[jub]

How do ob nurses handle deliveries where a shoulder dystocia has resulted in a brachial plexus injury? Could it have been prevented? How? Did the doc just pull too hard too hard on the infant's head? Why does the injury occur? Is it malpractice? Thanks so much for any input on this!

[jub]

No one has ever encountered a shoulder dystocia???

[bbnurse]

Most all nurses have seen shoulder dystocia in their practice but this is not a simple question to answer. I suspect that is why no one is answering your questions. Shoulder dystocia is considered an urgent situation in order to deliver the baby before it becomes deprived of oxygen. There are very subtle signs that it might occur during labor but are not positive signs. Nurses have to help the physician by getting the pt. into a variety of positions to attempt a variety of manuvers to get the shoulder unstuck quickly, safely and get a healthy baby. Sometimes in the process, the clavicle is broken. It heals quickly. Nurses' role after this is usually support and possibly immobilization of the affected arm for the comfort of the baby. People claim malpractice many times but this happens without it being poor technique. I am of the opinion that I'd rather have a live baby with a fractured clavicle than a dead baby or mother. I'd even prefer a baby with a fx. than brain damage from O2 deprivation. So you see, it is not an easy question to answer. Nurses' follow the physicians lead in the delivery and in the care of the baby. We do drills on the manuevers periodically just to avoid the consequences of damage which are potential in this situation. So if you have had this, count yourself fortunate. It could have been much much worse. That's my opinion.

Hi JUB
I definitely agree with bbnure in every comment made....shoulder dystocia is an emergency situation...as much of an emergency for the baby as gross abruption or complete umbilical cord obstruction...there is no o2 going to the babe....the babe is dying slowly while not being delivered....the longest shoulder dystocia i have been on was 23 minutes...the babe was brain damage (CP) and still has seizures at age 5....a broken clavicle is no big deal...the bones are so soft, they heal fine.....in south america, the OB physician will cut the symphysis pubis to open the pelvis, and usually cutting through the bladder, etc...so it can get pretty ugly, but bbnurse is right that it is either these things or a dead baby....negligence ...no...estimation of the pelvic inlet is just that...and estimate...take a look at the father of the baby.....big shoulders...think about it....also a labor that stalls during transition or prolonged pushing....signs the babe aint fittin right....remember for the baby to offer tylenol in addition to immobilization.....good luck

[jub]

I appreciate both replies on this topic, but I'm not convinced the injury couldn't be prevented. I'm not worried so much about the broken clavicle, I'm concerned about brachial plexus injuries, when the nerves are damaged, leaving the arm, shoulder and hand paralyzed. The injury comes from excessive traction on the head, not being stuck. There are warning signs when an infant is too big for the birth canal and I've seen too many cases where those warning signs have just been ignored. At some point, someone has to be responsible for failing to appreciate the danger in delivering the babies vaginally. I can't even imagine how a doc would justify leaving an infant oxygen deprived for 23 minutes. How can that be anything BUT malpractice? Maybe I just don't understand, is there some kind of code where nurses don't utter the m word even when it's blatantly obvious? Please respond to this because I genuinely want to hear opinions.

[jub]

I'm interested in hearing why you think most brachial plexus injuries cannot be avoided? Are you aware of the warning signs, red flags, maneuvers to safely dislodge the shoulder? Or are you stating this from a strictly "deny the malpractice" point of view? The poster above stated that a doc left a child stuck, deprived of oxygen for 23 minutes! Where is the outrage?? What if that was YOUR infant? No one is agruing that a dead baby is preferred over an injured one, that's just ridiculous. The fact of the matter is that the warning signs are there 99% of the time. Who's job is it to appreciate the risk involved? I'm just baffled here. I couldn't live with myself if I watched a doctor permanently disable an infant and did nothing about it. That's not what I got into nursing for. Is it what nursing becomes??

[jub]

I apologize if I seem to be attacking anyone, that is not my intent. I'm just dumbfounded and saddened at the "at just happens and can't be helped" attitude. It can be helped!

There are many warning signs long before the childs head is delivered - fetal macrosomia,
maternal diabetes/gestational diabetes, maternal obesity, gestation over 40 weeks, short maternal stature, platypelloid pelvis,
maternal weight gain of more than 35 lbs., protracted first stage of labor, prolonged second stage, breech birth (or other abnormal presentation), history of dystocia births, history of large babies, ALL of these are warning signes that occur long before the head is delivered. I've never known a doc to notify a mom of the risks of delivering a baby when these warning signs are present.

To answer your questions, the specific case I have in mind involves a 1st time pregnancy, mom gained 75 lbs., was never tested for gestational diabetes, u/s showed 10 lb. at 36 weeks, prolonged 1st stage, induced with pit, deep varying decels on the baby, prolonged 2nd stage, "turtling" of the head, shoulder dystocia, and finally the baby was pulled out so hard the cord snapped. Apgar was 2 at 1 min, baby was intubated and resuscitated and mom was told feel lucky he was alive. He weighed 11 lb. 6 oz., right arm limp, no clavicle fracture. C5 - C7 torn and mom was told to go home and wait 3 years to see what happens with the arm.

What would you do?

