Fractured clavicle
  and Erbs palsy unrelated to birth trauma Am J
  Obstet Gynecol 19971771038-40

Roger V Clements EditorClinical Risk
32
BRACHIAL PLEXUS INJURY AT BIRTH
RISK
CLINICAL
AVMA Conference July 12th 2002

• A review of the literature leads to the following
  conclusions-
• 1. Downward and lateral traction in an attempt to
  free the anterior shoulder in the presence of
  shoulder dystocia is the most likely cause of
  damage to the anterior brachial plexus
• Stirrat GM Taylor R Mechanisms of Obstetric
  Brachial Plexus Palsy - A Critical Analysis
• Clinical Risk November 2002 (in Press)

Roger V Clements EditorClinical Risk
33
BRACHIAL PLEXUS INJURY AT BIRTH
RISK
CLINICAL
AVMA Conference July 12th 2002

• A review of the literature leads to the following
  conclusions-
• 2. There is currently no good evidence for
  asserting that, when there has clearly been
  shoulder dystocia and the anterior brachial
  plexus has been damaged,..
• Stirrat GM Taylor R Mechanisms of Obstetric
  Brachial Plexus Palsy - A Critical Analysis
• Clinical Risk November 2002 (in Press)

Roger V Clements EditorClinical Risk
34
BRACHIAL PLEXUS INJURY AT BIRTH
RISK
CLINICAL
AVMA Conference July 12th 2002

• A review of the literature leads to the following
  conclusions-
• 2. the injury was due to anything other than
  lateral and downward traction against resistance.
• Stirrat GM Taylor R Mechanisms of Obstetric
  Brachial Plexus Palsy - A Critical Analysis
• Clinical Risk November 2002 (in Press)

Roger V Clements EditorClinical Risk
35
BRACHIAL PLEXUS INJURY AT BIRTH
RISK
CLINICAL
AVMA Conference July 12th 2002

• A review of the literature leads to the following
  conclusions-
• 3. There, is in many cases, no documented account
  of shoulder dystocia when there is brachial
  plexus injury. Even when under-reporting is
  taken into consideration there may remain some
  cases in which shoulder dystocia has not
  occurred.
• Stirrat GM Taylor R Mechanisms of Obstetric
  Brachial Plexus Palsy - A Critical Analysis
• Clinical Risk November 2002 (in Press)

Roger V Clements EditorClinical Risk
36
BRACHIAL PLEXUS INJURY WITHOUT SHOULDER DYSTOCIA
RISK
CLINICAL
AVMA Conference July 12th 2002

• a. a vulnerable hypotonic fetus
• b. pressure from the sacral promontory
• c. pressure from fetal or uterine
  tumour/abnormality

Roger V Clements EditorClinical Risk
37
BRACHIAL PLEXUS INJURY AT BIRTH
RISK
CLINICAL
AVMA Conference July 12th 2002

• A review of the literature leads to the following
  conclusions-
• 4. The mechanism by which propulsive forces can
  produce traction on nerves that are below the
  point at which the force operates is not clear.
  The fact that the anterior aspect of the neck is
  flexed when the head is born..
• Stirrat GM Taylor R Mechanisms of Obstetric
  Brachial Plexus Palsy - A Critical Analysis
• Clinical Risk November 2002 (in Press)

Roger V Clements EditorClinical Risk
38
BRACHIAL PLEXUS INJURY AT BIRTH
RISK
CLINICAL
AVMA Conference July 12th 2002

• A review of the literature leads to the following
  conclusions-
• 4. ..and the anterior shoulder is fixed
  above the pelvic brim must be an added safeguard
  against stretching of the anterior plexus.
• Stirrat GM Taylor R Mechanisms of Obstetric
  Brachial Plexus Palsy - A Critical Analysis
• Clinical Risk November 2002 (in Press)

Roger V Clements EditorClinical Risk
39
BRACHIAL PLEXUS INJURY AT BIRTH
RISK
CLINICAL
AVMA Conference July 12th 2002

