DOI: 10.1097/JPN.0000000000000066
LEGAL ISSUES AND RISK MANAGEMENT Lisa A. Miller, CNM, JD
Shoulder Dystocia Planning for the Unpredictable hen it comes to the most common factors seen in obstetric malpractice cases, shoulder dystocia is second only to electronic fetal monitoring. An obstetric emergency that requires a coordinated team effort to successfully manage, shoulder dystocia can result in a number of adverse outcomes for both the mother and the newborn, including postpartum hemorrhage, brachial plexus injuries, and hypoxic ischemic neonatal encephalopathy. There are a great many resources in the literature on identification and management of shoulder dystocia, and this column will provide clinicians with an overview of common litigation issues arising from shoulder dystocia and focus on strategies for successful risk reduction and risk mitigation.
W
INCIDENCE AND COMMON ALLEGATIONS Shoulder dystocia is defined by the clinician as the need for additional maneuvers to deliver the shoulders and body of an infant following delivery of the head. The incidence of shoulder dystocia is reported as a range of 0.6% to 1.4% in vertex vaginal deliveries.1 Although a variety of risk factors including diabetes, maternal obesity, and fetal macrosomia have been reported in the literature, there are no risk factors that reach a high enough predictive value to be reliable; even the presence of both diabetes and macrosomia correctly predicted only 55% of shoulder dystocia cases.2 For these reasons, clinicians should be prepared to deal with shoulder dystocia as a potential obstetric emergency in virtually every vaginal delivery. Although shoulder dystocia is unpredictable, one of the most common allegations by the plaintiff in litigation is the failure to predict (and therefore prevent) a shoulder dystocia. Other allegations include improper management of a shoulder dystocia once it occurs (too Disclosure: The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article.
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www.jpnnjournal.com
much traction, failure to use proper maneuvers) and failure to prevent a shoulder dystocia by offering the patient a cesarean delivery in the face of multiple risk factors.3 Most often the plaintiff will use all of these alleged violations of the standard of care when a lawsuit is filed, and although the allegations related to excessive traction and prevention by cesarean delivery will apply exclusively to the case against the delivering physician or midwife, allegations related to failure to anticipate and/or improper management once diagnosed will be applicable to the entire obstetric team. Perinatal nurses need to be aware of both risk factors and proper interventions in shoulder dystocia to function effectively at the bedside. In addition, this knowledge will provide the requisite tools for his or her defense in litigation: the ability to answer questions related to the team response at the time of the shoulder dystocia.
RISK REDUCTION Risk management in obstetrics has 2 distinct but separate arms: risk reduction and mitigation of risk. Risk reduction focuses on the development of patient safety approaches geared toward avoiding or decreasing the chance of an adverse outcome, whereas mitigation of risk concentrates on the response of the obstetric team following an adverse outcome, usually in defense of malpractice litigation. Standardization of care and a systematic, planned response to shoulder dystocia when it does occur are the 2 primary risk-reduction strategies. Every obstetric clinician should be educated on the risk factors associated with shoulder dystocia1 (see Table 1) as well as the variety of maneuvers used in response to shoulder dystocia. For physicians and midwives, this education occurs during residency or training. For nurses, whose labor & delivery experience is limited during training, such education and knowledge should be part of orientation to the specialty of labor & delivery nursing. Multidisciplinary protocols for shoulder dystocia should be part of staff education. District II October/December 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Table 1. Factors associated with shoulder dystociaa Antepartum factors Maternal diabetes Suspected fetal macrosomia Maternal obesity Multiparity
Intrapartum factors Labor induction Epidural anesthesia Operative vaginal delivery Labor abnormalities (conflicting evidence)
History of macrosomic infant or shoulder dystocia a
From American Congress of Obstetricians and Gynecologists.1 Note that none of the factors, either individually or in combination, are predictive of shoulder dystocia to any degree of clinical usefulness.
of the American Congress of Obstetricians and Gynecologists (ACOG) has published a comprehensive monograph on shoulder dystocia that includes guidelines for the development of hospital protocols; it is available for download at its Web site.4 In addition to initial education regarding incidence, associated risk factors, and management of shoulder dystocia, all obstetric team members should participate in ongoing and repetitive training in shoulder dystocia response and management. Emergency drills and simulation training provide team members with an opportunity to practice emergency response and identify areas for improvement as well as rectify system issues that may result in unnecessary delays or inadequate response. As such, they are 2 important and effective strategies for risk reduction once team members have acquired the requisite knowledge base related to shoulder dystocia.
