Postterm pregnancy (a pregnancy of 42 or more week’s gestation) is one of the more common high-risk problems confronting obstetricians.

The reported frequency of postterm pregnancy is 3-12%. About 80% of all pregnancies last 38-42 weeks, 10% are delivered preterm, and the remaining 10% extend beyond the start of the 43rd week and are considered postterm. Accurate assessment of gestational age and diagnosis of postterm gestation, as well as recognition and management of risk factors, can reduce the risk of adverse effects in most cases.

Maternal surveillance, induction of labor using drugs and cesarean sections, are strategies used to theoretically diminish fetal risk of adverse outcomes to the mother and baby.

• Because the risks of post term pregnancy are known, any child born with brain damage after such a delivery may benefit from a medical-legal investigation of the events surrounding his/her delivery.

Nerve (brachial plexus/shoulder dystocia) injuries and fractures of the collar bone (clavicle) and upper arm bone (humerus) are associated with obstructed deliveries where the baby's shoulders get stuck behind the mother's pubic bone. If nerves in the upper arm/shoulder are injured during such a delivery, the baby's arm may not develop normally - loss of arm use may also occur. The most potentially serious brachial plexus injuries are caused by extreme amounts of traction and flexion exerted on the infant's neck by the physician or nurse attempting such a delivery. These injuries may result in permanent disability.

The reported incidence of brachial plexus injuries following a delivery complicated by shoulder dystocia varies widely from 4% to 40%. Fortunately, most cases resolve without permanent disability. Placed in perspective, fewer than 10% of all shoulder dystocia cases result in a persistent brachial plexus injury. Moreover, brachial plexus injuries can occur without shoulder dystocia and at birth weights of less than 4,000 grams. Accordingly, some, but certainly not all such injuries, are the result of medical malpractice.

The McRoberts maneuver relies on maternal manipulation of the stuck baby and is reported to be effective. Successful use of the McRoberts maneuver is documented in the medical/scientific literature. The maneuver involves sharply flexing the mother's legs against her abdomen. Results from a laboratory study using models of the maternal pelvis, fetal head and fetal shoulders demonstrate that less force is required to deliver fetuses using the McRoberts maneuver compared with the standard lithotomy position. Mothers with known or suspected large babies are at greater risk for an obstructed delivery. Diabetic women and women with a history of having large babies, or women with small pelvis' are at greatest risk for this sometimes foreseeable risk of pregnancy. Where a large baby is suspected, cesarean delivery may be the most effective preventative measure.

Release Techniques

• There is no evidence that any one maneuver is superior to another in releasing an impacted shoulder or reducing the chance of injury. However, the McRoberts maneuver is easily facilitated and has a high success rate without an associated increase in risk of injury to the newborn.
• Traction combined with fundal pressure has been associated with a high rate of brachial plexus injuries and fractures.
• In addition to injuries to the baby’s arm(s), a delivery too long delayed by a shoulder obstruction may also result in brain damage to the baby as a consequence of oxygen deprivation.
• If your baby has a non-functioning or abnormally developing arm, a medical/legal consultation with an attorney experienced in the field of obstetrics/gynecology may be warranted.

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© 1999 CHARFOOS & CHRISTENSEN, P.C. Updated: April, 2006