• A review of the literature leads to the following
  conclusions-
• 5. Unanswered questions remain about both
  shoulder dystocia and brachial plexus injury and
  these require carefully planned, large,
  prospective studies.
• Stirrat GM Taylor R Mechanisms of Obstetric
  Brachial Plexus Palsy - A Critical Analysis
• Clinical Risk November 2002 (in Press)

Roger V Clements EditorClinical Risk
40
BRACHIAL PLEXUS INJURY AT BIRTH
RISK
CLINICAL
AVMA Conference July 12th 2002

• A review of the literature leads to the following
  conclusions-
• 5. Despite the practical difficulties, there is
  some expectation that valid studies might
  eventually be forthcoming.
• Stirrat GM Taylor R Mechanisms of Obstetric
  Brachial Plexus Palsy - A Critical Analysis
• Clinical Risk November 2002 (in Press)

Roger V Clements EditorClinical Risk
41
SHOULDER DYSTOCIA
RISK
CLINICAL
AVMA Conference July 12th 2002

• Date Dependent
• Difficult to Win
• Notes
• Eye Witnesses

Roger V Clements EditorClinical Risk
42
Incidence of Shoulder Dystocia in Diabetics and
Non-Diabetics
43
SHOULDER DYSTOCIADate Dependent
RISK
CLINICAL
AVMA Conference July 12th 2002

• McRoberts 1983-1991
• OLeary (US) 1992
• Safe Practice late 1994
• Clinical Risk March 1995
• Mayes Midwifery 1997

Roger V Clements EditorClinical Risk
44
SHOULDER DYSTOCIADifficult to Win
RISK
CLINICAL
AVMA Conference July 12th 2002

• Elective Caesarean Section
• Emergency CS (in labour)
• Management at Delivery

Roger V Clements EditorClinical Risk
45
SHOULDER DYSTOCIADifficult to Win
RISK
CLINICAL
AVMA Conference July 12th 2002

• Elective Caesarean Section
• Suspicion of Macrosomia
• Confirmation of Macrosomia
• Diabetic gt 4.5 Kg
• Non-Diabetic gt 5 Kg

Roger V Clements EditorClinical Risk
46
SHOULDER DYSTOCIADifficult to Win
RISK
CLINICAL
AVMA Conference July 12th 2002

• Elective Caesarean Section
• Previous Shoulder Dystocia?
• Previous Brachial Plexus Injury
• Previous Associated Asphyxial Injury

Roger V Clements EditorClinical Risk
47
SHOULDER DYSTOCIADifficult to Win
RISK
CLINICAL
AVMA Conference July 12th 2002

• Emergency C S in Labour
• Foreseeable risk of injury
• Foreseeable risk of asphyxia

Roger V Clements EditorClinical Risk
48
SHOULDER DYSTOCIADifficult to Win
RISK
CLINICAL
AVMA Conference July 12th 2002

• Management At Delivery
• What is in the notes?
• What do the eye witnesses remember?
• What actually happened?

Roger V Clements EditorClinical Risk
49
SHOULDER DYSTOCIA
RISK
CLINICAL
AVMA Conference July 12th 2002

• Management at Delivery
• McRoberts position/all fours
• Suprapubic Pressure
• Woods/Rubin Screw
• Deliver Posterior Arm
• Zavanelli Manoevre

Roger V Clements EditorClinical Risk
50
SHOULDER DYSTOCIAEasy To Defend
RISK
CLINICAL
AVMA Conference July 12th 2002

• Particularly if-
• Nothing in the notes
• No third party or cant remember

Roger V Clements EditorClinical Risk
51
SHOULDER DYSTOCIARelationship with Asphyxia
RISK
CLINICAL
AVMA Conference July 12th 2002

• Early in labour favours the claimant
• Late in labour favours the defendant

Roger V Clements EditorClinical Risk
52

• The AVMA Medical and Legal Journal
• Incorporating
• Healthcare Law Digest