Abstract
Dear Editor,
The recent paper by Buttigieg and Micallef-Stafrace evaluates the current medico-legal aspects of shoulder dystocia through jurisprudence as a chronic and controversial obstetrical-medico-legal problem spanning centuries. In this paper, they interpret previous reports of patient autonomy and the links to preventing the consequences of shoulder dystocia with caesarean section in the presence of risk factors. 1
Acute peripartum injuries and chronic disability as a permanent consequence of intrapartum complications of shoulder dystocia, such as obstetrical brachial palsy (OBP) and the consequences of hypoxic-ischaemic encephalopathy (HIE), is the most common reason for litigation. The most significant isolated risk factors for shoulder dystocia are foetal macrosomia, gestational diabetes, or both, so expert recommendations in these cases are to induce labour at the 38th week of pregnancy with a significant reduction of shoulder dystocia and the need for primary and secondary caesarean section. In Croatian forensic obstetrics, as in other countries, shoulder dystocia, along with HIE, is the most common reason for litigation (>50%).2,³ In a recently published paper on the forensic aspect of shoulder dystocia, I offered the definition: “Foetal shoulder dystocia (FSD) is an unpredictable and critical obstetric intrapartum emergency, where an objective problem is the relationship between the mother's pelvis and the child, i.e., an anthropometric disorder of delivery mechanics and dynamics.” 2 The definition talks about the etiopathogenesis and emergence of the situation, which is anecdotal, alarming, accidental, anarchic and anxious (5A) because it is a dynamic process during childbirth that is basically this and depends on numerous factors.
As a long-term obstetrician and obstetrician-gynecological forensic expert, I have published numerous papers on shoulder dystocia, but also retrospective studies on the problem of shoulder dystocia from a clinical and medico-legal aspect. As this work of yours has prompted me to reflect, I consider stating in this letter the expert-forensic discussion as a contribution to this problem of world forensic obstetrics. The obstetric forensic facts, which leave shoulder dystocia a controversial medico-legal problem, are the following: the impossibility of adequate prediction of shoulder dystocia, the enormous increase in caesarean section did not reduce the incidence of shoulder dystocia, complications and litigation, shoulder dystocia is a possible and expected intrapartum risk. Thus, neither imaging techniques nor taking a careful medical history showed predictive power in reducing shoulder dystocia, 2 and it is not clear how haematological parameters can predict or interpret the occurrence of shoulder dystocia, as stated by the authors. 1 It is very important to mention that in forensic expertise it is necessary to distinguish between acute and chronic OBP, with or without shoulder dystocia, as Doumouchtsis and Arulkumaran warned in their work. 4 Significantly more often, acute OBP as a permanent consequence occurs when the brachial plexus is torn due to extensive traction or rotational traction of the foetal neck, and as such it is classified as an iatrogenic intrapartum traction injury. However, in less than 1% of cases there are non-tractional, chronic OBPs as a result of intrauterine malpositional compression or extension of neck structures lasting several weeks or months, and we find them in oligo/anhydramnios, torticollis and in foetal tumours of the neck, thorax or head. Thus, in my own forensic practice, I came across only one non-traction intrauterine OBP unrelated to shoulder dystocia. In Table 1, I list my own completed litigation cases: from the total number of expert’s reports until 2022, there were 38 shoulder dystocia cases (11.80%), of which 22 (57.89%) were declared complications, and 16 (42.10%) cases of malpractice. On this material, 52.64% of newborns had permanent OBP, cerebral palsy (CP) 19.44%, and OBP with CP as a permanent consequence was 8.3% of the total number of shoulder dystocia, which amounts to 78.94% of permanent and irreversible consequences. It is interesting that inthe five cases of peripartum death (13.15%) in which shoulder dystocia was clinically and forensically proved, this diagnosis was not recorded. The diagnoses of mors/asphyxia sub partu were recorded, but investigation and analysis proved refractory, severe shoulder dystocia as cause of death, even with proper procedures in 2/5 shoulder dystocia. From the above, our own long-term forensic experiences suggest that the following problems were the cause of litigation procedures:
Forensic verified complications of malpractice in cases of shoulder dystocia during 22 years of forensic obstetrics expert’s experience.
Inadequate medical documentation: failure to record shoulder dystocia as a diagnosis, the procedures that were applied, and the necessary time period during interventions.
Covering up the diagnosis of intrapartum foetal death, and shoulder dystocia is written in the background.
Insufficient competence of perinatal staff.
Unprofessional approach to solving shoulder dystocia with inadequate and suboptimal and prohibited procedures (for example Kristeller's fundal expression).
Continuous training, education of midwives and obstetricians and quick reaction to the situation according to the protocol is the basis for reducing the consequent complications of shoulder dystocia, which we proved in our recent work on about 50,000 births without permanent OBP and one CP for a total of 0.7% shoulder dystocia in a tertiary perinatal centre. 5 We suggest the above as a solution to the problem of shoulder dystocia with the goal of good clinical practice and adhere to the majority of recent works that advise continuous skill training and starting the gradual release of trapped shoulders immediately after diagnosis as an obstetric standard. Timely information to the mother and family is necessary, no matter how impossible it seems in a clinical emergency. That is why respect for the unpredictability of events and individuality, as well as competence in skills, is the basis of obstetrics, which has always been called “Ars obstetriciae” precisely because of the philosophy of unpredictability, the obstetrician's ability to react quickly and his or her manual dexterity.
Footnotes
Declaration of conflicting interests
The author declares that there is no conflict of interest.