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Brachial plexus injury causation in newborns debated

Brachial plexus injury in newborns is commonly ascribed to the occurrence of head rotation with entrapment of the shoulders and subsequent downward traction by the accoucheur on the fetal head, resulting in avulsion of the brachial plexus nerve roots with permanent paralysis. In brachial plexus injury cases, plaintiff attorneys usually contend that damage to the brachial plexus is always caused by negligence of the birth attendant. However, a review of current literature reveals evidence that additional etiologies may underpin brachial plexus injury and raises questions regarding the level of responsibility of the birth attendant in connection with the injury.

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Articles of Interest

Birth brachial plexus palsy: a race against time

Birth brachial plexus palsy continues to prove a burden for developed and developing countries due to the involvement of multiple risk factors.

Brachial Plexus and Erb’s Palsy – The Perils of Childbirth

However, these injuries are almost always preventable. Doctors are expected to recognize shoulder dystocia and either maneuver the child without causing injury, or change course and pursue an alternate delivery method (generally a C-section). Not to do so results in great pain and suffering to both the parent and the child, as well as the potential for a lifetime of physical difficulty.

Brachial Plexus Injury in the Newborn

Brachial plexus palsy in the neonate is classified according to the anatomic location and type of injury. Upper plexus lesions are observed most frequently. The overall rate of perinatal brachial plexus palsy (PBPP) has remained stable for the last 3 decades, although risk factors for the injury are well described. The true rate of full recovery after PBPP remains controversial.

Brachial Plexus Palsy: Pathophysiology, Diagnosis, and Management

Brachial plexus injuries were first described and documented in the late 1700s by William Smellie, a Scottish obstetrician. It wasn’t until the late 1800s, however, that a French neurologist, Guillaume Duchenne, coined the term obstetric palsy and described the mechanism for brachial plexus injury.

Brachial Plexus: What You Need to Know About This Childbirth Complication

It is very rare for newborns to be injured during childbirth. However, each year during the delivery process, about one out of 1,000 babies sustain injury to a network of nerves in their neck called the brachial plexus. The brachial plexus carries signals for feeling and movement from the spinal cord to the shoulder, arm and hand. When those nerves are damaged, the function of the entire arm can be seriously impacted.

Erb's Palsy

Erb's palsy or Erb–Duchenne palsy is a form of obstetric brachial plexus palsy. It occurs when there's an injury to the brachial plexus, specifically the upper brachial plexus at birth. The injury can either stretch, rupture or avulse the roots of the plexus from the spinal cord. It is the most common birth-related brachial plexus injury (50- 60%).

Erb’s palsies

Erb’s palsies are injuries of the brachial plexus (the network of nerves that provides movement and sensory function to the whole upper limb) that occur at birth due to traction applied in order to provide the birth of a child that got stuck in the delivery canal. In the majority of these cases, the baby is overweight (macrosomic baby) and their upper shoulder of the baby gets blocked by the mother’s pelvic bone during the passage in the birth canal. In order to take the baby out of the canal, the doctors have to apply traction on the baby’s head and this causes the forceful widening of the angle between the neck and the shoulder, resulting in overstretching of the ipsilateral brachial plexus.

Neonatal Brachial Plexus Palsy and Shoulder Dystocia

Though rare, it constitutes a very large category of litigation in obstetrics. Often, this injury results from a delivery complication known as shoulder dystocia, when the baby’s anterior shoulder gets caught above the mother’s pubic bone. This emergency represents a huge risk of morbidity for both the mother and fetus and is frequently associated with permanent birth-related injuries, including NBPP.

Neonatal brachial plexus palsy: a permanent challenge

Neonatal brachial plexus palsy (NBBP) is an ancient disease. There are references to this condition back to the the Old Testament, and Galen’s histories. The first scientific description was made by the Scottish obstetrician William Smellie, in 17681. The classical neurologic description of the upper brachial plexus lesion was done by Duchenne in 1872 and Erb in 18742.

Obstetric brachial plexus injury

Obstetric brachial plexus injury (OBPI), also known as birth brachial plexus injury (BBPI), is unfortunately a rather common injury in newborn children. Incidence varies between 0.15 and 3 per 1000 live births in various series and countries. Although spontaneous recovery is known, there is a large subset which does not recover and needs primary or secondary surgical intervention.

Obstetric Brachial Plexus Palsy (OBPP) Early Information and Advice A Guide for Parents

Obstetric Brachial Plexus Palsy (OBPP) or Erb’s Palsy is an injury caused by stretching of the network or nerves that run between the baby’s neck and the shoulder during a delivery with a large baby, breech presentation or a prolonged labour.

Obstetric Brachial Plexus Palsy of Newborns and Infants: Functional Outcomes after Rehabilitation by Their Own Parents

The OPBP are potentially disabling lesions whose early management is essential for a better functional prognosis. In a context of precariousness and/or inadequacy of the health system, the early and regularly monitored involvement of parents in the early functional rehabilitation of their children is a promising alternative with satisfactory functional results comparable to those of the literature.

Obstetric brachial plexus palsy: A birth injury not explained by the known risk factors

Risk factors are shoulder dystocia, macrosomy, diabetes, vacuum extraction and forceps delivery. The predictive power of these variables is poor.

Obstetric brachial plexus palsy: reviewing the literature comparing the results of primary versus secondary surgery

Obstetric brachial plexus injuries (OBPP) are a relatively common stretch injury of the brachial plexus that occurs during delivery. Roughly 30 % of patients will not recover completely and will need a surgical repair. Two main treatment strategies have been used: primary surgery, consisting in exploring and reconstructing the affected portions of the brachial plexus within the first few months of the patient’s life, and secondary procedures that include tendon or muscle transfers, osteotomies, and other orthopedic techniques.

Obstetrical Brachial Plexus Palsy

C5-C6 obstetrical brachial plexus palsies usually present spontaneous recovery in high percentage. However, in some cases spontaneous recovery may not occur or may be incomplete. Thus, surgery should be offered to these little patients in order to achieve a valid functional restoration; the correct timing is when the baby is between 6 to 8 months, yet many children may be late referrals.

The evaluation and management of neonatal brachial plexus palsy

Neonatal brachial plexus palsy presents at birth and can be a debilitating condition with long-term consequences. Presentation at birth depends on the extent of nerve injury, and can vary from transient weakness to global paresis, with active range of motion affected.

The natural history and management of brachial plexus birth palsy

Brachial plexus birth palsy (BPBP) is an upper extremity paralysis that occurs due to traction injury of the brachial plexus during childbirth. Approximately 20 % of children with brachial plexus birth palsy will have residual neurologic deficits. These permanent and significant impacts on upper limb function continue to spur interest in optimizing the management of a problem with a highly variable natural history. BPBP is generally diagnosed on clinical examination and does not typically require cross-sectional imaging.

The natural history and management of brachial plexus birth palsy

The key exam finding is return of antigravity elbow flexion. Both microsurgery and secondary shoulder and elbow procedures are effective and can substantially improve function.

The “Cookie Test” for brachial plexus birth injury

The “Cookie Test” can be used to assess biceps function at 9 months in infants with brachial plexus birth injury and aid in surgical decision-making. If the child can bring the cookie to the mouth without bending the neck forward more than 45 degrees, she or he passes the “Cookie Test.” If the child does not pass the cookie test, surgical repair of the brachial plexus should be considered.

Resources

United Brachial Plexus Network

The United Brachial Plexus Network strives to inform, support, and unite families and those concerned with brachial plexus injuries, its treatment and prevention worldwide.

Midwest Brachial Plexus Network

To inform. educate about prevention and treatment and provide support those touched by birth injuries.