The birth of a child should be a moment of celebration. However, for some families, the delivery room turns into a scene of panic when a sudden medical emergency occurs.
One of the most critical emergencies during birth is shoulder dystocia,where the baby’s head is delivered, but their shoulder becomes stuck behind the mother’s pelvic bone. While this is a frightening event, it is manageable with the right care. The injury to the child usually happens not because the shoulder got stuck, but because of how the medical team reacted to it.
If the doctor or midwife pulls too hard on the baby's head to force the delivery, the delicate nerves in the neck can be stretched or torn. This physical trauma is what leads to long-term conditions like Erb’s Palsy, Klumpke’s Palsy, or a permanent brachial plexus injury.
If your child has been diagnosed with nerve damage following a difficult birth, you may have been told it was “unavoidable.” At Michael Boylan LLP, we know that is not always the truth. We combine forensic medical expertise with the litigation strength of a top-tier personal injury firm. This allows us to investigate the medical records, challenge the standard of care, and determine if your child’s injury could, and should have been prevented.
What Is Shoulder Dystocia?
Shoulder dystocia is a specific medical emergency that occurs during childbirth. It happens when the baby’s head is delivered safely, but one or both shoulders become physically stuck behind the mother’s pelvic bone (the pubic symphysis).
Because the baby is stuck, they cannot be born until the shoulder is released. This creates a time-critical situation because the baby’s chest is compressed within the birth canal, preventing them from breathing properly. The obstetrician or midwife must act quickly and correctly to free the baby.
However, the urgency of the situation does not permit the use of excessive force. There are safe, established medical drills designed to release the shoulder without harming the infant. Legal actions in this area typically arise not because the baby became stuck,which is often an unpredictable complication,but because the medical team used inappropriate force (traction) instead of the correct techniques to free them.
The Injury Resulting from Shoulder Dystocia: Erb’s Palsy and Brachial Plexus Damage
To understand if a legal claim exists, it is necessary to understand the anatomy of the injury. The brachial plexus is a complex network of nerves that originates from the spinal cord in the neck (cervical spine), runs down through the armpit (axilla), and supplies the arm, wrist, and hand.
These nerves function like electrical cables, transmitting signals from the brain to the muscles. During a difficult birth involving shoulder dystocia, if the baby’s head is pulled away from the shoulder with too much force, these nerves can be stretched beyond their elastic limit.
Classifying the Severity of Nerve Injury
The medical and legal prognosis depends on the extent of the damage to the nerve roots (C5 to T1):
- Neurapraxia (Stretch Injury): The nerve has been stretched or shocked but remains intact. This is the mildest form of injury. The infant may present with a limp arm at birth, but recovery often occurs spontaneously within three months as the nerve recovers.
- Rupture: The nerve is torn, but the tear is not at the attachment to the spine. This injury will not heal on its own and usually requires complex neurosurgery to graft or repair the damaged sections.
- Avulsion: This is the most severe classification. The nerve root is torn completely away from the spinal cord. It cannot be surgically reattached to the cord. Surgeons may use nerve transfers (taking nerves from other muscles) to restore limited function, but full recovery is generally not possible.
Signs Parents Watch Out For
Parents often seek legal advice after noticing specific physical signs in their child:
- Limp Arm: The arm hangs loosely at the side and does not move actively when the baby is awake.
- Waiter’s Tip Deformity: The arm is rotated inwards, the elbow is straight, and the wrist is bent backwards.
- Asymmetric Moro Reflex: When the baby is startled, only one arm moves outwards.
- Horner’s Syndrome: If the lower nerves (T1) are avulsed near the spine, it can damage the sympathetic nerves controlling the face, causing one eyelid to droop and the pupil to appear smaller.
How Negligence Occurs in Delivery
It is a common misconception that all birth injuries are unavoidable accidents. While the complication of the shoulder getting stuck can be unpredictable, the management of that complication is strictly regulated by clinical guidelines.
Every maternity unit in Ireland operates under guidelines set by the Royal College of Physicians of Ireland (RCPI) and the Royal College of Obstetricians and Gynaecologists (RCOG). These guidelines dictate the specific steps a doctor or midwife should take to resolve the dystocia safely.
The Problem Caused by Traction
The primary cause of litigation in brachial plexus cases is excessive lateral traction. This is the medical term for pulling the baby’s head sideways or downwards with significant force.
