Case #2000: Shoulder Dystocia
On April 30, at 10:01 a.m., the Plaintiff, a 23 year-old woman presented to the Defendant Hospital at 38-6/7 weeks gestation with complaints of contractions. Her estimated date of confinement was May 8 and she had a past obstetrical history of a 40 week vaginal delivery of a 6 pound 7 ounce child. She had pregestational type 2 diabetes mellitus and her admitting glucose level was 143. On her initial physical examination, she was noted to have had a 25 pound weight gain, her fundal height was 40 centimeters and the estimated fetal weight was 4000 grams. A pelvic examination showed that she was 3-4 centimeters dilated, 100% effaced and at -1 station. Throughout the afternoon and evening, the Plaintiff was maintained on Pitocin with labor progressing. The obstetrician at that time noted that the overall tracing was reassuring and indicated that pediatrics would be present for delivery because they suspected macrosomia.
On May 1, at 12:24 a.m., the Plaintiff was instructed to begin pushing. At 12:51 a.m., the infant had descended to +3 station when a shoulder dystocia was encountered. With the Plaintiff already in McRoberts, an attempt to deliver the anterior shoulder was unsuccessful. The obstetricians then applied suprapubic pressure with downward pressure; however, the shoulder did not deliver. A Rubin’s maneuver was unsuccessful and the posterior arm was reduced anteriorly across the chest and delivered, followed by the anterior shoulder. The obstetricians noted that the shoulder dystocia lasted 40 seconds, and the Plaintiff sustained a 2nd degree perineal laceration.
At birth, the baby’s left arm was noted to be limp. Her Apgar scores were 5 and 9 and her birth weight was 4610 grams (10 pounds 2 ounces). On May 2nd, she was evaluated by a physician from the brachial plexus team who diagnosed her with a perinatal brachial plexus palsy and instructed her mother to follow-up in the Brachial Plexus Clinic. On September 2, the child underwent a cervical myelogram which demonstrated C6-7 out pouching of the dural sac towards the left lateral recess and that the left C7 nerve roots were not clearly identified, compatible with a pseudomeningocele and nerve root avulsion.
On October 14, the child underwent surgery. Intraoperative findings showed extensive neuroma formation involving the upper and middle trunk with the C7 nerve root was clearly involved in the neuroma formation. In addition there was swelling and neuroma formation of the middle trunk at the C7 root region. The neurosurgeon felt that this might be suggestive of a combination of an avulsion injury and a rupture. Despite successful nerve grafts of C5 and C6, the child has been left with a permanent, significant functional disability in the affected arm.