MITIGATION OF RISK Once a shoulder dystocia has occurred, a systematic approach to follow-up is key to mitigation of risk should litigation occur. Even with the use of appropriate corrective measures and a coordinated emergency response by the obstetric team, injuries can occur following a shoulder dystocia and this can result in litigation. Allegations of failure to recognize risk and failure to appropriately manage both the shoulder dystocia and any necessary neonatal resuscitation are common. Clinicians will be called upon in deposition and/or trial testimony to demonstrate their knowledge and explain their actions related to both anticipation and management of the shoulder dystocia in question. Because the roles of team members during a shoulder dystocia necessarily The Journal of Perinatal & Neonatal Nursing
vary, engaging in a team debriefing immediately following the occurrence of a shoulder dystocia is helpful in ensuring accurate and complete documentation. Documentation and deposition testimony are interrelated, and clinicians will be best served by medical and nursing records that reflect the coordinated team response to obstetric emergencies such as shoulder dystocia. To this end, a standardized checklist for documentation in shoulder dystocia cases has been developed by the ACOG, and like the monograph on shoulder dystocia, it is available for download at the ACOG Web site.5 The comprehensive checklist includes timing of events, key antepartum, intrapartum, and postpartum documentation items, and a summary of procedural elements for the management of shoulder dystocia. Whether using paper or electronic records, nurses, midwives, and physicians will find the incorporation of this detailed and standardized checklist invaluable in documentation of shoulder dystocia cases.
CONCLUSION Shoulder dystocia is an obstetric emergency that can occur without warning and carries with it serious risks of maternal and neonatal morbidity, even mortality. This makes shoulder dystocia both a patient safety issue and a significant potential source of malpractice litigation for nurses, midwives, and physicians. Obstetric team education on associated risk factors, anticipatory planning, and appropriate emergency response will prepare clinicians to respond quickly and in concert when faced with shoulder dystocia. Emergency drills and simulation training should be used to reinforce basic education and improve both response time and best practice as part of a risk-reduction effort. Following a shoulder dystocia, debriefing between team members and utilization of a standardized, multidisciplinary checklist can provide clinicians with effective defenses should litigation ensue. Although shoulder dystocia itself is unpredictable, clinical response must be predictably rapid, appropriate, and coordinated. —Lisa A. Miller, CNM, JD Founder Perinatal Risk Management and Education Services Portland, Oregon
References 1. ACOG Practice Bulletin 40, Shoulder Dystocia (reaffirmed 2010). Obstet Gynecol. 2002;100(5, pt 1):1045–1050. 2. Acker DB, Sachs BP, Friedman EA. Risk factors for shoulder dystocia. Obstet Gynecol. 1993;168:1732–1737; discussion 1737–1739. www.jpnnjournal.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
257
3. Lerner H. Three typical claims in shoulder dystocia lawsuits. CRICO/RMF Forum. 2007;15–17. http://www.rmfstrategies .com/∼/media/Files/_Global/KC/PDFs/Forum_V25N3_ dystocia.pdf. Accessed August 9, 2014. 4. ACOG District II. Managing shoulder dystocia. https://www .acog.org/∼/media/Districts/District%20II/PDFs/Optimizing_
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www.jpnnjournal.com
Protocols_In_OB_HTN_Series_3.pdf. Published 2013. Access -ed August 9, 2014. 5. ACOG checklist for documenting shoulder dystocia no. 6. http://journals.lww.com/greenjournal/Citation/2012/08000/ Patient_Safety_Checklist_No__6___Documenting.43.aspx. Published August 2012. Accessed August 18, 2014.
