Legal Review and Commentary

Traction during birth causes partial paralysis

$900,000 verdict issued in Ohio

News: An obstetrician encountered difficulty in delivering a baby because the baby's shoulders had become stuck. After attempting several maneuvers to disimpact the shoulders, the obstetrician finally delivered the newborn girl, but not before the infant had suffered a nerve injury, resulting in partial paralysis. The mother filed suit against the obstetrician and alleged that the doctor applied excessive downward traction to the baby's head during delivery. The jury returned a verdict in favor of the plaintiff in the amount of $900,000.

Background: A pregnant woman went into labor and was taken to the hospital's delivery room, accompanied by her birthing coach. During the delivery, the obstetrician delivered the fetal head, but then encountered shoulder dystocia, whereby the newborn's shoulders had become stuck. The doctor attempted several ancillary maneuvers to disimpact the baby's shoulders. She first attempted the McRobert's maneuver, in which she sought to rotate the mother's symphysis pubis cephalad by hyperflexing the woman's legs and straightening the maternal sacrum relative to the lumbar spine. The technique, if successful, would have enabled the baby's shoulders to pass over the woman's sacrum and through her pelvic inlet, which would be positioned so as to maximize the amount of expulsive force during birth.

Although the McRobert's maneuver failed, it enlarged the woman's episiotomy so as to allow more room for subsequent maneuvers. The obstetrician then applied suprapubic pressure to displace the baby's impacted shoulders into the mother's oblique diameter. After some time, the obstetrician was able to successfully deliver the newborn girl. During the birth, however, the infant suffered an injury to her right brachial plexus, a network of nerves conducting signals from her spine to her shoulder, arm, and hand, resulting in paralysis of her right arm.

The mother filed a lawsuit on behalf of her daughter and alleged negligence by the obstetrician and her clinic. At trial, the plaintiff claimed that the doctor applied excessive downward traction to the baby's head before attempting the McRobert's maneuver and applying suprapubic pressure. The mother's birthing coach, who also was a labor and delivery nurse, testified that the obstetrician pulled down on the baby's head so hard that it looked like she could not pull any harder.

The witness concluded that it was this application of excessive downward traction, before any suprapubic pressure was applied, that harmed the infant during delivery. Plaintiff's counsel also relied on the testimony of two expert witnesses, one in obstetrics and gynecology and one in neurology, which cost in excess of $100,000.

The obstetrician, who stopped practicing some time after the incident to become the hospital's vice president of medical affairs, denied she acted negligently. She had no clear memory of the delivery, which had occurred 14 years earlier, although she had written in her delivery note: "Mild shoulder dystocia relieved by suprapubic pressure." She argued that the baby's injury was caused by a combination of uterine contractions, the mother's expulsive forces during labor, and a normal amount of traction necessary to deliver the baby.

After trial, the jury returned a verdict in favor of the plaintiff in the amount of $900,000, $118,000 of which was for economic damages. The mother said she was planning on using the balance of the award to pay for specialty items, including cookware and doorknobs, to make her daughter's life easier.

What this means to you: Although this case presents similar facts to the prior case, it highlights different risk management concerns in the context of childbirth.

"Although no information is given in this case study regarding prenatal care, one wonders whether fetal size should have suggested the potential for delivery problems," says Beth Huntington, BSN, MSN, JD, director of risk management at Baylor Health Care System in Dallas. A fetus who is large for its gestational age (LGA) weighs more than the usual amount for the number of weeks of pregnancy, often resulting in a birth weight greater than the 90th percentile for its gestational age. A baby's birth weight can be estimated during prenatal consultations by measuring the height of the mother's fundus from her pubic bone or by conducting an ultrasound. Although LGA can be caused by genetics or excessive weight gain by the mother during pregnancy, the most common cause is maternal diabetes. Because LGA babies are so big, delivery can be difficult and result in prolonged vaginal delivery time and increase in cesarean delivery. Delivering mothers can be affected by postpartum hemorrhage, rectovaginal fistula, symphyseal separation or diathesis (with or without transient femoral neuropathy), third- or fourth-degree episiotomy, and uterine rupture. The fetus also is at risk for brachial plexus palsy, clavicle fracture, fetal hypoxia (with or without permanent neurologic damage), fracture of the humerus, and, in some cases, fetal death. A diagnosis of LGA may lead to a recommendation of early delivery via induction of labor before the baby grows bigger or a planned cesarean delivery to prevent the injuries potentially associated with a vaginal delivery.

Huntington recognizes the implications of the $900,000 verdict in this case. "The fact that a baby experiences shoulder dystocia and injury is not in and of itself sufficient for a finding of negligence," she says.

Because not all of the facts from this case study are known, it is unclear whether the obstetrician handled the situation appropriately. An occurrence of shoulder dystocia becomes obvious when the fetal head emerges and then retracts against the perineum. Once encountered, the situation must not be exacerbated by applying fundal pressure or excessive force to the fetal head or neck. Instead, an obstetrician should seek to increase the functional size of the pelvis, decrease the breadth of the fetal shoulders, or change the relationship of the fetal shoulders within the mother's pelvis. Some techniques used to accomplish these goals in the treatment of shoulder dystocia include evaluating for episiotomy, performing the McRobert's maneuver, applying suprapubic pressure, attempting internal rotation maneuvers, removing the fetal posterior arm from the birth canal, and rolling the patient to an all-fours position in an attempt to dislodge the impaction. If none of these techniques is successful, some "last-resort" maneuvers may aid in the ultimate delivery of the fetus, including a deliberate fracture of the fetal clavicle, the Zavanelli maneuver (rotating the fetal head into a direct occiput anterior position and then pushing the top of the head back into the birth canal while holding continuous upward pressure until cesarean delivery is accomplished), providing halothane or some other general anesthetic, rotating the infant transabdominally through a hysterortomy incision, and a symphysiotomy, whereby the fibrous cartilage of the symphysis pubis is intentionally divided.

Although the defendant-obstetrician testified at trial that she attempted at least two of the commonly used techniques — the McRobert's maneuver and the application of suprapubic pressure — the jury apparently did not find her testimony credible. Instead, the jury believed the account of the birthing coach, who testified that the obstetrician's application of excessive downward traction, before any suprapubic pressure was applied, harmed the infant during delivery.

Because an award of nearly 1 million dollars, including a proportionately larger amount awarded for noneconomic damages, is rather large for this type of case, Huntington surmises that the jury must have been motivated by something that occurred at trial. Specifically, Huntington wonders whether the jury got angry with the obstetrician. If so, this case highlights the importance of sufficient documentation in the patient's medical record.

Many cases whose outcomes rely on differing eyewitness accounts do not go to trial until several years have passed. Because human memories can fade, Huntington advises that the best eyewitness is a well-documented medical chart. In this case, the notations in the patient's record were not consistent with the birthing coach's eyewitness testimony regarding the difficulty of delivery.

"If the physician had carefully and in detail noted the techniques and maneuvers used to deliver the infant, the record would have been a more credible defense witness than the birthing coach, who was also relying on memory of events that occurred 14 years previously," Huntington notes. Of course, no doubt the plaintiff's investment of $100,000 in expert witnesses helped the jury see that the obstetrician was indeed responsible for the damages suffered in this case.

Reference

• Marion County (OH) Court of Common Pleas, Case No. 00 CV 0278.