Maternal diabetes, suspected macrosomia, a prior shoulder dystocia, a prolonged labor, an operative vaginal delivery — these can all raise the risk profile, but I want to be honest about something: prediction here is far from perfect. Estimated fetal weight carries real margin for error, and plenty of these events happen in patients who did not have a clearly identifiable antepartum risk factor. So the standard-of-care question can't stop at "were risk factors present." It has to go further than that.
When I review the intrapartum course, I'm looking at how quickly the shoulder dystocia was recognized, how the team communicated, how they responded, which maneuvers were used and in what sequence and timing, whether fundal pressure was avoided, and how the force and direction of any traction was actually described. There's no single maneuver sequence that guarantees success — McRoberts positioning, suprapubic pressure, delivery of the posterior arm, internal rotational maneuvers — the right combination depends on the circumstances in that room and the judgment of the person delivering.
Documentation matters enormously here. A good contemporaneous note tells you when the head delivered, when the body followed, which maneuvers were performed, who was in the room, how the baby looked, and how the mother did afterward. But I read the chart carefully — a note written in the middle of an emergency may be sparse simply because there wasn't time to write more, while a note that reads a little too polished and complete deserves a second look against the nursing records, the neonatal notes, and whatever time-stamped data exists.
Causation deserves the same discipline. Yes, a brachial plexus injury can follow shoulder dystocia — but the injury by itself doesn't tell you the clinician pulled too hard. I have to look at the type of injury and whether it's permanent, the mechanics of the delivery, the forces on both mother and baby, any fractures, the operative details, and whether there's another explanation that fits just as well. The opinions I trust most — whether I'm working with plaintiff or defense counsel — are the ones that keep risk, breach, and causation as three separate questions, instead of collapsing them into one tidy conclusion.
Questions for Counsel
- Is there documentation of the specific maneuvers performed, the order in which they were performed, and who performed each one — or is the delivery note retrospective and non-specific?
- Was fundal pressure applied at any point during the shoulder dystocia management, and if so, is that documented in the nursing or anesthesia record?
- What was the head-to-body delivery interval, and was a shoulder dystocia drill or team-based response protocol activated?
- Does the newborn examination document the pattern of brachial plexus injury (upper vs. lower vs. total plexus), and is that pattern consistent with lateral traction or with other injury mechanisms?
Disclaimer: This material is for general educational purposes and does not constitute legal advice, medical advice, or a case-specific standard-of-care or causation opinion. Clinical guidance changes over time. Every matter requires review of the complete record, applicable guidance in effect on the date of care, local resources, and jurisdiction-specific legal standards. For consultation on a specific case, contact OBGYN Peer.