MIDWIFERY STRATEGIES FOR LIABILITY RISK REDUCTION
SHOULDER DYSTOCIA

Definition: Shoulder dystocia occurs when the anterior shoulder becomes wedged above the
symphysis pubis preventing birth of the fetal body. Impacted shoulders that do not respond to
simple maneuvers to facilitate the birth of the body become a labor emergency.

The reported incidence of shoulder dystocia varies from less than one percent to two percent of
vaginal cephalic births. Risk factors for shoulder dystocia include fetal macrosomia, maternal
diabetes, postdates pregnancy, maternal obesity, estimated fetal weight one pound larger than
prior birth weights, and prolonged labor. However in many cases no risk factors are identified.

Antepartum Liability Risk Reduction Strategies:

• Performance and evaluation of a comprehensive history and physical examination
  
• Assessment of nutritional status including appropriate diabetic screening
• Utilization of appropriate laboratory studies, imaging studies, and antepartum surveillance methodology
  
• Confirmation and documentation of estimated due date by 20 weeks gestation
  
• Identification of risk by initial and interval assessments including estimation of fetal weight at term
  
• Counseling for individual risks related to shoulder dystocia
  
• Implementation and documentation of an individualized management plan
  
• Involvement of patient and family members in decision-making
  
• Education regarding anticipated outcomes, benefits and risks of treatments, potential side effects and alternatives
  
• Thorough documentation including the informed consent process
  
• Documentation of consultation, collaborative management, and/or referral as appropriate

Intrapartum Liability Risk Reduction Strategies:

• Documentation of a comprehensive history and physical examination
• Identification of risk by initial and interval assessments
• Counseling and education regarding expectations and individual risks for birth
• Assessment and documentation of gestational age, presentation and estimated fetal weight
• Utilization of appropriate laboratory, imaging studies and surveillance methodology
• Ongoing evaluation of labor pattern and fetal and maternal well-being
• Determination of location and route of birth based on assessment of risk
• Management of labor and delivery in accordance with practice and/or institutional guidelines
• Education regarding anticipated outcomes, benefits and risks of treatments, potential side effects and alternatives
• Thorough documentation including the informed consent process
• Provision for immediately available maternal/neonatal resuscitation and life support
• Documentation of the techniques and maneuvers used to disimpact the fetal shoulders
• Documentation of the minutes elapsed between birth of the fetal head and delivery of the newborn's body
• Documentation of consultation, collaborative management, and/or referral as appropriate

Postpartum Liability Risk Reduction Strategies:

• Assessment of maternal and infant status
• Utilization of appropriate level of neonatal care
  
• Evaluation, management, and follow-up of complications
• Assistance with maternal efforts to establish and maintain lactation
  
• Facilitation of maternal/family attachment
  
• Documentation of education concerning needs and care of the mother and infant
  
• Education regarding benefits and risks of treatments, potential side effects and alternatives
  
• Thorough documentation including the informed consent process
  
• Documentation of consultation, collaborative management, and/or referral as appropriate

Source: ACNM DOSP Professional Liability Section
BOD Approved: 12/03