Dr Jaspan is Chairman of the Department of Obstetrics and Gynecology, Einstein Health Care Network, Philadelphia, Pennsylvania, and Associate Professor, Thomas Jefferson University, Philadelphia, Pennsylvania.

David Jaspan, MD

	Dr Cohen is Chairman Emeritus, Einstein Healthcare Network, Philadelphia, Pennsylvania, and Professor of Ob/Gyn, Thomas Jefferson Medical College, Philadelphia, Pennsylvania.

	Dr Jaspan is Chairman of the Department of Obstetrics and Gynecology, Einstein Health Care Network, Philadelphia, Pennsylvania, and Associate Professor, Thomas Jefferson University, Philadelphia, Pennsylvania.

	Neither author has a conflict of interest to report with respect to the content of this article.

	In obstetrics there is nothing that produces more anxiety than a shoulder dystocia. We fear the fetal outcome, the potential maternal complication, and being sued.

	Imagine you are in the labor room with your patient, an anxious and excited 28-year-old G2P1 with no medical problems. You delivered her first baby, and she is thrilled to have you in the room for baby number two. After all, you were able to deliver her first baby using all your skill, knowledge, and maneuvers to overcome a serious shoulder dystocia. The current fetal heart rate tracing is a picture-perfect Category One, you have previously accessed the maternal pelvis for adequacy, and you have adeptly performed your best obstetric estimate of the fetal weight, 3300 g. She is progressing beautifully along Zhang’s new labor curve.

 The baby’s head is delivered; excitement fills the air … then a shoulder dystocia occurs followed by a brachial plexus injury and the baby is left with an Erb’s palsy.

	Obstetricians manage risk. We are trained to consider the risk and benefit of all medical and obstetric procedures performed during pregnancy as well as any medications prescribed or recommended during pregnancy. We use data to enable us to make rational decisions and/or counsel patients fairly. For example, the risk of uterine rupture after more than one cesarean delivery ranges from 0.9% to 3.7%, so we counsel our patients and inform them about this potentially catastrophic outcome. We also use risk-benefit data to determine when to recommend an invasive prenatal diagnostic procedure, such as an amniocentesis.

See also: High/low agreement in shoulder dystocia case complicated by patient history

	Why is it, then, that we have not routinely used such data to make decisions about recommended optimal delivery routes when a patient has a history of a prior delivery complicated by a shoulder dystocia?

	One of the greatest fears of every physician and midwife who provide obstetrical services is the unpredictability of shoulder dystocia and the risk of being sued for this “unpredictable” outcome.

NEXT: How things work in the Einstein Healthcare Network

	We at the Einstein Healthcare Network in Philadelphia have chosen not to allow women to undergo a trial of labor after 3 cesarean deliveries due to the increased risk of uterine rupture. We have chosen not to use misoprostol when inducing a woman after a prior cesarean delivery due to the elevated risk of uterine rupture. We have been asked not perform laparoscopic power morcellation of fibroids due to a 1-in-350 risk of undiagnosed sarcoma So why is it that many of us are willing to allow women to assume the risk of recurrent shoulder dystocia when delivering a term infant of comparable size? Data are not available to indicate the risk of permanent injury if the prior shoulder dystocia was relieved by one maneuver or more, nor on the recurrence rate of persistent brachial plexus injury if the previous shoulder dystocia was associated with a permanent injury.

	We understand that the first shoulder dystocia is usually unpredictable. American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin Number 40 states that the risk of recurrence of shoulder dystocia after a previous shoulder dystocia ranges from 1% to 16.7%.

 ACOG’s Neonatal Brachial Plexus Palsy document states that the incidence of neonatal brachial plexus palsy occurring with shoulder dystocia ranges between 4% and 23%.

 Therefore, we ask, "Is the second shoulder dystocia really that unpredictable? If we allow someone to deliver vaginally at term who has had a previous shoulder dystocia, aren’t we taking a chance with the baby, the mother, and the legal system?”

	In order to provide the safest care and limit our medicolegal risk, we have developed a prenatal counseling form to educate our patients about the risk of recurrence of a shoulder dystocia and the potential unpredictable and catastrophic events that may come from a vaginal delivery after a prior shoulder dystocia. We allow our patients to choose whether they want to have another vaginal delivery after a previous shoulder dystocia or to have an elective cesarean delivery to minimize risks to mother, baby, and obstetrician.

