The Healthcare Safety Investigation Branch (HSIB) published a National Learning report on 4 February 2021 which looks in detail at the factors that increase the risk that shoulder dystocia will occur during labour with larger babies.
HSIB routinely conducts independent investigations into patient safety concerns in NHS-funded care across England, this report was compiled through analysis of completed HSIB reports where shoulder dystocia was identified as one of the issues that contributed to severe brain injury or death.
Shoulder dystocia is a medical emergency which can happen during vaginal birth. During a normal delivery, once a baby’s head is born, the baby’s shoulders rotate to allow the body to descend through the birth canal.
Shoulder dystocia happens the baby’s shoulders get stuck behind the mother’s pelvic bone dangerously delaying the delivery of the baby. Treating medics are in a race against time to free the baby’s shoulder to minimise the risk of long-term damage using certain recognised manoeuvres to assist the baby’s progress.
Most cases of shoulder dystocia carry no long-term consequences but there are significant risks. In severe cases shoulder dystocia can result in brain injury or death of the baby, in other cases it can cause nerve injuries or fractures. Shoulder dystocia can also be dangerous for the mother, increasing the risk of haemorrhage and birth trauma.
Shoulder dystocia can effect infants of any size however it is accepted as more likely to occur when the baby is larger than average. The HSIB report reveals that there is wide variation between hospital trusts in terms of the way mothers carrying a larger than average baby are identified and treated. It appears that there is a lack of national guidance regarding suspected large babies and this is a contributing factor to the variation in practice. The report recommends that the Royal College of Obstetricians and Gynaecologists (RCOG) consider the report’s findings when updating their guidelines.
The review of 31 HSIB reports that related to shoulder dystocia revealed a number of common key recommendations:
- All predictive factors ought to be considered to identify mothers who are more likely to have larger babies.
- Mothers in labour with a suspected larger than average baby should be advised to give birth in an obstetric led unit.
- Mothers who are at greater risk of shoulder dystocia occurring during labour should receive proper counselling and advice regarding all the risks and benefits of a vaginal birth to ensure processes for obtaining informed consent are followed.
- Mothers identified as likely to have a high risk of shoulder dystocia occurring should be encouraged to develop a birth plan as early as possible and discussions regarding timing, mode and place of delivery should take place. This plan should be reviewed on an ongoing basis.
- If a higher risk mother chooses to use a birth centre in labour as opposed to an obstetric led unit that “multidisciplinary input and review is gained during labour so that the plan of care and decision making is not carried out in isolation”.
- Trusts should ensure that staff are supported to alert the neonatal team to attend as an emergency when shoulder dystocia occurs so that skilled staff are present at the birth/ resuscitation.
- Continual multi-disciplinary training including “scenario training” should be given by trusts “to develop joint skills and drills” for obstetric and neonatal emergencies across all services caring for women in labour.
HSIB’s recommendations recognise the need for improvement in the information and advice which is given to mothers so that they can make an informed decision. It is concerning that in the 31 cases which HSIB looked at the majority of mothers were not counselled regarding the risk of a shoulder dystocia when they were suspected to have a large baby . It is clear from the recommendations that more needs to be done to improve communication in the antenatal period so that mothers are properly involved in decision making.
We have specialist expertise in clinical negligence cases surrounding injuries to babies and mothers during birth. If you have concerns about the treatment which you or a loved one has received, please contact a member of our national clinical negligence team for a free, confidential discussion:-
- Carolyn Lowe, Partner (Oxford/London/Bristol/Milton Keynes) on 0186 578 1019 email@example.com
- Karen Reynolds, Partner (Derby/Stoke on Trent/Birmingham/Manchester/Liverpool) on 0845 274 6830 firstname.lastname@example.org
- Jane Williams, Partner (Nottingham/Leicester/Sheffield/Leeds) on 0845 272 5724 email@example.com
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“The increased risk of shoulder dystocia and larger babies was a thread appearing in our individual investigations and we felt that further system analysis was needed to understand the key factors that contributed to this. In this national learning report, we emphasised that national guidance that supports consistent and effective processes of identifying LGA babies and managing the mother’s care is crucial in reducing those risks, and aids planning for labour and birth.