When the shoulder is impacted behind the bone, pulling on the head does not assist in delivering the baby. Instead, it stretches the neck, placing tension on the Brachial Plexus. If the clinician continues to pull despite the obstruction, the nerves may snap. An important component of our legal investigation is determining if the clinician applied significant force rather than abandoning traction and moving to the correct internal or external manoeuvres.
The Correct Protocol (HELPERR)
In a medical setting, doctors and midwives use a standard set of steps to handle shoulder dystocia safely. This is often remembered using the acronym HELPERR.
- H, Help: The delivery team immediately calls for extra support. This usually includes a senior obstetrician (a doctor who specialises in pregnancy), a paediatrician (to care for the baby as soon as they are born), and additional nurses or midwives.
- E, Evaluate for Episiotomy: The doctor may perform a small surgical cut (an episiotomy) to widen the opening. It is important to know that this does not unstick the baby’s bone, but it gives the doctor more room to use their hands for the later steps.
- L, Legs (McRoberts Manoeuvre): This is often the most successful step. The mother is asked to lie flat on her back and pull her knees up as far as possible toward her chest. This movement changes the angle of the pelvis and flattens the lower back, which frequently allows the baby’s shoulder to slip through without any need for pulling.
- P, Suprapubic Pressure: A member of the medical team applies firm pressure from the outside, just above the mother's pubic bone. The goal is to "nudge" the baby's shoulder forward or to the side so it can move past the bone it is caught on.
- E, Enter (Internal Manoeuvres): If the shoulder is still stuck, the obstetrician will place their hand inside the birth canal to manually rotate the baby’s body. This is done to turn the baby into a better position for delivery, similar to how you might turn a key in a lock.
- R, Remove the Posterior Arm: The doctor gently reaches in to find the baby’s arm that is not stuck (the one at the back) and delivers it first. By bringing this arm out, the baby’s shoulder width is reduced, making it much easier for the rest of the body to follow.
- R, Roll the Patient: If other steps have not worked, the mother may be asked to roll over onto her hands and knees. This is known as the Gaskin manoeuvre. Gravity and the shift in the pelvic bones can often create the final bit of space needed for the baby to be born safely.
Medical Professionals Must Avoid Fundal Pressure
In a delivery involving shoulder dystocia, there is one specific action that medical staff are trained never to take: applying pressure to the very top of the mother’s bump to try and push the baby out. This is known as fundal pressure.
This is so dangerous because:
- It worsens the blockage: If the baby’s shoulder is already caught behind the pelvic bone, pushing from the top simply wedges the shoulder even tighter against that bone.
- Risk of serious injury: This downward force can cause the mother’s uterus to tear (uterine rupture) or cause severe internal trauma to both the mother and the baby.
- Increased nerve damage: Pushing from the top can put even more strain on the delicate nerves in the baby's neck.
During our investigation, we look closely at medical notes and listen to your account of the birth. If you remember a nurse or doctor pushing down hard on your upper abdomen during the emergency, this is often a major factor in proving that the medical team did not follow safe standards of care.
Establishing Negligence in Shoulder Dystocia Mismanagement Claims
In Irish law, an adverse outcome does not automatically imply negligence. To succeed in a claim, the plaintiff must prove that the medical care provided fell below the acceptable standard. The legal test for medical negligence in Ireland was established in the Supreme Court case of Dunne v. The National Maternity Hospital [1989].
To succeed in an action, we must prove the following:
- Substandard Care: We must demonstrate that the practitioner was guilty of such failure that no medical practitioner of equal specialist or general status and skill would be guilty of if acting with ordinary care. For example, if an expert witness confirms that no competent obstetrician would have applied traction before attempting the McRoberts manoeuvre, negligence may be established.
- Causation: It is not enough to prove the doctor made a mistake; we must also prove that the mistake caused the injury. We must demonstrate that if the correct manoeuvres had been used, the baby would likely have been born uninjured.
- Damage: We must document the extent of the injury and its financial and physical impact on the child’s life.
This is a rigorous legal threshold. It requires forensic analysis of the medical records. We look for discrepancies between the midwife’s notes and the doctor’s account, review the Cardiotocograph (CTG) traces, and analyse the timing of the delivery to build a coherent timeline of events.
Antenatal Risk Factors to Consider
Litigation in this area is not limited to the events of the delivery room. A significant number of claims arise from the antenatal period (care during pregnancy). Shoulder dystocia is more likely to occur in certain pregnancies, and obstetricians have a duty to assess these risk factors.
