Shoulder dystocia is often unpredictable, but the medico-legal assessment does not stop there. In birth injury claims, solicitors need to understand whether antenatal risks were recognised, whether the emergency was managed in line with appropriate guidance, and whether the documentation accurately records the timing and sequence of events.

Watch the full webinar with Nikki Khan here >

Antenatal Risk Factors and Clinical Warning Signs

Shoulder dystocia occurs when the baby’s head has been delivered, but the shoulders become impacted and cannot deliver without additional manoeuvres. As Nikki Khan explains in the webinar, this can place significant stretch on the nerves in the baby’s neck and shoulder, potentially resulting in Erb’s palsy or brachial plexus injury.

Although shoulder dystocia is often unexpected, there are risk factors that should be considered during antenatal care and when reviewing maternity records. These include previous shoulder dystocia, type 1 diabetes, gestational diabetes, suspected fetal macrosomia, booking BMI over 30, excessive maternal weight gain, advanced maternal age, induction of labour, and prolonged first or second stage of labour.

One point emphasised in the webinar is the importance of reviewing the records from the booking appointment onwards. Antenatal red flags may be visible long before the delivery itself.

“Often people don’t go back as far as the booking, but it’s quite important because there are red flags in antenatal care which can identify those at risk.”

A particular area of concern is late-onset gestational diabetes. Nikki highlights that some women may have a normal glucose tolerance test at 28 weeks, but later develop signs of excessive fetal growth in the third trimester. Where growth charts or fundal height measurements suggest increased growth, solicitors should consider whether further review, referral, scanning, or testing was indicated.

This matters because risk recognition can affect both the management plan and informed consent. Where a mother is known to have a suspected large baby, diabetes, previous shoulder dystocia, or other risk factors, there may be questions about whether she was offered appropriate options, including induction, planned caesarean section, or consultant-led care.

Medico-Legal Considerations

The central legal question is often whether the injury was avoidable. Shoulder dystocia itself is not automatically negligent. It may occur even where no obvious risk factors were present. However, once it is suspected, the response must be swift, structured, and properly documented.

Nikki explains that the first visible warning sign may be “turtlenecking”, where the baby’s head emerges and retracts. This should trigger urgent action. In medico-legal terms, the timing of recognition and escalation can be highly significant.

The webinar highlights several recurring breach issues:

• Failure to identify antenatal risk factors.
• Failure to provide appropriate counselling about delivery risks.
• Failure to call the emergency buzzer promptly.
• Delay in involving obstetric and neonatal teams.
• Incorrect or delayed use of recognised manoeuvres.
• Excessive traction.
• Use of fundal pressure.
• Poor documentation of timings and manoeuvres.

A key point is that the emergency buzzer should be called immediately. This is not simply a matter of asking another midwife to attend. The clinical emergency requires urgent multidisciplinary support.

“As soon as a midwife sees this or sees difficulty with delivering the chin, the urgency is relevant.”

Documentation is another major issue. Shoulder dystocia claims often depend on whether the notes record the time the head was delivered, the time the body was delivered, who was present, which manoeuvres were attempted, in what order, and for how long.

Nikki also stresses that the applicable guidelines must be those in place at the time of the incident. This is particularly important in birth injury cases, as some claims may relate to deliveries many years earlier.

Case Examples & Outcomes

The webinar discusses how errors in shoulder dystocia management can contribute to serious neonatal injury, including brachial plexus injury, Erb’s palsy, hypoxic-ischaemic encephalopathy, fractures, and, in the most severe cases, neonatal death.

Nikki explains that where the head-to-body delivery interval extends beyond five minutes, the risk of neonatal depression, brain injury, and death increases. Timing is therefore a central feature of expert analysis.

“Time is ticking as soon as this turtling is evident.”

The records should show whether each manoeuvre was attempted for an appropriate period before moving to the next step. McRoberts manoeuvre and suprapubic pressure are usually first-line measures. Internal manoeuvres, such as Woods screw or delivery of the posterior arm, may follow if initial measures fail.

The webinar also considers episiotomy. Nikki explains that episiotomy does not enlarge the pelvis or release the impacted shoulder. It may be necessary to create space for internal manoeuvres, but if performed too early it may increase the risk of significant maternal perineal trauma.

Fundal pressure is another important issue. It should not be used in shoulder dystocia, as it can worsen impaction and increase the risk of injury. Witness evidence may be especially important where the notes record suprapubic pressure, but the mother or birth partner recalls pressure being applied high on the abdomen.

“Witness statements are vital from everyone in the room.”

The webinar also refers to the importance of Montgomery and informed consent in maternity care. Where a mother has known risk factors, the question may be whether she was properly informed about the material risks and available options.

Key Takeaways for Solicitors

When reviewing a potential shoulder dystocia claim, solicitors should consider the full timeline, not just the delivery note. The antenatal records, growth charts, diabetes screening, scan reports, labour records, CTG evidence, shoulder dystocia pro forma, neonatal records, and witness statements may all be relevant.

Important questions include:

• Were antenatal risk factors identified and acted upon?
• Was the mother informed of material risks and delivery options?
• Was shoulder dystocia recognised promptly?
• Was the emergency buzzer pulled immediately?
• Were obstetric and neonatal teams called?
• Were McRoberts manoeuvre and suprapubic pressure performed correctly?
• Was fundal pressure used?
• Was excessive traction applied?
• Were timings recorded clearly?
• Do the notes match the mother’s or birth partner’s recollection?

Where there is a discrepancy between the records and witness evidence, this should not be ignored. Nikki explains that the court will ultimately determine factual disputes, but expert analysis should consider whether the records are complete, consistent, and clinically plausible.

The order of manoeuvres is also important. If internal manoeuvres were performed before external manoeuvres, or if the notes do not clearly record the sequence, this may require closer expert scrutiny.

“You’re looking at whether they’ve done them in the right order.”

Watch the full webinar here >