[bbnurse]

Well, things are clear now why the question. I agree that poor practice of medicine has to be addressed when we know it is occuring. I find it awful that "these things just happen", too. But the truth is, they sometimes do. Many red flags are there and we have the obligation to read them and report them. ANY injury is too much.
There is some complicity by the mother too and some accountability. We, far too often, have mothers in this situation who deliberately CHOSE not to seek prenatal care. She has added to the uncertainty of a healthy outcome. I do NOT fault the physician who has to wade through a case like that without previous history, testing or supervision of care if the mother did not seek care. OR the mother who has had a Fx clavicle and is told to follow up and to keep the arm supported and who fails to do so. AND then has the audacity to sue when the arm is not "moving very much". It became a brachial plexus injury which was compounded by her ignorance, cheapness or something...and of course, someone must pay.
I understand the frustration you must feel that the injury might have been prevented. No matter what else, if we know the manuevers and the way to get the baby out and we are ready to do so, we have some peace of mind if things go wrong, but we also agonize over the loss or failure. We are after all, humans with regrets built in.

[jub]

Originally posted by bbnurse:

There is some complicity by the mother too and some accountability. We, far too often, have mothers in this situation who deliberately CHOSE not to seek prenatal care. She has added to the uncertainty of a healthy outcome. I do NOT fault the physician who has to wade through a case like that without previous history, testing or supervision of care if the mother did not seek care. OR the mother who has had a Fx clavicle and is told to follow up and to keep the arm supported and who fails to do so. AND then has the audacity to sue when the arm is not "moving very much". It became a brachial plexus injury which was compounded by her ignorance, cheapness or something...and of course, someone must pay.

For the record, this mom did receive proper prenatal care starting at 6 weeks gestation and never missed an appt. Try as you might, you simply cannot blame any part of this on the mother. I agree that it's a shame when women don't get prenatal care and then blame the doc when things go wrong. However, there is no excuse for a doctor to use excessive traction on an infant's head. If he's gotten himself into a situation where he's ignored the red flags and the head is delivered, o2 is compromised and the shoulder is still stuck, well, then he's put himself AND the baby in a bad spot. In my experience, it's the baby and not the doc that comes out on the bad end of a situation like this. It's interesting though that you would automatically assume the mom had been remiss in her responsibilities and not the doctor.

[This message has been edited by jub (edited April 09, 2001).]

[jub]

Originally posted by kday:
Jub, it WAS your baby, wasn't it??? It was YOU who was the patient....I read your post in the 'how much do you make' thread, and you stated you take your son to Texas Children's for treatment of his 'brachial plexus birth injury.' No wonder you seem so intense and vaguely hostile about this subject. Look, what happened to you sucked, okay? The doc should have been more prudent. BUT...let me just say this....there can be many so-called 'flags' that would indicate you MIGHT have a shoulder dystocia, but they're not always right. And a shoulder dystocia simply means the shoulder is stuck behind the pubic symphysis...it can usually be easily reduced and the baby is delivered without injury. Just because 'flags' are there doesn't mean you should automatically run for a c-section. Oh, and by the way variable (not 'varying') decels are in no way related to shoulder dystocia. They are indicitave of cord compression, which can happen with a 4lb. baby or a 10lb. baby, and are not always an 'ominous' sign that a baby is in trouble. Also, this 'turtling' of the head you refer to, I assume you mean the 2 steps forward and 1 step back of head descent with pushing. Well, this is a NORMAL occurance with first time moms. Their bodies haven't stretched to accommodate a baby before, and their muscles naturally hold the head back a little. It's simple physics. And again, this happens with 4, 5, 6, 8, and 10lb. babies in first time moms...and isn't necessarily indicative of an impending shoulder dystocia.

What happened to your baby sounds like a combination of CPD (cephalopelvic disproportion) and excessive traction on the head. It's horrible that your baby was injured, and you're right to be angry. I just wanted you to realize, however, that not all shoulder dystocias result in injuries, and not all large babies end up getting 'stuck.' I've seen an 11lb. 13oz. baby delivered vaginally on a first time mom go off without a hitch. As in all things in OB, there are many gray areas, and you can't always use one bad outcome to say that what led up to that outcome will cause it to happen EVERY single time. I hope you and your baby are okay, and I hope the next time you have a baby, it goes better for you. God bless.

Yes, Kday, I am talking about my baby. He is the one who was injured at birth. I didn't want to say that I was the mother and this happend to me because I wanted to get unbiased opinions on how nurses deal with this type of emergency. I know how often mothers are blamed for these injuries and didn't want that to be an issue here. As you've read above, however, it's second-nature to blame the patient and protect the doctor.

Also, I am an RN, so I know full well what varying/variable decels are as well as turtling. Also, I'm sure I am "intense" and "vaguely hostile" about this subject, and that's because it's my child who's injured. I'm a little offended that you'd think you could "teach me" anything about this injury at this point. Once my child was diagnosed as having this lifelong disability, I had no choice but to become the subject matter expert.

I've read many of your posts and generally enjoy them and agree with a lot of things you have to say. All I'm asking is that you, and others, learn all the facts concerning brachial plexus injuries before you make snap judgements and place blame. Thank you.