Common risk factors include:
- Macrosomia (Large Baby): If the baby is estimated to weigh over 4.5kg (or 4kg in diabetic mothers), the risk of dystocia rises significantly.
- Gestational Diabetes: Diabetes in pregnancy can cause the baby to grow disproportionately, with broader shoulders and a larger abdomen.
- Maternal Obesity: A high Body Mass Index (BMI) can complicate the delivery.
- Previous Dystocia: If a mother has experienced shoulder dystocia in a previous pregnancy, the recurrence risk is high.
- Prolonged Labour: If the labour is progressing very slowly, or if the second stage (pushing) is prolonged, it may indicate that the baby is too large for the pelvis.
If you had these risk factors but were not counselled about the risks of vaginal delivery, or if your request for a C-section was dismissed, we investigate whether your consent to the vaginal delivery was fully informed.
The Investigation Process
At Michael Boylan LLP, we employ a structured approach to investigating medical negligence and personal injury claims. We do not initiate proceedings without a solid evidential basis.
Step 1: Taking Instructions and Data Access
We begin by taking a detailed statement from the parents. We then issue a formal request for the complete medical file under the Data Protection Acts 1988,2018 and the Freedom of Information Act 2014. This includes the antenatal card, the partogram (labour log), operation notes, and neonatal records.
Step 2: Independent Expert Review
To ensure objectivity and avoid any local conflicts of interest, we typically instruct consultant obstetricians based in the United Kingdom to review the records. The expert will provide a report on liability, detailing whether the management of the birth complied with the Dunne principles.
Step 3: Causation Reports
If liability is established, we must quantify the injury. We engage paediatric neurologists, plastic surgeons (specialising in peripheral nerves), and occupational therapists to assess the child’s current condition and future prognosis.
Step 4: Issuing Proceedings
If the expert evidence supports the claim, a personal injury summons is issued in the High Court. The defendant is usually the Health Service Executive (HSE), represented by the State Claims Agency, or a private consultant’s indemnity insurer.
The Statute of Limitations for Shoulder Dystocia Mismanagement Claims
A common concern for parents is whether too much time has passed to bring a claim. Under the Statute of Limitations, an adult typically has two years from the date of an injury to initiate legal proceedings.
However, the law provides an exception for minors. For a child injured at birth, the limitation period is "tolled" (paused) until they reach the age of 18. This means that, legally, a claimant has until their 20th birthday to issue proceedings for a birth injury.
Why Early Investigation Is Recommended
Despite the extended time limit, it is legally prudent to investigate claims as early as possible. Over time, hospital records can be lost or destroyed, medical staff may retire or emigrate, and the recollection of witnesses (such as the father or birth partner) may fade. Investigating the claim earlier ensures the evidence is preserved and allows access to interim therapies that can improve the child's outcome.
Frequently Asked Questions
Is a diagnosis of shoulder dystocia automatically proof of negligence?
No. Shoulder dystocia is a recognised medical complication that can happen even with excellent care. Negligence arises only if the management of that complication fell below the accepted standard. If the doctor followed the HELPERR protocol correctly and avoided excessive force, but the injury occurred anyway, there may be no liability. We investigate to determine which scenario applies to your case.
Can I claim for the psychological impact on the parents?
Yes. It is recognised that a traumatic birth can cause significant psychological injury to the parents, particularly the mother. If a parent suffers a recognised psychiatric illness, such as post-traumatic stress disorder (PTSD), as a result of witnessing the negligent delivery, they may be entitled to bring a separate action for nervous shock. This is distinct from the child’s claim.
What if the hospital records are missing or incomplete?
Incomplete records are a challenge, but they do not necessarily stop a case. In fact, a failure to maintain adequate records can sometimes be viewed by the courts as indicative of poor practice.
Does the claim affect the child’s public medical entitlements?
No. Bringing a claim against the HSE or a hospital does not affect your child’s entitlement to public medical care. However, a successful claim often provides the funds to access private medical care, bypassing public waiting lists for necessary surgeries and ongoing therapies.
Contact Michael Boylan LLP
If you require legal advice regarding shoulder dystocia, Erb’s Palsy, or any form of birth trauma, please contact our offices. We treat every enquiry with the strictest confidentiality and sensitivity.
We will arrange an initial consultation to discuss the circumstances of the birth and advise on the merit of a legal investigation.
*In contentious business, a solicitor may not calculate fees or other charges as a percentage or proportion of any award or settlement.
