Compound presentation, obese mother, bad outcome
This shoulder dystocia case presented several hurdles for the defense.
A 26-year-old woman vaginally delivered a 9 lb, 1 oz baby in October 2009. Her history included 1 prior uncomplicated vaginal delivery of a baby with a birth weight of 7 lb, 6 oz. The prenatal period for the 2009 pregnancy was uneventful with a total of 14 office visits, at first monthly, then bi-weekly in September, and weekly by October. While there was a family history of diabetes noted and a couple of instances of elevated glucose levels during the summer, a fasting glucose test in August was within normal limits.
The mother presented to the hospital in labor in the early morning on October 27, 2009. Her prepregnancy weight was noted to be 225 lb and she was 5 ft 6 in tall. She was at 39 weeks + 6 days, and according to sonogram, this was her due date. She came with contractions, mild abdominal pain, and no unexpected complaints. The notes reflect a 30-lb weight gain during pregnancy and that the woman was initially found to be 4 cm dilated, 60% eff aced and station +3.
By 7 am, she had dilated only to 5 cm. Her membranes were artificially ruptured and her pelvis was listed as “probably clinically adequate.” Oxytocin was stopped at roughly 9 am, when an epidural catheter was placed.
Between 9 and 10 am, the patient became fully dilated. Up until that time, the notes reflect reassuring fetal heart rate (FHR) tracings. At 10:15, a nurse wrote: “Difficulty noted following delivery of infant’s head. Drs. A, B and Mid-Wife C were in attendance. The patient was put in position and McRobert’s maneuver was used along with suprapubic pressure being applied. Pediatricians were called.”
Dr A performed the delivery and Dr B applied suprapubic pressure. The child’s Apgar scores were 7 and 8. Dr D saw the child for the first time in the nursery and diagnosed a fractured left humerus.
The delivery notes state, “There was moderate shoulder dystocia. The time between head delivery to complete delivery was one minute. The following was a sequence of maneuvers done to relieve the shoulder dystocia. Maneuver 1, posterior arm delivery, suprapubic pressure, delivery of the posterior arm. The placenta was thereafter delivered spontaneously and intact. The mother suffered no lacerations.”
Attending Dr A wrote: “I was scrubbed during the procedure. I was immediately available during the procedure. Patient became fully dilated at 10:00 a.m. and began to push. The head descended with 3 contractions and pushing, head was delivered indirect OA, the shoulder was slow to deliver, exam showed that the shoulders in transverse with compound presentation of the posterior arm. The posterior arm delivered and the interior shoulders followed. There was a popping sensation and pediatrics was immediately notified in responding. The baby’s APGAR (sic) was 7/8; the baby was taken to NICU for further evaluation. Total time from head to shoulders was less than one minute.”
The pediatricians reported that they were paged to a vaginal delivery of a term baby with shoulder dystocia with “difficult labor.” They wrote, “Reached after baby was born; one minute APGAR was 7 and at one minute was given by OB/Gyn. Noticed that baby had a low tone and was not moving both the hands and MORO was asymmetrical. OB/Gyn mentioned hearing a popping sound while delivering and explained situation to mother. Baby was pink and had a good heart rate and respiratory effort started developing few retractions and tachypnea and was transferred to NICU for respiratory distress. Mom was explained of the baby’s condition (sic).”
The maternal plaintiff remained in the hospital until October 29, without complication, while the child stayed behind in the neonatal intensive care unit (NICU). The infant was ultimately transferred from the NICU. X-rays revealed a displaced fracture of the left humerus, with no fractures of the clavicle or the right humerus. Prior to discharge on November 12, 2009, the issue with the left humerus resolved with some compression dressings.
After discharge the child was treated at a hand therapy center for several months. While the patient had excellent triceps function and good hand function, he was unable to shoulder abduct, rotate the shoulder externally, or have any significant bicep function. Accordingly, on June 19, 2010, when he was 8½ months old, the infant underwent a spinal accessory nerve transfer. The infant tolerated the procedure well and was discharged the same day. Thereafter, he had occasional therapy.
Physical examinations were performed by pediatric rehabilitation and sports medicine specialists on October 8, 2011, who confirmed a moderate-to-severe Erb’s injury. The rehab doctor noted that the child’s fine motor skills are delayed on the injured arm. The child reaches left preferentially and does not effectively reach, grasp, or shake with the right arm. While the child can open and close the right hand and move his fingers and thumb, the right grasp is weaker than the left. Additionally, the child is unable to bring his right hand to his mouth independently without the left arm assisting.