Severe brain injury, early neonatal death and intrapartum stillbirth associated with larger babies and shoulder dystocia

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

Investigation summary

In March 2020, we published a national learning report to highlight the themes emerging from the initial investigations carried out as part of our maternity investigation programme.

These initial investigations were carried out between April 2018 and December 2019.

One of these themes was babies significantly larger than average who were at increased risk of a birth injury, brain damage or very rarely death because their shoulders get stuck during birth (known as shoulder dystocia).

This was identified as an area where further analysis could benefit system-wide learning.

Our national learning reports can be used by healthcare leaders, policymakers, and the public to:

Aid their knowledge of systemic patient safety risks
Understand the underlying contributing factors
Inform decision making to improve patient safety

The information in these reports is also used to inform future HSIB investigations or programmes of work.

As defined by the Royal College of Obstetricians and Gynaecologists (RCOG), shoulder dystocia is where additional manoeuvres are required to complete the birth of a baby, after routine traction has failed to release the shoulders during a vaginal birth (Royal College of Obstetricians and Gynaecologists, 2012).

The majority of cases of shoulder dystocia occur when the uppermost shoulder of a baby impacts behind a mother’s pelvic bone after the birth of the head, preventing the birth of the body.

It is a time-critical obstetric emergency that can result in severe brain injury or death and other injuries such as brachial plexus injuries (nerve injuries affecting the arm) or fractures to the arm or collar bone of a baby.

Shoulder dystocia may also cause increased injury to the mother including bleeding and perineal trauma.

We examined the factors that increase the likelihood that shoulder dystocia will occur with larger babies, from pregnancy to labour and birth.

From the analysis of their reports, we have pinpointed that many of the challenges lie in how larger than average gestational age babies (LGA) are identified and the subsequent management of care of the mother during pregnancy.

Safety recommendations

Royal College of Obstetricians and Gynaecologists

It is recommended that the Royal College of Obstetricians and Gynaecologists (RCOG) takes into consideration the findings of this HSIB review when updating the RCOG Green Top shoulder dystocia guideline (No.42).

Thank you for your request and we can confirm that the findings of the HSIB report will be incorporated into the next iteration of the RCOG guideline for shoulder dystocia.

It is common ground in all national guidelines that shoulder dystocia is unpredictable – there are no clinically useful predictors, including for Large-for-Gestational-Age (LGA) babies.

The RCOG has commissioned a national Scientific Paper for the management of Large for Gestational Age infants and after extensive and robust peer review, publication has been deferred until the results of the NIHR Big Baby study are available.

The Montgomery judgement applies to all pregnancies; all women should be able to discuss their options for mode of birth with a balanced discussion of the risks and benefits of each.

The RCOG has published a patient information for elective caesarean birth and there is a shared decision-making tool for Induction of Labour at term from the Cochrane group for suspected LGA babies.

The RCOG shoulder dystocia guideline will acknowledge that the median Head-Body Delivery Interval in the HSIB cohort was seven minutes, which is very likely to be both causally associated with the hypoxic insult and is significantly longer than the median in large cohorts, post training.

The RCOG guideline will acknowledge the unrecognised discrepancies in the umbilical cord gases in the HSIB cohort and likely substandard management of the shoulder dystocia.

The RCOG guideline will acknowledge that the HSIB report recommendations relating to LGA infants are predominantly based on 10 babies that were recognised to weigh more than 4kg but did not have any documented discussion about their options.

This represents, at most, 0.2% of the infants whose birth was complicated by shoulder dystocia in England & Wales per annum and therefore is not representative.

The RCOG guideline update will emphasise that accurate and efficient management of shoulder dystocia is currently the most effective way of reducing neonatal injury and will provide recommendations for effective training, including alternative management manoeuvres, management of shoulder dystocia in a birth centre and optimising neonatal management after shoulder dystocia.

Response received on 11 May 2021.

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Safety recommendations

Royal College of Obstetricians and Gynaecologists