October/December 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LEGAL ISSUES AND RISK MANAGEMENT Lisa A. Miller, CNM, JD
Shoulder Dystocia Planning for the Unpredictable hen it comes to the most common factors seen in obstetric malpractice cases, shoulder dystocia is second only to electronic fetal monitoring. An obstetric emergency that requires a coordinated team effort to successfully manage, shoulder dystocia can result in a number of adverse outcomes for both the mother and the newborn, including postpartum hemorrhage, brachial plexus injuries, and hypoxic ischemic neonatal encephalopathy. There are a great many resources in the literature on identification and management of shoulder dystocia, and this column will provide clinicians with an overview of common litigation issues arising from shoulder dystocia and focus on strategies for successful risk reduction and risk mitigation.
W
INCIDENCE AND COMMON ALLEGATIONS Shoulder dystocia is defined by the clinician as the need for additional maneuvers to deliver the shoulders and body of an infant following delivery of the head. The incidence of shoulder dystocia is reported as a range of 0.6% to 1.4% in vertex vaginal deliveries.1 Although a variety of risk factors including diabetes, maternal obesity, and fetal macrosomia have been reported in the literature, there are no risk factors that reach a high enough predictive value to be reliable; even the presence of both diabetes and macrosomia correctly predicted only 55% of shoulder dystocia cases.2 For these reasons, clinicians should be prepared to deal with shoulder dystocia as a potential obstetric emergency in virtually every vaginal delivery. Although shoulder dystocia is unpredictable, one of the most common allegations by the plaintiff in litigation is the failure to predict (and therefore prevent) a shoulder dystocia. Other allegations include improper management of a shoulder dystocia once it occurs (too Disclosure: The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article.
256
www.jpnnjournal.com
much traction, failure to use proper maneuvers) and failure to prevent a shoulder dystocia by offering the patient a cesarean delivery in the face of multiple risk factors.3 Most often the plaintiff will use all of these alleged violations of the standard of care when a lawsuit is filed, and although the allegations related to excessive traction and prevention by cesarean delivery will apply exclusively to the case against the delivering physician or midwife, allegations related to failure to anticipate and/or improper management once diagnosed will be applicable to the entire obstetric team. Perinatal nurses need to be aware of both risk factors and proper interventions in shoulder dystocia to function effectively at the bedside. In addition, this knowledge will provide the requisite tools for his or her defense in litigation: the ability to answer questions related to the team response at the time of the shoulder dystocia.
RISK REDUCTION Risk management in obstetrics has 2 distinct but separate arms: risk reduction and mitigation of risk. Risk reduction focuses on the development of patient safety approaches geared toward avoiding or decreasing the chance of an adverse outcome, whereas mitigation of risk concentrates on the response of the obstetric team following an adverse outcome, usually in defense of malpractice litigation. Standardization of care and a systematic, planned response to shoulder dystocia when it does occur are the 2 primary risk-reduction strategies. Every obstetric clinician should be educated on the risk factors associated with shoulder dystocia1 (see Table 1) as well as the variety of maneuvers used in response to shoulder dystocia. For physicians and midwives, this education occurs during residency or training. For nurses, whose labor & delivery experience is limited during training, such education and knowledge should be part of orientation to the specialty of labor & delivery nursing. Multidisciplinary protocols for shoulder dystocia should be part of staff education. District II October/December 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Table 1. Factors associated with shoulder dystociaa Antepartum factors Maternal diabetes Suspected fetal macrosomia Maternal obesity Multiparity
Intrapartum factors Labor induction Epidural anesthesia Operative vaginal delivery Labor abnormalities (conflicting evidence)
History of macrosomic infant or shoulder dystocia a
From American Congress of Obstetricians and Gynecologists.1 Note that none of the factors, either individually or in combination, are predictive of shoulder dystocia to any degree of clinical usefulness.
of the American Congress of Obstetricians and Gynecologists (ACOG) has published a comprehensive monograph on shoulder dystocia that includes guidelines for the development of hospital protocols; it is available for download at its Web site.4 In addition to initial education regarding incidence, associated risk factors, and management of shoulder dystocia, all obstetric team members should participate in ongoing and repetitive training in shoulder dystocia response and management. Emergency drills and simulation training provide team members with an opportunity to practice emergency response and identify areas for improvement as well as rectify system issues that may result in unnecessary delays or inadequate response. As such, they are 2 important and effective strategies for risk reduction once team members have acquired the requisite knowledge base related to shoulder dystocia.
