“Severe brain injury, early neonatal death and intrapartum stillbirth associated with larger babies and shoulder dystocia.” A review of the report from the Healthcare Safety Investigation Branch (HSIB).
The Healthcare Safety Investigation Branch is an independent body who investigate circumstances where there has been an adverse event during childbirth and/or pregnancy. HSIB release reports routinely, known as Maternity National Learning reports. These reports make recommendations to improve patient safety.
Shoulder dystocia occurs when a baby’s shoulder becomes impacted against the mother’s pelvic bone following delivery of the head; different movements and manoeuvres are then needed to deliver the baby. Shoulder dystocia is time critical, and failure to manage it quickly enough can cause severe brain injury. If excessive traction is placed on the baby’s head then this can cause a brachial plexus injury (Erb’s plasy) and, in some cases, trauma to the mother such as perineal tears. However, despite this risk, there is a very low rate of brain injury if the baby is delivered within five minutes. Cases of shoulder dystocia account for 9.5% of all HSIB reports, and 11% of all reports of babies with Hypoxic Ischaemic Encephalopathy (HIE).
Shoulder dystocia can happen with a baby of any birth weight, but there is a higher risk for LGA babies (large for gestational age). Factors that can cause increased risk of this occurring include previous instance of shoulder dystocia, LGA babies, gestational diabetes mellitus (GDM), high maternal BMI, induction of labour, slower first and second stages of labour, mother being given synthetic oxytocin, and assisted birth with vacuum/forceps.
There is no national guidance regarding the management of pregnancy in LGA babies, however, there have been recommendations made by NICE (National Institute of Clinical Excellence) and RCOG (Royal College of Obstetricians and Gynaecologists) that appear contradictory.
- NICE (2008a) recommends that ultrasound scans to check suspected LGA babies should “not be undertaken in a low-risk population”. (2008b) recommends that labour should not be induced simply on the basis of a suspicion of a large birthweight. NICE (2014) recommends obstetric-led care during labour when a baby is suspected to be LGA, and that mothers be given the option to choose between caesarean section and augmented labour in such cases. NICE (2015) recommends that in cases of gestational diabetes, mothers be offered the options of induced labour and caesarean section between 37 weeks and 38+6 weeks, and that the risks and benefits should be discussed with mothers. Finally, NICE (2020) recommends that mothers should be informed of the heightened risk of shoulder dystocia and brachial plexus injury with vaginal birth in cases of obstetric complication during labour.
- RCOG (2012) guidelines that induction of labour will not prevent shoulder dystocia in LGA babies of non-diabetic mothers, however it can be used to reduce cases in diabetic mothers and that diabetic mothers with an LGA baby should consider caesarean section. RCOG (2018) recommends induction in cases of obese mothers where it is suspected the baby is large, and that this should be discussed with mothers. The Cochrane Review found that there is an increased risk of perineal damage in those who were induced into labour, but that induction reduces the incidence of shoulder dystocia amongst LGA babies.
The Big Baby Trial is currently being undertaken to ascertain whether induced labour at 38 weeks when the baby is large will decrease the incidence of shoulder dystocia. This collection of data aims to be complete in 2022.
The HSIB report also identified the following key themes, divided into antenatal and intrapartum (during labour) issues.
- Antenatal - Identification and management of large babies during pregnancy; There is no consistent approach in how to identify LGA babies and how to manage pregnancy and birth when an LGA baby has been identified. HSIB findings show that each trust has its own protocol when the baby is LGA, with some trusts not undertaking growth ultrasound scans when the baby is over the 90th centile, some trusts investigating further and some not taking any action at all. There is conflicting guidance from the RCOG and the Cochrane review on whether labour induction can reduce incidence of shoulder dystocia, with the Cochrane review recommending further investigation and trials of other management methods of harm reduction. NICE set the clear guideline that when there is suspected LGA baby, mothers should follow obstetric-led care plans and that these mothers should be made aware of the increased risks (e.g., shoulder dystocia, brachial plexus injuries) and the options available (e.g., assisted birth, augmented labour, caesarean section).
