The Malpractice Experience of Obstetricians with Shoulder Dystocia: Preparation May Mitigate Risks With This Unpredictable Event

Jacqueline Ross, RN, PhD, Coding Director, Department of Patient Safety and Risk Management, The Doctors Company, Part of TDC Group; Larry Veltman, MD, FACOG, DFASHRM, Director, National Perinatal Information Center; and Peter S. Bernstein, MD, MPH, Professor and Program Director, Department of Obstetrics and Gynecology and Women’s Health, Maternal Fetal Medicine, Albert Einstein College of Medicine

Obstetrical injuries are a major concern in terms of both patient injury severity and financial impact. One of the more costly injuries is a brachial plexus injury. Fortunately, shoulder dystocia (SD) is a rare complication of vaginal delivery. Furthermore, not every occurrence of SD will result in an injury and/or a malpractice claim. The purpose of this study was to better understand factors that may contribute to medical malpractice claims with SD and to offer recommendations to practicing obstetricians (OBs) regarding the management of SD.

The Doctors Company is the largest physician-owned medical malpractice insurance company in the United States. Our mission is to advance, protect, and reward the practice of good medicine. The Doctors Company studies malpractice claims to better appreciate what motivates patients and their families to pursue claims, to gain a broader overview of system failures and processes that result in patient harm, and to create risk mitigation approaches to improve patient safety.

Characteristics of Claims Studied

A total of 72 cases were reviewed, involving dates of delivery from 2002 to 2016.

  • Average patient age 29.14 (17–46) years old; 46% of patients were obese (BMI > 30).
  • 75% of patients were multiparous; 6% had a history of previous SD; 14% had previous deliveries of macrosomic newborns (> than 4,000 grams).
  • 7% of patients did not speak English.
  • 40% of patients were white, 27% were black, 18% were Hispanic, 4% had other ethnicities, and 11% had ethnicities that were unknown.
  • 35% of patients had gestational diabetes.
  • 49% of patients had an estimated fetal weight (EFW) recorded (average EFW 3335.35 g).
  • 18% of patients had both gestational diabetes and obesity.
  • 51% of patients had deliveries in teaching hospitals, 49% in non-teaching hospitals.
  • 35% of patients were induced.
  • 64% of patients had oxytocin, including those who were induced.
  • 73% of patients had their primary OB involved in delivery. Six midwives and five residents were involved in the deliveries.
  • 72% of patients who had babies over 4,000 g said that vaginal delivery was the wrong choice for delivery, and 38% of those said they had inadequate consent for other treatment options, such as a possible C-section.
  • 36% of patients had operative vaginal deliveries (n=20 vacuum, n=3 forceps, and n=3 with both vacuum and forceps).
  • Average time to release SD was 2.7 minutes.

Contributing Factors

The most prevalent contributing factors seen in these claims involved technical, clinical judgment, and communication issues:

  • 60% of the claims had a possible technical problem or a known complication.
  • 53% of the claims had the clinical judgment factor of proceeding with vaginal birth over cesarean.
  • 23% of the claims had improper use of traction during delivery.
  • 17% of the claims had inadequate informed consent for other treatment options like a cesarean.
  • 4% of the claims contained aspects of insufficient documentation as determined by expert reviews of these 32 cases. In particular, the deficient areas in documentation were related to informed consent on the use of a vacuum and informed consent discussion of the risks/benefits for cesarean birth versus vaginal birth.

Case Study 1 Reflection

In this study communication emerged as a common theme. Communication issues between both the provider and the patient/family, such as inadequate discussion or informed consent for other treatment options. Communication lacked with providers in the failure to read medical records when the primary OB was not involved in the delivery, including when the most recent medical records were not readily available.

Case Study 2 Reflection

In our retrospective review of the mothers with the larger infants (> than 4,000g) data we noted differences in the decision to proceed with the vaginal delivery rather than a cesarean birth. Additionally, there were differences in the communication between the obstetrical provider and the patient/family prenatally.

Case Study 3 Reflection

Clinical practices must ensure that systems for communication and workflow are effective. For example, having a system to contact a patient quickly with new clinical findings or a system to ascertain that a missed diagnostic test is completed timely are essential. Multiple claims in this study illustrated the negative impact that the failure to implement well-designed systems can have on outcomes.

