Is Erb’s palsy associated with medical error during labor and delivery?
Erb’s palsy (also known as brachial palsy, brachial plexus birth injury, Erb-Duchenne Palsy, Dejerine-Kumpke Palsy) is the paralysis of the upper brachial plexus. The brachial plexus is a large network of nerves that send signals from the spine to the shoulder/arm/hand (diagram).
Delicate nerves, potential for serious injury
If these nerves are damaged, it can cause the arm to be paralyzed, lack of sensation, lack of muscle control in the arm/hand/wrist. The American Academy of Orthopaedic Surgeons (AAOS) reports that Erb’s Palsy occurs in 1-2 out of every 1,000 babies.
In infants, injury to the brachial plexus usually occurs during delivery when the shoulder is stretched as it passes through the birth canal. Shoulder dystocia is when a baby’s shoulders get stuck during vaginal delivery, which can damage the brachial plexus nerves. Brachial plexus injuries can occur during difficult deliveries:
- Infant’s head and neck are pulled to the side as the shoulders pass
- During head first delivery, pulling on the shoulders
- During breech birth (feet first) delivery, pressure exerted on baby’s raised arms
There are risk factors that doctors can be on the lookout for in order to prevent difficult pregnancies:
- Determine if newborn is larger than average
- Determine if fetus is oriented feet first signaling a breech delivery
- Difficulty delivering the baby’s shoulders (dystocia)
Types of Brachial Plexus Injuries:
There are four types of brachial plexus injuries. The most severe is avulsion, where the nerve is actually torn from the spine. Rupture is when the nerve is torn at an area other than the spine. Neuroma is where the nerve tears and heals, but the scar tissue presses on the injured nerve so it cannot send signals. Neuropraxia/stretch is where the nerve is only damaged, not torn. The least severe type of brachial plexus birth injury (neuropraxia) is the most common.
Prognosis for children who sustain a Brachial Plexus Injury:
The prognosis is dependent on the type of brachial plexus injury. For rupture and avulsion injuries, the only treatment is timely surgery; otherwise, there is no potential for recovery. In neuropraxia cases, many children spontaneously recover with an almost complete return of function to the shoulder/arm/hand.
Preventing Brachial Plexus Injuries During Labor & Delivery:
The presence of injury does not necessarily mean negligence occurred, but Erb’s palsy occurring in patients who had shoulder dystocia is an indicator that medical malpractice may have occurred. It has been acknowledged that shoulder dystocia may be underreported. Because of this under-reporting in shoulder injuries sustained during delivery, Erb’s palsy cases can be difficult to show causation because there are cases where Erb’s palsy occurs with no shoulder dystocia.
Evaluating brachial plexus cases from a liability perspective
However, the failure to undertake appropriate and recognized maneuvers in order to effectuate the delivery of the shoulders, arm, and body of a newborn, along with other deviations of the standard of care such as exerting excessive force, can cause the infant to suffer serious and debilitating injuries including brachial plexus palsy. For example, cesarean delivery is used more often when doctors suspect the delivery may be difficult. In these cases, cesarean delivery is a safer option for both mother and child. If the baby was in breech position or if labor was prolonged, cesarean delivery may have been a more appropriate and safer delivery. Again, shoulder dystocia and Erb’s palsy can be indicators that the health care providers’ actions have deviated from the appropriate standard of care.
- NINDS: Brachial Plexus Injuries Information Page
- NINDS: Erb-Duchenne and Dejerine-Klumpke Palsies Information Page
- Medline: Brachial palsy in newborns
- PubMed Health: Brachial palsy in newborns
- AAOS: Erb’s Palsy
- University of Maryland Medical Center: Brachial palsy in newborns – overview
- American Journal of Periontology: Shoulder dystocia recognition – differences in neonatal risks for injury
- March of Dimes: Pregnancy complications – Shoulder Dystocia
- M.H. Beall et al., Objective Definition of Shoulder Dystocia—A Prospective Evaluation, 179 AM. J. OBSTET. GYNECOL. 934-37 (1998).