 This post is the third in a series of articles that explain what Texas law requires you to prove in different types of birth injury cases, who can actually be sued, and how much time you have to act. Additionally, this particular post walks through what shoulder dystocia is, what the medical literature actually says about what causes brachial plexus injuries, and what separates an unavoidable complication from a preventable one.
A baby is born with a limp arm, a diagnosis of brachial plexus injury follows, and a family is told the delivery involved shoulder dystocia. The natural question is whether someone did something wrong. The honest answer is more complicated than yes or no. Shoulder dystocia itself is widely recognized in the medical literature as largely unpredictable, but how a delivery team responds to it, and whether the resulting injury came from that response or from the natural forces of labor, is where a real legal question can exist. What Is Shoulder Dystocia, and Why Does ACOG Call It Unpredictable? Shoulder dystocia occurs when a baby's anterior shoulder becomes lodged behind the mother's pubic bone after the head has been delivered, preventing the rest of the body from following. It is an obstetric emergency requiring a quick, coordinated response, but according to the profession's own guidance, it is not something a physician can reliably predict or prevent in advance. The American College of Obstetricians and Gynecologists' (“ACOG”) Practice Bulletin No. 178 on shoulder dystocia describes shoulder dystocia as an unpredictable and unpreventable obstetric emergency, noting that pre-pregnancy, antepartum, and intrapartum risk factors, including fetal macrosomia, maternal diabetes, and a prolonged second stage of labor, have extremely poor predictive value. That matters legally, because it means the mere fact that shoulder dystocia occurred, even in a pregnancy with known risk factors, is generally not by itself evidence of negligence. ACOG's guidance instead focuses on what happens after dystocia is recognized: a systematic, practiced response using recognized maneuvers, with the McRoberts maneuver typically used first, followed by suprapubic pressure and, if needed, delivery of the posterior arm or other techniques. If Shoulder Dystocia Itself Isn't Preventable, What Part of the Delivery Can Be Malpractice? The legal question in most shoulder dystocia cases is not whether the dystocia happened. It is whether the delivery team responded to it consistent with the recognized standard of care, using appropriate maneuvers in appropriate sequence, without applying excessive or misdirected force to free the baby. ACOG's guidance and the broader obstetric literature emphasize a systematic approach:
A shoulder dystocia delivery note that documents which maneuvers were attempted, in what order, and how much time elapsed between delivery of the head and delivery of the body is often central to evaluating whether the response met that standard. A delivery note that simply says “shoulder dystocia managed, baby delivered” without that detail can itself become a point of dispute. Does Excessive Traction Always Cause the Brachial Plexus Injury? No, and this is genuinely contested in the medical literature, not just a defense talking point. Excessive lateral traction by the delivering physician has traditionally been treated as the primary cause of brachial plexus injury, but a substantial body of obstetric research shows that some of these injuries occur without any physician traction at all. Multiple studies have documented brachial plexus injuries occurring in deliveries without a recognized shoulder dystocia, following cesarean sections with no traction applied to the fetal head, and affecting the posterior arm, which is not subjected to the same lateral traction as the anterior shoulder during standard maneuvers. These findings have supported what is sometimes called the propulsive force theory, the idea that the natural, powerful forces of uterine contractions and maternal pushing during a prolonged second stage can themselves stretch or injure the brachial plexus independent of anything the delivering physician does. Some courts have found, based on this literature and case-specific expert testimony, that a baby's injury resulted from the natural forces of labor rather than physician conduct. None of this means excessive traction never causes these injuries. It does mean that a brachial plexus injury following shoulder dystocia is not, by itself, proof of malpractice, and the specific facts of the delivery, not just the diagnosis, drive the outcome. Texas Civil Practice and Remedies Code §74.351 reflects this reality by requiring a Claimant to serve a preliminary expert report establishing the standard of care, the breach, and causation before a health care liability claim can proceed. In a shoulder dystocia case, that causation element is often the most contested part of the entire claim. What Evidence Do Experts Look At to Determine Whether Excessive Force Was Used? Experts on both sides of a case typically start with the delivery note itself: which maneuvers were used, in what sequence, and how much time passed from delivery of the head to delivery of the body. A prolonged head-to-body interval combined with a sparse or inconsistent delivery note is one of the more common patterns that draws scrutiny. Beyond the delivery note, experts often look at which arm was affected, since posterior arm injuries are harder to attribute to the physician's lateral traction on the anterior shoulder and can point toward a natural-forces explanation instead. The fetal heart rate tracing in the period before delivery can show whether the baby was already in distress prior to any traction being applied. Nursing documentation, including who was present and what was announced during the emergency, can corroborate or contradict the physician's own delivery note. The infant's Apgar scores and the initial newborn examination findings also factor into reconstructing the timeline. No single piece of this evidence is conclusive on its own. Together, they let a qualified obstetric expert form an opinion about whether the specific delivery is more consistent with a properly managed emergency or a departure from accepted technique. What Should a Family Do If Their Baby Was Diagnosed With a Brachial Plexus Injury After Shoulder Dystocia? First, request the complete delivery record before drawing conclusions either way. Given how genuinely contested the causation question can be, a brachial plexus injury diagnosis alone does not tell a family whether they have a case, and it does not tell them they do not. When requesting the records, make sure to ask for the full labor and delivery record, including the physician's delivery note, nursing notes from the time of the emergency, fetal heart rate monitoring strips, and the newborn's initial examination and Apgar documentation. Because the medical literature on this question is genuinely split, a case usually cannot be evaluated from the diagnosis alone. It typically requires a qualified obstetric expert reviewing the specific facts of the delivery against the records. Texas's statute of limitations for health care liability claims generally requires action within two years, so it's worth having that record review happen sooner rather than later. A birth injury attorney can help coordinate that expert review and explain what the records do and do not show before you have to decide whether to pursue a claim. We Can Help At The Borah Law Firm, PLLC, we only handle medical malpractice cases in Texas, nothing else. As part of our practice, we represent patients and families in cases just like the one discussed in this blog. If you believe a loved one received substandard birth injury care, whether in a nursing home, assisted living facility, or hospital, we can help you understand whether a case exists and what your options are. Contact us today so you can tell us your story. Frequently Asked Questions Is shoulder dystocia always caused by medical negligence? No. Shoulder dystocia is widely recognized in the medical literature as largely unpredictable and unpreventable, even in pregnancies with known risk factors. The legal question usually is not whether it occurred, but whether the delivery team's response to it met the accepted standard of care. What is a brachial plexus injury and is it always permanent? A brachial plexus injury involves damage to the network of nerves that runs from the spinal cord to the shoulder, arm, and hand, and it's one of the possible complications of a shoulder dystocia delivery. Most of these injuries are temporary and resolve with time and therapy, though a meaningful percentage result in permanent nerve damage. How do I know if my baby's brachial plexus injury was caused by excessive traction? You generally can't know from the diagnosis alone. The medical literature recognizes that brachial plexus injuries can result from physician traction or from the natural forces of labor, and distinguishing between the two typically requires a qualified obstetric expert reviewing the specific delivery record. About the Author: J.T. Borah is a Texas-licensed medical malpractice attorney and Texas Super Lawyer at The Borah Law Firm, PLLC in Austin, Texas. He has testified before both the Texas House and Senate on patient safety issues and focuses exclusively on medical malpractice cases statewide. About this article: AI writing tools assisted Mr. Borah in drafting this article. All legal analysis reflects his independent professional judgment. This article is for general informational purposes only. It is not legal advice and does not create an attorney-client relationship. Link: https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2017/05/shoulder-dystocia Comments are closed.
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