Delayed Diagnosis of Shoulder Dystocia Leads to Blue Baby Syndrome

This case involves the complicated vaginal delivery of a male born prematurely at 34 weeks gestation. The mother was diagnosed with maternal diabetes and pregnancy induced hypertension and during a prenatal visit, her doctor told her that the baby may be too large and need to be delivered via a C-section to prevent any complication. Upon admission on the day of delivery, a bedside sonogram revealed that the fetus was in a cephalic presentation and that there was normal fetal movement but no reports of shoulder dystocia were mentioned. The parents mentioned the previous claims by doctors that shoulder dystocia may be a problem but the physician on call told them not to worry. The on-call physician elected to proceed with a natural delivery and unfortunately ran into several complications with a delivery that lasted several hours. As a result of the difficult delivery, the infant suffered from neurological injuries including the inability to use his right arm, and brain injuries due to hypoxia including severe cognitive and developmental delays.

Question(s) For Expert Witness

1. Was it a departure from accepted standards of medical care for the doctor to not to have diagnosed the shoulder dystocia before electing for a vaginal delivery?

2. Since both parents informed the doctor that they have been told that a Cesarean Section would be required, was it a departure from accepted standards of medical care for him to opt for a vaginal delivery under the circumstances?

Expert Witness Response E-000170

Complications from shoulder dystocia are many. Maternally, postpartum hemorrhage can result from uterine atony caused either by overdistention from fetal macrosomia and/or dysfunctional contractility caused by mechanical obstruction. Another complication is third or fourth degree perineal laceration or extension of episiotomy. Since episiotomy is not necessary for most shoulder dystocia deliveries, this complication may be avoidable; however, fetal size alone may cause these extensive lacerations. This case depends on how promptly they determined that the baby was too big for a normal birth and if they made the call soon enough to do the C section. Furthermore, once the shoulder dystocia was identified, the doctors need to make sure they take all the right safety precautions in order to deliver the baby as safely and as soon as possible.