Shoulder Dystocia Presentation November 19-20, 2009
Shoulder Dystocia • The words “Shoulder Dystocia” were first used in 1902 by Fieux.
Shoulder Dystocia Overview • Unpredictable • Ultrasound Very Unreliable • Estimated Fetal Weight Unreliable • Risk Factors Unreliable • Labor Factors Unreliable
Shoulder Dystocia Overview • Delivery Factors Unreliable • Patient Observations Unreliable • Nursing Observations Unreliable • Traction Estimates Unreliable • Clinical Pelvemetry Unreliable • Physician Very Reliable
1730 Smellie 1851 Danyau 1878 Speilberg 1905 Clark 1920 Taylor 1925 Sever 1926 Williams 1930 Jepson 1939 Koff 1943 Woods History of Traction
1980 Koenigsberger (later refuted by Gonik 1998) 1985 Dunn & Engle (a chronic congenital injury) 1992 Jennett 1995 Nocon 1995 Hankins 1997 Ouzounian 1997 Gherman 1997 Gilbert 1998 Gherman 1999 Ouzounian 2000 Sandmire 2001 Gonik Defense History of Non-Traction
The Gonik Epiphany • 1998 B.P.I. – result from traction • 2000 – not clearly elucidated • 1998 B.P.I. – avoid traction • 2000 – force limits not recognizable • 1998 B.P.I. – occurs from excessive force • 2000 – greatly debated Precis – 6th Edition, Vol. 6 1998 & 2000
Authoritative Textbooks • Neurology • Pediatrics • Pediatric Neurology • Orthopedics • Pediatric Orthopedics • Neurosurgery • Pediatric Neurosurgery • ALL SAY TRACTION!
John P. Laurent, M.D.Texas Children’s Hospital • 4,000 permanent brachial plexus injuries • 2 from cesarean sections • Both had cephalic replacement after failed vaginal maneuvers • See Laurent deposition testimony
Intrauterine Injury, Laurent, M.D. • “I do not believe that.” • “Baby floating in water = no fixed point.” • “Ultrasounds show limb movement.” • “No doubt it is excessive traction.” • “No excessive traction = no injury.” November 13, 2000
Uterine Forces • 1) Relatively uniform • 2) 50 to 75 MM of HG • 3) Why are injuries so variable?
Labor • Uterine contractions are uniform and symmetrical. • How can the injury be so focal, local, and asymmetrical?
EFM • No evidence of fetal pain. • (a) accelerations • (b) tachycardia • Hyperstimulation • Tetanic contractions • Sustained contractions = tetany • NO B.P.I.!!! • ACOG = Amalgamated Coalition of OB-GYN
Defense “Expert” Opinion • “We are beginning to understand that it occurs for reasons we don’t know about.” January 26, 2004
Deposition Testimony • Q Okay. We'll talk about that in a little bit. You've delivered lectures to physicians and adjusters for insurance companies telling them how the medical records should be written to best defend the physician, haven't you? • A That's a -- only a partially true statement. By writing a good medical record, it helps with the defense, but a good medical record is a good thing in and of itself. So in the talks I've given to risk management groups, I talk about what I feel would be a better or more ideal medical record than is generally the standard of care in the community. That is a good thing to do for medical care. It has the side benefit of making cases more defensible because there's more information in them. Deposition of Henry Lerner, M.D., May 7, 2008
Deposition Testimony • Q You've actually told them what should be in the record to make it more defensible or easier for you to defend, haven't you? • A Sure, on the basis of being told by plaintiff attorneys what various doctors were negligent for not having put in the record. Deposition of Henry Lerner, M.D., May 7, 2008
Deposition Testimony • Q (By Mr. Puga) Okay. Dr. Lerner, on what date did you submit your article, "Permanent Brachial Plexus Injury Following Vaginal Delivery Without Physician Traction or Shoulder Dystocia," that's been marked as Exhibit 4? On what date was that case report submitted to the American Journal of Obstetrics and Gynecology? • A I submitted it on or about June 11, 2007. Deposition of Henry Lerner, M.D., June 5, 2008.
Deposition Testimony • Q (By Mr. Puga) All right. I just asked you a few minutes ago the question, and it's your testimony that on at least two occasions of thoroughly and carefully reviewing these records that you missed on one of the records a note that there was a left Erb's palsy due to mild shoulder dystocia at delivery. You said missed in terms of not remembering seeing it, yes. Explain what you mean by that answer. • A I do not recall seeing it in either review. Deposition of Henry Lerner, M.D., June 5, 2008.
Deposition Testimony • Q Would you agree with me that if you had seen it, it would be important information for both your opinions as an expert witness and to be included in the case report? • A No. Deposition of Henry Lerner, M.D., June 5, 2008.