|February 2013 · Vol. 25, No. 2
The natural history of obstetric brachial plexus injury
Ten percent to 30% of these injuries persist for years following birth.
Can we reduce the incidence? Can we reduce our risk of litigation?
Editor in Chief
CASE: Shoulder dystocia resulting in persistent injury to C5 and C6
A 30-year-old, G2P1 woman presented in labor at 39 weeks and reported a strong desire to have a natural childbirth. She was taking insulin for gestational diabetes mellitus diagnosed in the second trimester. Her body mass index was 43 kg/m2, and her height was 4 ft 11 in. The estimated fetal weight was 9 lb. She had a prior vaginal delivery. During her antepartum care the patient was extensively counseled about the risk of shoulder dystocia and obstetric brachial plexus (OBP) injury.
The patient progressed normally through labor without anesthesia. At birth, the baby delivered occiput posterior and restituted to right occiput transverse. There was a turtle sign, and the obstetrician diagnosed a shoulder dystocia, called for help, and told the mother to stop pushing. An attempt to deliver the fetal head with gentle downward guidance was unsuccessful. The McRoberts maneuver and suprapubic pressure combined with gentle downward guidance on the fetal head did not result in delivery. A mediolateral episiotomy was made and the Rubin and Wood maneuvers were attempted without success. The obstetrician then successfully delivered the posterior arm and the body of the baby was easily delivered.
The shoulder dystocia lasted 2 minutes before successful delivery. The Apgar scores were 3 and 6 at one and five minutes, respectively. The umbilical cord artery pH was 7.18. The birthweight was 9 lb 2 oz. A diagnosis of OBP injury involving C5 and C6 was made. At discharge the OBP injury persisted.