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Brain injury in the setting of shoulder dystocia

In the setting of birth, shoulder dystocia occurs either when, during delivery the baby’s uppermost shoulder gets stuck on the mother’s pubic bone or, more rarely, the lower shoulder gets stuck on a large triangular bone at the base of the spine.   Shoulder dystocia is a medical emergency, which can cause injury to the baby if not managed correctly.

Erb’s Palsy is caused by damage to the nerves which supply the arm, and which are known as the brachial plexus.  It is associated with varying degrees of paralysis within the affected arm.  In severe cases, babies can also suffer from oxygen deprivation causing brain damage as a result of shoulder dystocia, which I discuss further below.

Risk factors for shoulder dystocia

There are a number of factors which may be known during pregnancy which may increase the risk of shoulder dystocia, including:

  • There is an association between maternal diabetes and shoulder dystocia;
  • There is also a relationship between larger babies and the development of shoulder dystocia;
  • There is an increased incidence of shoulder dystocia in babies born to overweight mothers;
  • If a delivery has been complicated by a previous shoulder dystocia there is an increased chance that this may happen again in a future delivery.

Mechanism of brain injury and preventative measures

Once shoulder dystocia has occurred, there is a limited time to release the stuck shoulder and deliver the baby before serious injuries occur.  A delay in delivering the baby’s body will heighten the risk of oxygen starvation.  Once the baby’s head has delivered, the umbilical cord can become compressed, meaning that there is limited or no blood exchange between the placenta and the baby. The risk that the oxygen levels will drop increases over time, but the levels can drop very quickly. Consequently, deliveries should occur within five minutes where possible after delivery of the head. The risk of injury to one or more organs – including the brain – increases with the time to full delivery.

Shoulder dystocia is an emergency, and a rapid response is obligatory. That rapid response should also be structured and should follow the relevant Royal College of Obstetricians’ Guidelines, which should usually prevent the baby suffering from such injuries.

Signs of brain injury following delivery

Birth asphyxia (damaging lack of oxygen at the time of birth) can be indicated from a range of factors, including:

  • An umbilical cord blood pH level that is significantly acidic (7.0 or lower) would be evidence of oxygen starvation prior to birth;
  • Apgar scores can also be used to assess of the condition of a child at birth. The scores measure a range of factors including pulse rate, respiratory effort and activity. The maximum score is 10; a score of half of that (or less) could mean that the baby is in trouble – in particular if low scores persist for some while after birth. APGAR scores are however inherently subjective, because they rely upon the judgment of the doctors reviewing the baby;
  • If a baby suffers convulsions or fits following birth, or has problems affecting more than one organ, e.g. the heart and lungs, that should be cause for serious concern, and may indicate an irritation of the brain. It would be good practice in this setting to perform a scan of the brain to rule out a developing injury and further imaging may sometimes be necessary.

Shoulder dystocia can lead to Erb’s Palsy, but also to brain injuries ranging from quite subtle learning difficulties, problems with fine co-ordination and behavioural issues, to profound injuries including cerebral palsy, which is why it is vital that shoulder dystocia is managed correctly during delivery.  Any suspicions in this regard should not be ignored, because help to a child to develop to the best of their ability is better given earlier rather than later. The more subtle effects of a brain injury at the time of birth may not become apparent for many years. If a child begins to struggle at secondary – as opposed to primary – school, when the educational and social demands upon them increase, this could be related to problems at the time of birth.

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