1. Shoulder Dystocia Presentation November 19-20, 2009

2. Shoulder Dystocia The words “Shoulder Dystocia” were first used in 1902 by Fieux.

3. Shoulder Dystocia Overview Unpredictable Ultrasound Very Unreliable Estimated Fetal Weight Unreliable Risk Factors Unreliable Labor Factors Unreliable

4. Shoulder Dystocia Overview Delivery Factors Unreliable Patient Observations Unreliable Nursing Observations Unreliable Traction Estimates Unreliable Clinical Pelvemetry Unreliable Physician Very Reliable

5. History of Traction 1730 Smellie 1851 Danyau 1878 Speilberg 1905 Clark 1920 Taylor 1925 Sever 1926 Williams 1930 Jepson 1939 Koff 1943 Woods

6. Defense History of Non-Traction 1980 Koenigsberger (later refuted by Gonik 1998) 1985 Dunn & Engle (a chronic congenital injury) 1992 Jennett 1995 Nocon 1995 Hankins 1997 Ouzounian 1997 Gherman 1997 Gilbert 1998 Gherman 1999 Ouzounian 2000 Sandmire 2001 Gonik

7. U.S. is the Home of Intrauterine Caused Brachial Plexus Injuries

8. The Gonik Epiphany 1998 B.P.I. – result from traction 2000 – not clearly elucidated 1998 B.P.I. – avoid traction 2000 – force limits not recognizable 1998 B.P.I. – occurs from excessive force 2000 – greatly debated Precis – 6 th Edition, Vol. 6 1998 & 2000

9. Authoritative Textbooks Neurology Pediatrics Pediatric Neurology Orthopedics Pediatric Orthopedics Neurosurgery Pediatric Neurosurgery ALL SAY TRACTION!

10. John P. Laurent, M.D. Texas Children’s Hospital 4,000 permanent brachial plexus injuries 2 from cesarean sections Both had cephalic replacement after failed vaginal maneuvers See Laurent deposition testimony

11. Intrauterine Injury, Laurent, M.D. “I do not believe that.” “Baby floating in water = no fixed point.” “Ultrasounds show limb movement.” “No doubt it is excessive traction.” “No excessive traction = no injury.” November 13, 2000

12. Uterine Forces 1) Relatively uniform 2) 50 to 75 MM of HG 3) Why are injuries so variable?

13. Labor Uterine contractions are uniform and symmetrical. How can the injury be so focal, local, and asymmetrical?

14. EFM No evidence of fetal pain. (a) accelerations (b) tachycardia Hyperstimulation Tetanic contractions Sustained contractions = tetany NO B.P.I.!!! ACOG = Amalgamated Coalition of OB-GYN

15. Defense “Expert” Opinion “We are beginning to understand that it occurs for reasons we don’t know about.” January 26, 2004

