The Atlanta Journal-Constitution
Obstetricians must have courage to make unthinkable choice
To save mother during birth, drastic measures are sometimes required.
As an OB/GYN hospitalist, I am called in when a pregnant mother or baby’s life is in danger. I know obstetrical emergencies. Shoulder dystocia is one of the worst.
I was not involved in the case in Georgia where a baby was decapitated. No one knows every detail of that emergency, including the medical staff and the family in the room. In traumatic situations, people remember some moments with laser-etched precision, other events incorrectly or not at all.
I have cared for thousands of women in labor over my 30-year career. One of the first obstetrical emergencies I trained for as an intern was shoulder dystocia. The Society of OB/GYN Hospitalists, of which I am a former president, trains obstetricians nationwide to address this life-threatening complication.
At the very end of labor, when a baby won’t fit through the mother’s birth canal, its shoulders can get stuck. Shoulder dystocia occurs in 0.15% to 2% of deliveries, but no one can predict which mom will have it with certainty.
The mismatch is only partly due to the baby’s size; it also depends on the way the baby’s weight is distributed and the shape of the mother’s pelvis. I have delivered a 10-pound, 9-ounce baby in three pushes. The worst shoulder dystocia of my career happened in a 7-pound baby.
When a shoulder dystocia occurs, we initiate an obstetrical code: an orchestrated, team response to a life-threatening event. We call for help, move the family to the side and start the clock. We attempt one maneuver after another in choreographed sequence to get the baby unstuck. We have only minutes to release the baby’s shoulders and thwart death, even fewer to prevent temporary or permanent injury.
Fortunately, the first steps we try allow the infant to deliver most of the time. We often perform these before the family has fully registered there’s an emergency. When those first actions don’t work, however, we move on. The next steps require the obstetrician to intentionally harm the baby. Sometimes we have to cause injury to prevent death. Ten years ago, I had to break a baby’s arm to get her to deliver. I can still hear the sound of that bone cracking. It still makes me nauseous.
The last option to fix a shoulder dystocia is a Zavanelli maneuver. We rotate the baby’s head and shoulders back up through the birth canal, where they’re wedged, into the womb, so we can perform a Caesarian section. This procedure is the hardest of all.
Every obstetrician fears the Zavanelli maneuver. Thankfully, almost all of us will complete our careers without ever performing one. By the time this procedure is attempted, the baby has died. The obstetrician is fighting with every skill and prayer they have to save the mother.
All pregnancies must end, and all babies must deliver. The last resort in the most severe shoulder dystocias is to separate the baby’s head from its body. The head delivers vaginally and the body delivers through the abdomen.
A tragic outcome is not proof a doctor made a mistake, just as a good outcome is not evidence they didn’t.
Performing a Caesarean section on every mother could prevent most shoulder dystocias. Caesarean sections can also cause dangerous complications, such as hemorrhage, infection, blood clots and even death. More frequent Caesarean sections contribute to the disproportionate morbidity and mortality of Black women.
We think of beheading as an act committed by terrorists.
It is hard to imagine it would ever be justified, let alone required. But when a baby has died and the mother’s life is in peril, the obstetrician must have the courage to make this unthinkable choice. We still have one patient to save.
I hope the Georgia family’s legal team has only a profound misunderstanding of obstetrical emergencies and is not deliberately exploiting their tragedy. The obstetrician did not choose to decapitate a baby. She chose to save a mother.