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    First Person: Our shoulder dystocia policy

     

    Dr Cohen is Chairman Emeritus, Einstein Healthcare Network, Philadelphia, Pennsylvania, and Professor of Ob/Gyn, Thomas Jefferson Medical College, Philadelphia, Pennsylvania.

     

     

     

    Dr Jaspan is Chairman of the Department of Obstetrics and Gynecology, Einstein Health Care Network, Philadelphia, Pennsylvania, and Associate Professor, Thomas Jefferson University, Philadelphia, Pennsylvania.

    Neither author has a conflict of interest to report with respect to the content of this article.

     

     

    In obstetrics there is nothing that produces more anxiety than a shoulder dystocia. We fear the fetal outcome, the potential maternal complication, and being sued.

    Imagine you are in the labor room with your patient, an anxious and excited 28-year-old G2P1 with no medical problems. You delivered her first baby, and she is thrilled to have you in the room for baby number two. After all, you were able to deliver her first baby using all your skill, knowledge, and maneuvers to overcome a serious shoulder dystocia. The current fetal heart rate tracing is a picture-perfect Category One, you have previously accessed the maternal pelvis for adequacy, and you have adeptly performed your best obstetric estimate of the fetal weight, 3300 g. She is progressing beautifully along Zhang’s new labor curve.1 The baby’s head is delivered; excitement fills the air … then a shoulder dystocia occurs followed by a brachial plexus injury and the baby is left with an Erb’s palsy.

    Obstetricians manage risk. We are trained to consider the risk and benefit of all medical and obstetric procedures performed during pregnancy as well as any medications prescribed or recommended during pregnancy. We use data to enable us to make rational decisions and/or counsel patients fairly. For example, the risk of uterine rupture after more than one cesarean delivery ranges from 0.9% to 3.7%, so we counsel our patients and inform them about this potentially catastrophic outcome. We also use risk-benefit data to determine when to recommend an invasive prenatal diagnostic procedure, such as an amniocentesis.

    See also: High/low agreement in shoulder dystocia case complicated by patient history

    Why is it, then, that we have not routinely used such data to make decisions about recommended optimal delivery routes when a patient has a history of a prior delivery complicated by a shoulder dystocia?

    One of the greatest fears of every physician and midwife who provide obstetrical services is the unpredictability of shoulder dystocia and the risk of being sued for this “unpredictable” outcome.

    NEXT: How things work in the Einstein Healthcare Network

    David Jaspan, MD
    Dr Jaspan is Chairman of the Department of Obstetrics and Gynecology, Einstein Health Care Network, Philadelphia, Pennsylvania, and ...
    Arnold W. Cohen, MD
    Dr Cohen is Chairman Emeritus, Einstein Healthcare Network, Philadelphia, Pennsylvania, and Professor of Ob/Gyn, Thomas Jefferson ...

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