MITIGATION OF RISK Once a shoulder dystocia has occurred, a systematic approach to follow-up is key to mitigation of risk should litigation occur. Even with the use of appropriate corrective measures and a coordinated emergency response by the obstetric team, injuries can occur following a shoulder dystocia and this can result in litigation. Allegations of failure to recognize risk and failure to appropriately manage both the shoulder dystocia and any necessary neonatal resuscitation are common. Clinicians will be called upon in deposition and/or trial testimony to demonstrate their knowledge and explain their actions related to both anticipation and management of the shoulder dystocia in question. Because the roles of team members during a shoulder dystocia necessarily The Journal of Perinatal & Neonatal Nursing
vary, engaging in a team debriefing immediately following the occurrence of a shoulder dystocia is helpful in ensuring accurate and complete documentation. Documentation and deposition testimony are interrelated, and clinicians will be best served by medical and nursing records that reflect the coordinated team response to obstetric emergencies such as shoulder dystocia. To this end, a standardized checklist for documentation in shoulder dystocia cases has been developed by the ACOG, and like the monograph on shoulder dystocia, it is available for download at the ACOG Web site.5 The comprehensive checklist includes timing of events, key antepartum, intrapartum, and postpartum documentation items, and a summary of procedural elements for the management of shoulder dystocia. Whether using paper or electronic records, nurses, midwives, and physicians will find the incorporation of this detailed and standardized checklist invaluable in documentation of shoulder dystocia cases.
CONCLUSION Shoulder dystocia is an obstetric emergency that can occur without warning and carries with it serious risks of maternal and neonatal morbidity, even mortality. This makes shoulder dystocia both a patient safety issue and a significant potential source of malpractice litigation for nurses, midwives, and physicians. Obstetric team education on associated risk factors, anticipatory planning, and appropriate emergency response will prepare clinicians to respond quickly and in concert when faced with shoulder dystocia. Emergency drills and simulation training should be used to reinforce basic education and improve both response time and best practice as part of a risk-reduction effort. Following a shoulder dystocia, debriefing between team members and utilization of a standardized, multidisciplinary checklist can provide clinicians with effective defenses should litigation ensue. Although shoulder dystocia itself is unpredictable, clinical response must be predictably rapid, appropriate, and coordinated. —Lisa A. Miller, CNM, JD Founder Perinatal Risk Management and Education Services Portland, Oregon
References 1. ACOG Practice Bulletin 40, Shoulder Dystocia (reaffirmed 2010). Obstet Gynecol. 2002;100(5, pt 1):1045–1050. 2. Acker DB, Sachs BP, Friedman EA. Risk factors for shoulder dystocia. Obstet Gynecol. 1993;168:1732–1737; discussion 1737–1739. www.jpnnjournal.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
257
3. Lerner H. Three typical claims in shoulder dystocia lawsuits. CRICO/RMF Forum. 2007;15–17. http://www.rmfstrategies .com/∼/media/Files/_Global/KC/PDFs/Forum_V25N3_ dystocia.pdf. Accessed August 9, 2014. 4. ACOG District II. Managing shoulder dystocia. https://www .acog.org/∼/media/Districts/District%20II/PDFs/Optimizing_
258
www.jpnnjournal.com
Protocols_In_OB_HTN_Series_3.pdf. Published 2013. Access -ed August 9, 2014. 5. ACOG checklist for documenting shoulder dystocia no. 6. http://journals.lww.com/greenjournal/Citation/2012/08000/ Patient_Safety_Checklist_No__6___Documenting.43.aspx. Published August 2012. Accessed August 18, 2014.
October/December 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
