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A risk to big babies Birth injury to nerve bundle controlling arms and hands limits motion Tuesday, August 21, 2001 By Jane Miller
Jonathan David Stragar was born blue, not breathing and his right arm hanging limp. He was immediately placed in an oxygen tent and whisked to an intensive care nursery.
"We were told he might not make it," said his mother Pattye Stragar of Ben Avon, recalling the birth seven years ago.
David had gotten stuck in his mother's pelvis during birth because he was so large -- 9 pounds, 7 ounces. He recovered, but couldn't move his right arm until he was 4 months old.
Through an Internet search his parents learned that the birth has a term: shoulder dystocia delivery. He had an injury to a bundle of nerves called brachial plexus behind the collar bone that controls arm and hand movement. A previous difficult delivery and David's large size were significant risk factors.
Pattye Stragar's medical records indicated that because of these risks she was a possible candidate for a Caesarean, but no one discussed this with her before the birth.
"I may have said 'I don't want a C-section,' but somebody should have talked with me about this possible complication," Stragar said.
Francine Litz, a doula who assists women in labor, never heard of shoulder dystocia, either -- until it happened to her daughter, Maia, now 3.
"Every year thousands of babies are injured -- and a few die -- from this birth complication. Why aren't more doctors and midwives informing their patients who are at risk?"
Litz, of Ambler, Montgomery County, has a Web site, www.injurednewborn.com to raise awareness of this complication.
Dr. Henry Fetterman, a gynecologist in Allentown, Lehigh County who has studied shoulder dystocia, believes these complications are becoming more common, partly because women are delivering larger babies and because of insurers are trying to reduce the rate of the more expensive Caesarean births.
Dr. Adam Duhl, director of Medical Education and Perinatal Outreach at Allegheny General Hospital, said a shoulder dystocia birth is when the baby's shoulders get stuck in the mother's pelvic opening.
This complication cannot be diagnosed until just before birth. In most cases a labor progresses normally until the baby's head appears and then retracts between contractions and maternal pushes.
"When that happens, the birth becomes an obstetrical emergency, and the baby's life is in danger. You have no more than five, six minutes to get the baby out. If the baby is stuck, the umbilical cord [which sends oxygen to the baby] could be compressed," Duhl said.
"The first rule is: don't panic. You want to work quickly and call in help. You would want a properly trained pediatrician or neonatologist to be at that delivery, and have a nurse keep an eye on the clock."
Women at risk include diabetics (the insulin serves as a fetal growth hormone, producing babies with large chest cavities and pectoral regions), obese or short women, those with babies determined to be at least 8 pounds, 14 ounces, or those with overdue babies beyond 40 weeks.
Two percent of all births at at Magee-Womens Hospital -- the region's largest maternity hospital with 7,892 births in 2000 -- involve shoulder dystocia problems.
Treating brachial plexus injuries
The Brachial Plexus Clinic at Children's Hospital opened five years ago to treat children with such injuries. Many are caused by shoulder dystocia births, but these injuries also can result from accidents or breech births.
Up to 90 percent of these babies are born healthy, says Robert Allen, a biomedical engineer at John Hopkins University in Baltimore, who has been working with obstetricians since 1985 to help them reduce the risk of injury associated with dystocia.
Allen developed a glove with a sensor to determine how much neck traction can be applied safely during delivery. Tugging and pulling to dislodge the baby can result in brachial plexus injuries.
Most injuries heal within a few days to a few months, but 10 percent are permanent. One baby in 400 shoulder dystocia births will die, "because they can't get the baby out in time," Allen said.
He calls for better training in vaginal delivery techniques and fetal ultrasound, which does not always give an accurate measurement of the shoulders.
Most lawsuits filed over delivery complications involved shoulder dystocia, said Fetterman, the Allentown gynecologist. He examined obstetrical lawsuits for the Pennsylvania Medical Society Liability Insurance Co. filed between 1984 and 1994.
He said more of these births could be prevented if more women were given the option of delivering by Caesarean.
"This is a dollars-and-cents issue," Fetterman said. "The insurance industry is to blame mostly for the pressure they put on doctors to hold down the number of C-sections."
Most obstetricians should be able to see "red flags flying" as early as the first prenatal visit, he said in an address to the American College of Obstetrics and Gynecology. At least one warning sign was present in 88 percent of the cases he reviewed.
Despite Fetterman's assertions, midwife Nancy Niemczyk of the private, nonprofit Midwife Center for Birth & Women's Health on the North Side believes vaginal births can still be safer than Caesareans for women at risk if proper techniques are followed.
For example, having a woman get on her hands and knees in a position called the Gaskin Maneuver causes the fetus to rock within the pelvis, possibly easing these births.
"Women need a choice on how much risk they are willing to take during the birthing of their babies," said Litz.
Jane Miller is a free-lance writer who lives in Avalon.
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