Patient Safety Strategies for Shoulder Dystocia: Lessons Learned

by Cynthia Morrison, BSN, ARM, CPHRM,
and Louis Marzano, MD, FACOG

This quarter, Cynthia Morrison and Dr. Louis Marzano discuss patient safety approaches for shoulder dystocia. 
        —Robin Diamond, JD, RN; AHA Fellow–Patient Safety Leadership         

Historically, obstetricians/gynecologists have one of the highest risk profiles of any specialty group, and the majority of this risk relates to the practice of obstetrics. Shoulder dystocia (SD) claims that result in neonatal injuries (brachial plexus injuries, fractures, asphyxia, etc.) are the second leading cause of obstetrical suits and are among the most challenging claims to defend. Based on loss data and evidence-based practices, there are many lessons to be learned when dealing with this obstetrical complication.

Use of Protocols

Protocols for identifying women at risk for shoulder dystocia and protocols for managing deliveries complicated by shoulder dystocia should be developed by all health care providers involved in obstetrical care. These protocols should reflect the guidelines of the American College of Obstetrics and Gynecology (ACOG). Other guidelines, such as the CALM Shoulder Screen,¹ may also assist in identifying women at risk.

Patient Education and Informed Consent

Educating the patient and informed consent are also important in making sure the treatment plan is complete and the patient is fully informed of potential risks. Once a patient has been identified as at risk for SD, the optimum time for education and informed consent begins during the antepartum phase of pregnancy. The discussion should include such topics as ACOG recommendations, risk factors for SD, treatment methods, including the possibility of elective cesarean section, and maternal and neonatal risks related to SD.

Effective Communication

Proper patient communication and documentation of these efforts are essential parts of the informed-consent process. Communication impediments such as low literacy levels, non—English-speaking patients, cultural barriers, and unrealistic patient expectations should be addressed. The Ask Me 3² program or repeat-backs are just two techniques that have been proven effective and should be considered.

Credentialing and Staff Education

Professional liability exposure can be minimized by adhering to evidence-based practices. This requires a commitment to proper training for physicians, nurses, and all obstetrical team members. There may be obstacles to achieving these goals. Cost constraints, downsizing, and inadequate staffing present challenges to the physician and hospital labor and delivery units. It is not unusual in today’s health care environment to utilize cross-trained staff within the OB area. A commitment to training and maintenance of staff competency participating in high-risk obstetrical care must be supported by the physicians and hospital leadership. Formal education, proper credentialing, and thorough training for nurses and physicians are critical components.

Documentation—Last, But Certainly Not Least

Good documentation in the medical record can never be overemphasized. It serves to support the standard of care, and the labor and delivery team relies on it to track the patient’s progress. The medical record may be the sole source of information in a retrospective review of the case. In court, the medical record can support the defense of a medical malpractice claim or work against it.

Patient Safety/Risk Management Strategies

Based on lessons learned from obstetrical claims involving SD, consider the following strategies for managing patients³ and the documentation required in the medical record:

In conclusion, using evidence-based practices, communicating with the patient through an informed-consent process, and ongoing teamwork with OB personnel provide a solid framework for patient safety while minimizing obstetrical liability exposure in SD cases.