	If the patient elects to attempt a vaginal delivery knowing the increased risk and the unpredictability of the outcome, we encourage the patient to seek care at another institution. If she chooses not to go to another institution and she and her provider are willing to take the risk of proceeding with a trial of labor after a prior shoulder dystocia (TOLAPS), the provider must agree to be present for the labor and delivery and not transfer this risk to others.

	We feel that this policy benefits the patient, the newborn, and the delivering physician. It is a “win-win-win” policy for all involved. It decreases the provider’s fear and significantly decreases the malpractice risk for the obstetrician and the hospital, and most importantly limits the risk to the baby.

Contemporary patterns of spontaneous labor with normal neonatal outcomes: 

	2. Sokol RJ, Blackwell SC; American College of Obstetricians and Gynecologists, Committee on Practice Bulletins-Gynecology. ACOG practice bulletin, Shoulder dystocia, Number 40, November 2002. (Replaces practice pattern number 7, October 1997). 

	3. Executive Summary: Neonatal Brachial Plexus Palsy Report of the American College of Obstetricians and Gynecologists’ Task Force on Neonatal Brachial Plexus Palsy

	SAMPLE Prior shoulder dystocia patient form

	Shoulder dystocia (“stuck shoulder”) occurs when the baby’s head delivers and the shoulder gets stuck on the mother’s pelvic bone (pubic bones). This is a true obstetric/birth emergency that happens in approximately 1-2 out of 100 deliveries. If this happens, your doctor or midwife will try to help free the baby's shoulders. Following shoulder dystocia deliveries, some babies may suffer some sort of injury, either temporary or permanent. For example, shoulder dystocia may cause a bone (the clavicle) to be broken or a nerve to be injured in the baby’s arm. Most often these problems heal quickly. However, sometimes the nerve(s) to the arm and hand do not heal and the baby can be left with weakness or inability to move the arm or hand (Erb’s Palsy). There are also cases when the baby could suffer brain injury due to lack of oxygen during the time that the baby is stuck. This could result in cerebral palsy or death. Additionally, for the mother, shoulder dystocia may cause tears around the vaginal opening and bleeding after birth.

	Shoulder dystocia is usually not something we can predict or prevent, but is common when the baby is over 9 ½ lb, the mother is overweight or has diabetes. We also know that a major risk factor for shoulder dystocia is when a mother has had a previous delivery with shoulder dystocia. It has been reported that the risk of a shoulder dystocia happening again increases to as high as 15 out of 100 deliveries. There is no guarantee that another shoulder dystocia will not result in permanent neurologic injury or death this time, even if your baby has no problems from a prior shoulder dystocia

	Because the doctors and midwives who deliver at XXX hospital desire to minimize the risk to your baby, we are asking you to agree to a cesarean section (c-section) delivery for your baby. There are risks to a cesarean section that include, but are not limited to, infection, blot clots, injury to other organs, and bleeding. If you agree to a c-section, your doctor signing below and his/her partners will continue to provide you with prenatal care and you can deliver at XXX hospital. If you do not want a c-section, we are asking you to obtain your prenatal care and deliver your baby at another hospital unless your doctor and the other doctors in his/her practice agree to guarantee that one of them will be there while you are laboring and during your delivery at XXX hospital. If your doctor is unable to guarantee to be there for the labor and delivery, you understand you will need to find another obstetrical provider to care for you during your pregnancy. If you experience an emergency regarding your pregnancy during any time you are locating another obstetrician, you should go to the nearest emergency department.

By signing my name below, I agree to have a cesarean section (c-section). 

	________________________________      ________________________                 

	Patient Name (print)                                   Clinician Name (print)     

	_____________________________          ________________________

	Patient Signature                                       Clinician Signature                          

	Date: __________________                  Date: ______________

By signing below, I agree to be present or agree that one of my partners will be present during this patient’s entire labor and delivery at XXX Hospital.

	I understand the information on this counseling document that I have received. I have had an opportunity to ask questions which have been answered to my satisfaction, and I do not want to have a cesarean section for this pregnancy. 

By signing my name below, I do not agree to a cesarean section (c-section). 

	__________________________                        ________________________                 

	Patient Name (print)                                            Clinician Name (print)     

	_____________________________           _______________________

	Patient Signature                                              Clinician Signature                          

	Date: _______________________                Date: __________________

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This hospital uses a counseling form to educate their patients about the risk of recurrence of a shoulder dystocia and to choose whether they want to have another vaginal delivery.

David Jaspan, MD

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First Person: Our shoulder dystocia policy