Shoulder Dystocia And Brachial Plexus Injuries in Infants
Presently, the American College of Gynecological and Obstetrical Surgeons is recommending to patients who required a previous C-section to have a trial of labor and a vaginal birth with their next pregnancy. This recommendation is based upon current studies and is made by the gynecologist to the patient if no other risk factors are present which would complicate the birth. HMOs also put pressure on the surgeon to perform a trial of labor rather than a C-section in order to reduce costs. However, there is a risk of uterine rupture with having a trial of labor for a birth after a previous C-section.
Uterine rupture comes about from the C-section scar ripping open. It is associated with a drop in your baby’s blood pressure at the time of delivery and can cause the baby severe brain damage or death.
The standard of care dictates that your physician should fairly and thoroughly advise you of the risks and benefits of a trial of labor if you have had a previous C-section. If your doctor fails to provide you with this information, your doctor may have liability if your baby develops brain damage or cerebral palsy. If a uterine rupture does occur, your doctor must perform an emergency C-section within approximately 13 minutes or less in order to deliver the baby without it having brain damage.
Shoulder dystocia is one of the most feared complications of any birth. It occurs when the baby’s shoulder nearer to the mother’s abdomen gets stuck behind the pubic bone. Shoulder dystocia is an obstetrical emergency because often the umbilical cord is compressed, shutting off the baby’s oxygen supply.
It can lead to serious injuries to the child including Erb’s palsy, brain damage, and even death. Erb’s palsy is an injury to the upper roots of the brachial plexus, a nerve bundle in the armpit that supplies nerves in the upper arm. This injury causes paralysis of the upper arm muscles causing the arm to hang limply close to the side.
Most injuries resulting from shoulder dystocia, including Erb’s palsy, can be avoided if the doctor heeds the warning signs of a potential shoulder dystocia or treats the dystocia appropriately once it is apparent.
There are several risk factors for the occurrence of shoulder dystocia: gestational diabetes, obesity in the mother, excessive weight gain during pregnancy, macrosomia. (a baby weighing more than 4000 grams or approximately 9 lbs.), a previous large baby, a post-term pregnancy, and a small pelvis. Having one or more of these factors increases your risk of shoulder dystocia.
Also, the more factors that are present, the more likely it is that your doctor may consider a caesarean section, most commonly known as a C-section. For example, if you have gained more than 40 lbs. during your pregnancy, have been diagnosed with gestational diabetes, and an ultrasound shows that you have a macrosomic, or large, infant along with a small pelvis, then your doctor may recommend a caesarean
In most cases, however, only a couple of the risk factors are present and women are given a “trial of labor” to see if it is possible to have the baby naturally. Doctors will monitor the different stages of labor to determine if you are making appropriate progress. If the labor does not progress normally then a caesarean section may be needed.
The first stage of labor is from the onset of regular contractions until you become completely dilated. This stage should not last more than 24 hours and is normally much shorter.
If a woman’s water has broken and she has not completely dilated within 24 hours, a caesarean section generally will be performed. In addition, the mother should be monitored during this first stage to ensure that her contractions are strong enough. If her contractions are strong enough, and the cervix does not dilate during a two to three hour period, a caesarean section may also be considered.
The second stage of labor occurs from the time the mother is completely dilated until the baby is born. A prolonged second stage of labor is generally considered to be one that lasts more than four hours.
A prolonged second stage of labor is a sign of feto-pelvic disproportion, which occurs when there is a difference between the size of the baby and the size of the mother’s pelvis. A caesarean section should be performed when risk factors for shoulder dystocia exist in combination with a prolonged second stage of labor.
Many instances of shoulder dystocia can be anticipated and prevented if the warning signs are heeded. There are some instances of shoulder dystocia that cannot be anticipated. However, injury to the infant can still be prevented if the appropriate steps are taken once the shoulder dystocia occurs.
For example, the only known cause of Erb’s palsy in a head first vaginal delivery is excessive lateral traction to the baby’s head. Lateral traction to the head occurs when the baby’s head is pulled sideways in an attempt to dislodge the trapped shoulder. Once the dystocia occurs, no lateral traction should be applied to the baby’s head.
All the means necessary to successfully deliver the child can be done without applying lateral traction to the head. An example of a safe intervention during a shoulder dystocia is to perform McRobert’s maneuver. During this procedure, the patient’s legs are held back in a flexed position. At the same time, pressure is applied to the mother’s lower abdomen, which is called suprapubic pressure.
Under no circumstances should pressure be applied to the upper abdomen. This is called fundal pressure and may cause serious injury to both the mother and the baby. If the McRobert’s maneuver is not successful then there are a number of methods that the doctor can perform to safely rotate the baby and free its shoulders.
Almost all deliveries can be successfully resolved with no injury to the baby with the proper use of these proven methods where shoulder dystocia occurs. Unfortunately, birth injuries resulting from attempts to pull the baby free continue to take place during deliveries.