Shoulder Dystocia and Erb's Palsy
The birth of a child is an awe-inspiring event. So often Mother Nature and skilled doctors work together to provide a smooth entry for the baby into the world. However, it is well-known that many births have complications, and sometimes those complications lead to injuries. Some are preventable, some are not.
One of the most common birth injuries is known as Erb's Palsy. This condition is the result of Brachial Plexus and Shoulder Dystocia during the delivery. Simply put, the nerves in the shoulder get stretched, compressed, or torn when the doctor pulls too hard on the baby (usually the baby's shoulder has been stuck behind the mother's Pubis Symphysis bone).
What causes Brachial Plexus and Erb's Palsy injuries?
What are the risk factors?
How do I know if negligence is a possibility?
What are our legal rights?
What are the treatment options?
Shoulder Dystocia is preventable
What causes Brachial Plexus and Erb's Palsy injuries?

Many instances of shoulder dystocia can be anticipated and prevented if the warning signs are heeded. There are some instances of shoulder dystocia that cannot be anticipated. However, injury to the infant can still be prevented if the appropriate steps are taken once the shoulder dystocia occurs.

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For example, the only known cause of Erb’s palsy in a head first vaginal delivery is excessive lateral traction to the baby’s head.

Lateral traction to the head occurs when the baby’s head is pulled sideways in an attempt to dislodge the trapped shoulder. Once the dystocia occurs, no lateral traction should be applied to the baby’s head.

All the means necessary to successfully deliver the child can be done without applying lateral traction to the head. An example of a safe intervention during a shoulder dystocia is to perform McRobert’s maneuver.

During this procedure, the patient’s legs are held back in a flexed position. At the same time, pressure is applied to the mother’s lower abdomen, which is called suprapubic pressure.

Under no circumstances should pressure be applied to the upper abdomen. This is called fundal pressure and may cause serious injury to both the mother and the baby.

If the McRobert’s maneuver is not successful then there are a number of methods that the doctor can perform to safely rotate the baby and free its shoulders.

Almost all deliveries can be successfully resolved with no injury to the baby with the proper use of these proven methods where shoulder dystocia occurs.

What are the risk factors?
  • gestational diabetes
  • obesity in the mother
  • excessive weight gain during pregnancy
  • macrosomia (a baby weighing more than 4000 grams or approximately 9 lbs.)
  • a previous large baby
  • a post-term pregnancy
  • a small pelvis.
How do I know if negligence is a possibility?
Birth injury as the result of negligence often occurs in the following circumstances
  • Not recognizing or properly responding to fetal distress,
  • Allowing the pregnancy to go beyond 41 weeks without proper testing, or 42 weeks in any event,
  • Failing to act on changes in the mother's condition during pregnancy,
  • Causing or failing to respond to the umbilical cord being entrapped or compressed,
  • Misuse of a vacuum extractor or forceps,
  • Misuse of the labor-stimulating drug Pitocin (Oxytocin),
  • Delay in ordering or performing a C-section,
  • Poor resuscitation and newborn care after birth.
What are our legal rights?

The process of childbirth is extremely complicated and requires a high level of care on the part of doctors. Childbirth is extremely unpredictable, in fact, 80% of childbirths have some form of complication. All of these potential complications mean that doctors must make sudden split-second decisions to react to problems during childbirth. Unfortunately, too often a doctor or nurse may make the wrong decision under pressure and that error could cause Erb's Palsy (Brachial Plexus).

Modern medical technology and techniques make Erb's Palsy largely preventable. There are several things doctors can do to decrease the risk of an Erb's Palsy childbirth:

Estimate the baby's weight before delivery (higher-weight babies are more at risk and parents should be informed of this risk).

If there is a high risk of Erb's Palsy, perform a caesarean section, which removes the risk of the shoulder getting caught.

If the doctor sees that the baby is not properly aligned, the doctor should use appropriate techniques to prevent the shoulder from getting caught. There are numerous techniques doctors know to prevent the shoulder from getting caught. For example, if the shoulder or the baby is gently shifted, the risk of the shoulder getting caught can be greatly reduced. Or, the doctor could press down on the mother's belly to push the baby's shoulder into the correct position.

This is not to say that all Erb's Palsy cases are the result of negligence. Often there is little or nothing a doctor can do. Nevertheless, parents should consider the possibility that a doctor may not have done all that is possible to prevent Erb's Palsy and at least request some form of inquiry.

What are the treatment options?

It is essential that treatment for a Brachial Plexus injury be obtained as soon as possible from experienced medical professionals who specialize in treating Brachial Plexus injuries. Early treatment for Brachial Plexus injuries most likely will include occupational and/or physical therapy to help maximize use of the affected arm while preventing contactures (tightening of the muscles and joints).

It is important to note that even with ongoing therapy treatment and surgical intervention, complete recovery from a Brachial Plexus injury may not occur.

What can be expected with treatment?
Most mild cases of Brachial Plexus injuries recover in 3 to 4 months. The more severe cases improve slowly over 18 to 21 months. By 2 years of age, any recovery that will occur should have occurred, and no further improvement is expected. Treatment consists of Physical Therapy and Surgery.

Therapy for Brachial Plexus Injuries
An occupational or physical therapist will work with your child. The therapist will also help you (the parent) learn to do the exercises. Most parents need to do the range of motion exercises at home with their children two to three times a day for several years.

We recommend daily exercises that help to keep the muscles and joints moving normally. They are called range of motion exercises.

  1. Provide tactile stimulation to provide sensory awareness
  2. Use exercise to develop strength.
  3. Most exercises inclus tasks to increase flexibility, stength and feeling.

If your child is not able to use muscles in the arm and hand, these muscles will stay weak. The arm may not grow normally, and your child may feel tightness in some muscles and joints. A joint that stays in the same position all the time can actually "freeze". Exercises keep the muscles and joints flexible. When the nerves start working better, the muscles and joints will be ready to work.

Surgery for Brachial Plexus Injuries
Surgery may help children who do not recover by the age of 5 months. Nerve surgery is most effective when it is done between the ages of 5 and 12 months and becomes less effective after 1 year. Nevertheless, surgical correction for permanent disability or deformity can be performed in the school-aged child where necessary.

For some children, neurosurgery is not recommended or is not sucessful. In these instances, other procedures can be done to transfer muscles and tendons. This surgery is done by a plastic surgeon when the child is older.

Paying for medical care
The costs for treatment and surgery could overwhelm most families. Families must be able to dedicate long hours to doctor's visits and treatment. Financial support may be available to families in the form of legal compensation.

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