Larger babies and the occurrence of the ‘time critical emergency’ known as shoulder dystocia was identified as an emerging theme from our maternity investigations, which take place across England.
This national learning report is based on a review of 31 completed reports. In the cases examined, three babies died. Two of those cases were related to shoulder dystocia and one was due to another health condition. The other 28 babies had to be transferred to neonatal intensive care units for treatment after being diagnosed with a potential brain injury.
Shoulder dystocia mainly occurs when the uppermost shoulder of the baby gets stuck behind the pelvic bone, once the baby’s head is already out. The health of the baby is dependent on the crucial time window between the delivery of the head and the rest of the baby’s body.
Shoulder dystocia can result in the death of the baby, severe brain injury or nerve damage and fractures to the arms and collarbone. Mothers can also suffer injury such as bleeding or 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 how the mother is subsequently cared for during pregnancy.
The findings of the reviews suggested an opportunity for national change and we have set out one recommendation to the Royal College of Obstetricians and Gynaecologists (RCOG). This is focused on RCOG considering the review’s findings when updating their current guidelines.
The report also highlights that once shoulder dystocia is diagnosed, we saw many examples of good teamwork and the positive impact of specialist training in manoeuvres to deliver the baby safely.
As well as the recommendation to RCOG, the report sets out three tools that would be beneficial for Trusts across the country. The report also contains excerpts from individual reports, example recommendations put forward to individual trusts and the experiences of staff and families.
Sandy Lewis, Director of Maternity Investigations at HSIB says:
“In the majority of cases of shoulder dystocia, babies do not sustain long term harm. However, in the 31 cases we examined, shoulder dystocia has sadly contributed to nerve damage, brain injury and, rarely death. The emergency nature of this also adds to the distress and trauma felt by the families and staff involved.
“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.
“HSIB’s role is always to ensure that the findings, recommendations and experiences in our individual reports are translated into learning that can be seen at a national level, especially as maternity services continue to tackle the effects of Covid-19 pandemic. It also helps trusts across the country to consider their own processes and make changes to improve the safety of mothers and babies in their care and prevent devastating outcomes for families.”
Key findings summarised
- Lack of national consistency across maternity services in how larger than gestational age babies (LGA) are identified and then how the care of the mother is managed.
- Potential that some at-risk mothers are excluded for screening for diabetes in pregnancy (known as gestational diabetes mellitus). Diabetes raises the risk that shoulder dystocia occurs and a larger baby would increase that further.
- Better communication is needed with mothers about the risks and benefits of having a vaginal birth or caesarean section when an LGA baby is suspected. In 10 of HSIB’s reports, there was no evidence of a discussion with the mother about the risks of shoulder dystocia and what this meant for labour and birth.
- Mothers in labour with a suspected LGA baby should be advised to give birth in an obstetric-led unit. Some cases of shoulder dystocia occurred outside of an obstetric-led unit when an LGA baby had been suspected during pregnancy.
- The signs of imminent shoulder dystocia were not always recognised during birth and this led to delays in escalation for support from neonatal and obstetric teams.
- In the majority of cases, when a shoulder dystocia was recognised, it was managed using recognised manoeuvres in a structured way with examples of excellent teamwork.
- Multi-professional training for shoulder dystocia appears to be well embedded in practice.