16. 1973 – Brachial plexus paralysis is caused by damage to nerve fibers consequent to excessive lateral traction of the neck during delivery. Am J Obstet Gynecol, Gordon, et al. 1986 - Injuries to the brachial plexus occur when there is a strong lateral traction on the head and neck or a downward traction on the shoulders... Obstet Gynecol, McFarland, et al. 1992 – Injuries to the brachial plexus occur when there is a strong lateral traction on the brachial plexus that may cause stretching, tearing, or avulsion of the nerve roots C5-T1. Shoulder Dystocia and Birth Injury, O’Leary. 1992 – Nor can brachial plexus impairment with diagnosed shoulder dystocia be taken as prima facie evidence that the two are causally related in all such instances. Am J Obstet Gynecol, Jennett, et al. 1995 – Thus there is a strong suggestion that some brachial plexus injuries may be completely unrelated to manipulations performed at the time of delivery. In these cases it is most likely that maternal expulsive forces of delivery may be partly or totally responsible for posterior or anterior arm injuries. For example, the posterior shoulder may become temporarily lodged behind the sacral promontory, yet delivery of the head results from maternal expulsive efforts or use of instruments. Am J Perinatol, Hankins, et al. 1997 – In the cases with permanent Erb palsy in the posterior shoulder of the deliverying infant, we hypotesize that the injury was not a product of traction applied at delivery but rather preceded expulsion of the fetal head. Obstet Gynecol, Ouzounian, et al. 1998 – Recent literature supports the hypothesis that some cases of brachial plexus palsy may have an intrauterine origin. Am J Obstet Gynecol, Gherman. 1999 – The brachial plexus is subject to injury when excessive downward traction and lateral extension of the fetal head and neck occur in the attempt to delivery the anterior shoulder; however, there are exceptions to that cause of brachial plexus injury... Brachial plexus palsy may involve the arm that was in the posterior pelvis at the time of delivery. Maternal-Fetal Medicine, Creasy. 2000 – Recent reports have documented cases of brachial plexus injury in the neonate unrelated to recognized birth trauma. As Jennett and Tarby pointed out, “[t]o maintain a posteriori that brachial plexus impairment in itself is evidence that such (extreme lateral traction] pressure must have been used is unteneble.” Am J Obstet Gynecol, Gonik, et al. 2001 - Jennett and associates and Gherman and colleagues have presented evidence that brachial plexus injuries may precede the delivery itself and may occur even prior to labor. Williams Obstetrics. 2003 – Current expert opinion evidence supports the notion that forces of labor constitute the major cause of shoulder dystocia with the potential result of a brachial plexus injury. Therefore, the belief that all brachial plexus injuries result from inappropriate maneuvers at delivery has no scientific foundation. Prolog Obstetrics, American College of Obstetricians and Gynecologists. 2004 - In considering the etiology of these injuries [brachial palsy], one should remember that a significant number of cases of brachial palsy (often bilateral and in association with other nerve palsies) occur in utero and in the absence of birth trauma. Maternal-Fetal Medicine, Creasy. 2005 – The fact that almost half of the brachial plexus injuries occur without any difficulty during delivery of the shoulders, suggests that the injury does occur in-utero, atraumatically. Am J Obstet Gynecol, Chauhan, et al. 2005 – The propulsive efforts of normal delivery may cause brachial nerve stretching and damage. Williams Obstetrics.

17. Deposition Testimony Q Okay. We'll talk about that in a little bit. You've delivered lectures to physicians and adjusters for insurance companies telling them how the medical records should be written to best defend the physician, haven't you? A That's a -- only a partially true statement. By writing a good medical record, it helps with the defense, but a good medical record is a good thing in and of itself. So in the talks I've given to risk management groups, I talk about what I feel would be a better or more ideal medical record than is generally the standard of care in the community. That is a good thing to do for medical care. It has the side benefit of making cases more defensible because there's more information in them. Deposition of Henry Lerner, M.D., May 7, 2008

18. Deposition Testimony Q You've actually told them what should be in the record to make it more defensible or easier for you to defend, haven't you? A Sure, on the basis of being told by plaintiff attorneys what various doctors were negligent for not having put in the record. Deposition of Henry Lerner, M.D., May 7, 2008

19. Deposition Testimony Q (By Mr. Puga) Okay. Dr. Lerner, on what date did you submit your article, "Permanent Brachial Plexus Injury Following Vaginal Delivery Without Physician Traction or Shoulder Dystocia," that's been marked as Exhibit 4? On what date was that case report submitted to the American Journal of Obstetrics and Gynecology? A I submitted it on or about June 11, 2007. Deposition of Henry Lerner, M.D., June 5, 2008.

21. Deposition Testimony Q (By Mr. Puga) All right. I just asked you a few minutes ago the question, and it's your testimony that on at least two occasions of thoroughly and carefully reviewing these records that you missed on one of the records a note that there was a left Erb's palsy due to mild shoulder dystocia at delivery. You said missed in terms of not remembering seeing it, yes. Explain what you mean by that answer. A I do not recall seeing it in either review. Deposition of Henry Lerner, M.D., June 5, 2008.

22. Deposition Testimony Q Would you agree with me that if you had seen it, it would be important information for both your opinions as an expert witness and to be included in the case report? A No. Deposition of Henry Lerner, M.D., June 5, 2008.