The Expert: Dr. Sean Blackwell, a maternal-fetal medicine specialist at the University of Texas, in Houston, testifying for the defense, outlines standards on deliveries.
Testifying for the defense in a medical malpractice trial in Milwaukee County, Wisconsin, Dr. Sean Blackwell, a maternal-fetal medicine expert opines regarding the claim that negligence during childbirth caused the plaintiff’s brachial plexus injury.
The doctor, from the University of Texas-Houston, begins this clip with a discussion about how shoulder dystocia impedes a normal delivery by the impaction of the baby’s front shoulder against the mother’s pubic bone as it attempts to rotate and descend in the birth canal. When this occurs and halts the progress of the delivery, there are certain steps to be followed in a defined order to try to facilitate a normal vaginal delivery without injuring the child.
The first action that should be taken in a case like this — the McRoberts maneuver— was performed by the delivering obstetrician in this case. This involves tightly hyperflexing the mother’s legs to her abdomen. This rotates the symphysis pubis toward the head and flattens the sacrum and lower lumbar spine to some extent, hopefully allowing the neonate to complete its rotation and descend. If this manipulation of the mother still does not help the baby’s progress, then a second maneuver is performed. This involves an assistant putting manual pressure on the fundus of the uterus during the previous maneuver, essentially pushing the child down into the canal, making the shoulder width smaller and perhaps rotating its body. These maneuvers do not always work, but they increase the chances that a safe vaginal delivery can be accomplished without pulling on the baby’s head or arm.
Referring to an excerpt from an American College of Gynecology (ACOG) Practice Bulletin, an evidence-based document that summarizes current information on techniques and clinical management issues for OB-Gyns, the attorney points out that Blackwell assisted in the production of this bulletin about the management of shoulder dystocia and his name appears on this document. The doctor points out that the Bulletin endorses the “preferred and suggested way” of dealing with this problem, but that it is not the only way of correcting it. Methods that are contraindicated or ineffectual will be listed in the Bulletin, but not all acceptable means are listed, only the preferred methods.
The expert notes that there are many forces being exerted on the newborn, including uterine contractions, the conscious efforts by the mother to push the child out, and fundal pressure by the assistant, while the opposite force resisting expulsion is happening due to the shoulder’s positioning against the rigid pubic bone. This conflict of expulsion forces against resistance can injure the shoulder even if everything is done right.
There is a question regarding whether the performance of an episiotomy, or controlled incision of the vagina and perineal skin would have helped in this case. The expert feels that the only time an episiotomy is helpful for shoulder dystocia is when the structures of the pelvis are so small that the obstetrician needs to widen the vaginal opening to allow room for his or her hands to reach in and attempt to turn the baby. In this case, the patient had previous deliveries which had dilated the vaginal opening so that the episiotomy was unnecessary. This procedure can be fraught with significant complications, so it is not performed except for good reason. In general, it allows the soft tissues of the perineum to be opened, but does not loosen the bony structures of the pelvis, so it is of limited utility in a case like this. Blackwell concludes that episiotomy “was not indicated in this case.”
If the first two maneuvers do not deliver the child, the expert notes that a “corkscrew maneuver” should be attempted. This involves finding the back shoulder and pushing it clockwise or counter-clockwise to free the child posteriorly and allow rotation to thus dislodge the anterior shoulder.
The maneuvers performed became effective within two to three minutes, so there was no reason to perform any more radical procedures to effect delivery. However, brachial plexus injury can occur with severe shoulder dystocia even if all of the right maneuvers are performed appropriately and in the right order. This is a generally accepted fact by obstetricians, and was stated within the testimony of the plaintiff expert witness.
The jury agreed with this expert, who contributed to the ACOG Bulletin setting the standard in such cases, when they ruled for the defense.
Gary Gansar, MD, is residency-trained in general surgery. He served as Chief of Surgery and Staff at Elmwood Medical Center and on the Medical Executive Committee at Touro Infirmary and Mercy Hospital in New Orleans, LA. Dr. Gansar was Board Certified in general surgery while in active practice. He joined AMFS in 2015 as a Physician Medical Director.
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