Brachial plexus injuries are among the more common and most damaging types of birth injuries. They result from stretching or tearing of the network of nerves that runs from the spinal cord through the neck and into the arm, and they typically produce permanent loss or impairment of motor function in the affected arm. Most are caused by the forces applied during delivery, particularly when delivery is complicated by shoulder dystocia.
Rathan et al v Scheufler et al, 2023 ONSC 3232 is an Ontario trial decision in which the trial judge found that an obstetrician at Mississauga Hospital applied more than gentle downward traction during a shoulder dystocia emergency, causing a permanent brachial plexus injury to the baby. Liability was established. The case is a useful illustration of how Ontario courts approach this fact pattern.
What shoulder dystocia is, and why it matters
Shoulder dystocia is an obstetric emergency that arises when, after the baby’s head has been delivered, the anterior shoulder becomes impacted behind the mother’s pubic bone. Until the impacted shoulder is freed, the baby cannot be delivered.
The instinctive response, when the head is delivered but the body is not following, is to pull harder on the head. In the context of shoulder dystocia, that response is dangerous. The shoulder is fixed; pulling on the head simply stretches the head away from the shoulder, increasing the strain on the brachial plexus nerves running through that space. Downward traction (pulling the head toward the floor) and lateral traction (pulling away from the mother’s body) are particularly likely to cause brachial plexus injury.
The proper management of shoulder dystocia is to use specific manoeuvres, in sequence, to free the impacted shoulder without applying excessive traction to the head. The McRoberts manoeuvre, which involves repositioning the mother’s legs to flatten the pelvis and increase the available space, is typically the first step. Other manoeuvres include suprapubic pressure, internal rotation, and (rarely) more invasive approaches.
The facts
The plaintiff infant was delivered at Mississauga Hospital by Dr. Scheufler, an experienced obstetrician. During the delivery, the baby’s anterior shoulder became impacted, and a shoulder dystocia emergency was identified. The McRoberts manoeuvre was performed.
The baby was delivered with a permanent brachial plexus injury affecting one arm.
The plaintiffs sued Dr. Scheufler in negligence, alleging that the obstetrician had applied excessive traction to the baby’s head during the management of the shoulder dystocia, and that the excessive traction had caused the injury.
The case proceeded to trial on liability only.
The competing theories
The two sides offered fundamentally different theories of how the brachial plexus injury had occurred.
The plaintiffs argued that the injury was caused by the obstetrician’s application of negligent excessive traction during the shoulder dystocia. Their experts, including a UK obstetrician with subspecialty expertise in shoulder dystocia and a US biomedical engineer, opined that the pattern of injury was consistent with externally applied force in excess of the gentle traction that the standard of care permits.
The defence argued that the injury was caused by non-negligent in-utero propulsive forces, the natural forces of contraction and descent during labour, without any contribution from the obstetrician’s actions. Their experts, including a Canadian obstetrician and a US biomedical engineer, opined that the pattern was consistent with maternal forces alone.
The competing theories on the cause of brachial plexus injuries are now familiar in birth-injury litigation. The biomedical engineering analysis on both sides has become increasingly sophisticated, and the question of how to distinguish injuries caused by clinician traction from injuries caused by maternal forces is contested in the published literature.
The decision
The trial judge accepted the plaintiffs’ theory. He found that Dr. Scheufler had applied more than gentle downward traction after identifying the shoulder dystocia, either before or during the performance of the McRoberts manoeuvre, and that this caused the injury.
The trial judge made an observation at paragraph 186 of the reasons that is worth quoting:
This is not to say that Dr. Scheufler is not a skilled physician who has had a long and distinguished career. However, Dr. Scheufler had been on shift for over 15 hours of a 24-hour shift by the time he delivered [the baby]. In a normal shift where he would deliver an average of 10 to 12 babies, he completed five caesarian sections and delivered 14 babies that night. Dr. Scheufler was an obstetrician in a busy, urban hospital, where demand for care is high, and the volume of cases is great. I have no way of concluding with certainty if Dr. Scheufler unintentionally injured [the baby] when managing her birth, but the law does not require me to find facts on any degree of certainty.
The observation does not diminish the finding of liability. The standard of care does not bend because the physician is overworked. The observation does, however, frame the breach in a way that recognizes the systemic conditions in which it occurred. The fact pattern (a fatigued obstetrician at the end of a long, high-volume shift, in a busy urban hospital) is not unique to Rathan. It is a familiar shape in Ontario birth-injury litigation.
The doctrinal context
Rathan applies well-established principles on shoulder dystocia and brachial plexus injuries. Specifically:
- Shoulder dystocia is a foreseeable obstetric emergency, and the standard of care requires that obstetricians be prepared to manage it without excessive traction
- Downward and lateral traction on the head during shoulder dystocia, beyond the gentle traction needed to assess the situation, is below the standard of care because it predictably causes brachial plexus injury
- Causation in brachial plexus cases is often a battle of biomedical engineering experts, with each side opining on whether the injury pattern is consistent with clinician traction or maternal forces. The trial judge’s task is to weigh the competing analyses and draw a conclusion on the balance of probabilities
The case is also a worked example of how systemic conditions (fatigue, workload, volume) intersect with individual clinical performance. The standard of care does not change with the conditions. But the cases in which the standard is breached often emerge from contexts where the conditions made the breach more likely.
Why this case matters
For plaintiffs and their counsel. Rathan is a useful precedent in shoulder dystocia and brachial plexus injury cases. The judgment confirms that, where the expert evidence supports a finding of excessive traction during the management of a shoulder dystocia, the trial judge can find liability even in the face of strong defence biomedical engineering evidence. The case also illustrates the value of expert pairings on the plaintiff side: an obstetrician who can speak to standard of care and clinical mechanism, and a biomedical engineer who can speak to the biomechanical analysis of the injury pattern.
For defence counsel. The case is a reminder that the in-utero propulsive forces theory, while well-supported by some defence experts, is not always accepted by trial judges. Where the clinical narrative is consistent with the application of significant traction during a shoulder dystocia, and particularly where a senior physician was managing a difficult delivery at the end of a long shift, trial judges may be more receptive to the plaintiffs’ clinical mechanism than to the biomechanical defence.
For obstetricians. Rathan underlines the importance of formal training and ongoing simulation in shoulder dystocia management. The standard manoeuvres, performed in sequence and without excessive traction, can resolve most shoulder dystocia emergencies without injury. Where they are performed with excessive traction, particularly in conditions of fatigue or volume pressure, brachial plexus injury can result. The systemic conditions that make breaches more likely (long shifts, high case volume) are the conditions in which adherence to the trained protocol matters most.
For more on birth-injury claims in Ontario, see the Birth Injury practice page. For other Canadian birth-injury decisions, see Woods v Jackiewicz: An $11.5 Million Verdict for a Mismanaged Twin Pregnancy and KY v Bahler: A Failed Referral and a Preventable Birth Injury. For an overview of the legal process for medical malpractice claims in Ontario, see Suing for Medical Malpractice in Ontario: What You Need to Know.
Decision Date: May 31, 2023
Jurisdiction: Ontario Superior Court of Justice
Citation: Rathan et al v Scheufler et al, 2023 ONSC 3232 (CanLII)