Clinical Recommendations

  1. Antenatally, evaluate and discuss risk factors for SD. One of most important risk factors to be alert for is a history of previous SD. There are standard lists of risk factors, but certainly obesity, diabetes, and a history of large babies are very important. When there are significant risk factors (including an EFW >4,000 g), a discussion of the risks and benefits of elective cesarean should occur and, according to the judgment of the physician, perhaps be offered.
  2. Beware of false positive glucose screening. Patients with a positive screening test and a normal glucose tolerance test (GTT) are at risk for adverse outcomes, including SD.
  3. SD is unpredictable, regardless of the size of the infant. Therefore, hold drills and simulation training for each unit (including physicians) in the management of SD. This training includes communication at the time of the discovery of the SD and debriefing after the incident. This training aims to limit allegations of disorganization and chaos in the delivery room. Evidence supports that this training helps reduce the incidence of brachial plexus injuries through the improvement of team communication, technical skills, documentation, and coordination.
  4. Since SD is unpredictable, ensure all providers on your team are well-trained to manage it with the appropriate maneuvers. For guidance, consult the website of the American College of Obstetricians and Gynecologists (ACOG) (
  5. Help nurses understand their role in management of SD. This instruction includes how to perform the McRoberts maneuver, apply suprapubic pressure, and record times. Place a foot stool in every delivery room to assist nurses with giving suprapubic pressure.
  6. To strengthen the patient’s and family’s understanding of the necessary interventions, involve the patient and her family in decision making as much as possible during the labor process. Document this discussion. Reinforce the informed consent as the need for manual manipulation techniques or cesarean section becomes evident.
  7. Recognize that operative vaginal delivery is a risk factor. The use of sequential instruments (vacuum and forceps or vice versa) is associated with a significant increase in neonatal morbidity.
  8. Learn how to communicate with patients when there is an adverse outcome. For physicians, knowing how to apologize, accept anger, follow up, visit the NICU, etc. is important, even though a suit may not be prevented. The use of empathetic statements, such as “I am going to do all I can to find out why this happened, and I will keep you informed about what I learn,” is essential to assure good communication. It may help to read some examples of empathetic and nonempathetic statements.
  9. Consider utilizing a documentation template to help capture every aspect of the SD delivery. Documentation is critically important.
  10. Document the EFW as part of the admitting physical examination for every patient. In this analysis, only 35 of the 72 claims had the EFW documented. Although EFW is not always accurate, it can be defended when documented; otherwise, it can appear that the estimation of fetal weight was never done. Showing that the EFW was done (and documented) indicates that the practitioner likely went through the mental process of considering whether a vaginal birth was a reasonable option.
  11. Give attention to potential race and ethnicity risk factors. Although they were not a significant finding in this analysis, they are worthy of consideration. A 2017 study examined over 19,000 deliveries in five locations and illustrated risk factors associated with SD in racial/ethnic groups. Having an epidural with labor (OR=4.4) and/or delivering past 40 weeks (OR=2.4) were strong risk factors for white non-Hispanics. Using insulin to manage gestational diabetes (OR=4.6) and/or having an epidural with labor (OR=5.3) were risk factors for black non-Hispanics. Hispanic mothers had a strong risk factor when Spanish was their primary language (OR=2.3).


This study has several limitations. First, this analysis was a review of medical legal cases involving SD claims that resulted in injuries. The claims came from closed malpractice claims from one large national insurer, and do not represent all closed malpractice claims in the United States.

Additionally, in the use of malpractice claims, there was no comparison to any information on SD cases that did not proceed to a claim being filed. This limitation is especially significant since not all SD cases result in injury.

Some information was not consistently available in the records for a more detailed examination of the claims regarding management. Lack of documentation affected the ability to fully analyze SD. These restraints included dependable information on which shoulder presented, what maneuvers were performed, and in what order they were completed.


SD is unpredictable and can occur even with the most experienced practitioner; therefore, a memorized, well-orchestrated plan of action is necessary to help prevent complications that could lead to brachial plexus injury, brain damage, or death. While the presence of risk factors cannot truly predict SD, the first step toward loss prevention is an accurate prenatal assessment to identify patients who may be at risk. Identifying the at-risk patient, predicated on timely and complete prenatal assessments, should cause the physician to closely monitor the patient’s labor progression for indications of difficulty. The need for clear, concise documentation, teamwork, and patient communication are recurring themes in these SD claims. Our goal is to decrease and prevent future SD and brachial plexus injuries.

Further Reading and Resources

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.


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