- Antenatal - Screening for gestational diabetes mellitus; Diabetes that develops during pregnancy is known as gestational diabetes mellitus (GDM), it affects around 18% of all mothers during pregnancy and often occurs during the mid to late stages of pregnancy. Diabetes can cause a baby to be a larger size and therefore it is recommended that there is extra monitoring of the fetal growth. Further to this, diabetic mothers are 2-4 times more likely to encounter shoulder dystocia during birth regardless of the fetal weight. RCOG guidelines (2012) also indicate that mothers with diabetes should be offered a caesarean section when their baby is deemed to have a large birthweight. HSIB’s report finds that all 31 mothers investigated were screened for GDM with 4 having confirmed cases. HSIB findings show that some trusts have developed their own methods for managing pregnancies of LGA babies with guidance on growth ultrasounds, testing for gestational and providing mothers with options regarding delivery. It appears that there are guidelines in place for when a diabetic mother has an LGA baby, there is an absence of guidance for LGA babies where there is no maternal diabetes.
- Antenatal – Information Sharing and consent; HSIB reports have found that that out of the 14 mothers who had suspected large babies, 10 of the mothers did not have a discussion regarding the risks associated with labour and birth. Previous Court rulings have clarified that mothers must be informed of all risks and benefits of different birth options by all healthcare professionals in order for her to make an informed decision about her delivery and care, irrespective of the size of the baby. There should also be discussions with the mother when there are individual risk factors such as a high maternal BMI or diagnosis of gestational diabetes. HSIB have recommended that trusts discuss all risks regarding mother and baby in order to identify those who are at high-risk of dystocia. Mothers who are identified as high-risk should have this in their healthcare records and should be provided with counselling regarding the risks that a vaginal birth may involve and information on the alternative options she may wish to try. HSIB has found that the Cochrane Review (2016) may be helpful to encourage discussion with mothers regarding their care decisions.
- Intrapartum – place and mode of birth; When delivering a suspected LGA baby, whether identified antenatally or during labour, there is national guidance that obstetric-led care is recommended. HSIB investigations have found that of the 31 cases investigated, 20 of these were induced into labour, with all mothers who suffer from GDM being induced as per guidance. HSIB recommend that trusts should make sure that a birth plan is created early on and is accessible for the maternity staff to ensure all specific care requirements are met. HSIB also recommend that trusts take a more updated and complete approach in making sure that risk assessment is ongoing and thorough.
- Intrapartum – recognition of shoulder dystocia; Throughout HSIB’s investigation, the recurrent theme of delayed recognition of shoulder dystocia has been identified. This lack of recognition has further led to the absence of neonatal and obstetric support teams in attendance in 4 of the 31 cases. HSIB recommend that staff should be encouraged to use the escalation 2222 process in order to ensure that specialist staff are in attendance during infant resuscitation, and that neonatal clinicians are a called as a matter of emergency in cases of shoulder dystocia.
- Intrapartum – management of shoulder dystocia; HSIB have noted that following recognition of shoulder dystocia, a majority of cases were managed within the shoulder dystocia algorithm provided by RCOG in 2012. It was found that training across multiple professions appeared to be routine in all trusts, with staff able to complete the manoeuvres to a high standard. It has been noted in the report that following the introduction of shoulder dystocia training, one hospital has reduced incidence of brachial plexus injury by 100% and HIE by 50%. HSIB has made the recommendations that trusts continue to implement training in emergency drills.
- Intrapartum - Injuries to babies following shoulder dystocia; HSIB’s report into hypoxia (low oxygen) has found that the most common causes are compression of the umbilical cord, compression of the baby’s neck and blood vessels by the mother’s perineum and premature separation of the placenta. Alongside a lack of oxygen, multiple babies suffered further injuries such as brachial plexus injuries and bone fractures. HSIB has recommended that RCOG take these findings into account when updating their shoulder dystocia guidelines.
RWK Goodman have a clinical negligence team with specialism in birth injuries. If you would like further information on the HSIB reports and birth injury claims, you can click below to read our HSIB guide or contact us directly for legal advice.