BIRTH-RELATED BRACHIAL PLEXUS INJURIES
Each year, up to 8 out of every 1000 babies suffers a brachial plexus injury at birth. In the vast majority of these babies, traumatic stretching of the nerves during the delivery process is the cause of the brachial plexus injury.
The brachial plexus is a complex set of important nerves that exit the spinal cord at the level of the neck, extend through the shoulder into the armpit, down the arm and into the fingertips. The brachial plexus nerve network covers the C5-T1 region of the neck. There is a brachial plexus on each side of the neck.
A baby's brachial plexus is especially vulnerable to injury. During delivery, if the doctor or midwife delivering the baby pulls too hard on the baby's head or neck, the baby's brachial plexus is traumatized and may be damaged.
A brachial plexus injury is usually first noticed in the delivery room or hospital nursery immediately after birth - usually because the baby isn't moving her arm or has decreased movement or tone in her arm. The diagnosis of a brachial plexus injury can be confirmed by imaging studies such as an MRI, by electronic studies such as an EMG, or during exploratory surgery on the brachial plexus itself.
Brachial plexus injuries take different forms and differ in severity. A praxis is a mild brachial plexus injury in which the nerve hasn't been torn. In cases of praxis, the injury heals on its own, with improvement showing within three months of the injury. This mild brachial plexus injury occurs when the brachial plexus is stretched from its normal position. Mild brachial plexus injuries are often referred to as "transient," meaning that they heal in a very short period of time without any medical or surgical treatment.
A brachial plexus injury may also occur as a result of a "rupture." With a rupture, the nerve has been torn completely or partially somewhere along its length, but the nerve's root is still intact in the spinal cord. This is a more serious brachial plexus injury and is less likely to heal on its own.
A "neuroma" is a "footprint" of a rupture. A neuroma exists after a brachial plexus injury has attempted to heal itself. A neuroma is scar tissue that has developed around the damaged nerve. This scar tissue puts pressure on the injured nerve, and thereby blocks signals from the nerve to the muscle.
Finally, the most severe type of brachial plexus injury is an "avulsion." An avulsion occurs when the root of the nerve is torn completely from its origin in the spinal cord. An avulsion usually requires the most amount of force to occur. Avulsions are best diagnosed during a primary repair surgery or by MRI.
Avulsions result in a complete loss of function that does not improve over time. Ideally, brachial plexus injuries that occur as a result of an avulsion should be treated with surgery before the baby's first birthday. If a brachial plexus injury does not heal by the baby's first birthday, it is more likely to be permanent and to require some type medical and/or surgical treatment.
Brachial plexus injuries are usually classified as "Erb's palsy," "Klumpke's palsy," or "Horner's syndrome." Erb's palsy is the more common form of the brachial plexus injury and involves complete or partial paralysis of the muscles of the upper arm due to a brachial plexus injury at the level of the fifth and sixth cervical nerves (C-5, C-6). Erb's palsy is also known as "Duchenne-Erb paralysis." Children with Erb's palsy are unable to raise their injured arms completely above their heads or touch their lower backs with their injured arms. They have difficulty with activities of everyday life such as combing their hair or tucking a shirt into their trousers.
"Klumpke's palsy" is another type of brachial plexus injury in which there is complete or partial paralysis of the muscles of the forearm and hand due to an injury to the roots of eighth cervical and first thoracic roots or the lower part of the brachial plexus (C8-T1). A Klumpke's palsy often includes a "waiter's tip" deformity of the hand which results in the baby holding his hand in a backwards position at rest. Children with Klumpke's palsy have trouble rotating their injured hand from palm down to palm up and with finger strength and dexterity. They have difficulty with activities of every day life such as bringing their injured hand up to feed themselves with a fork or a spoon, brushing their teeth or putting in a contact lens.
Babies with brachial plexus injuries may also be diagnosed with "Horner's syndrome," a combination of facial symptoms including drooping of the upper eyelid on the same side as the Erb's palsy or Klumpke's palsy, with constriction of the pupil of that eye, lack of sweating and flushing of the affected side of the face.
Severe birth-related brachial plexus injuries may also, uncommonly, involve problems with breathing, speaking, swallowing, gait or balance due to injuries to nerves going to those areas.
BIRTH-RELATED BRACHIAL PLEXUS INJURIES AND SHOULDER DYSTOCIA
The vast majority of babies born with brachial plexus injuries have deliveries complicated by shoulder dystocia. Shoulder dystocia occurs when the baby's head delivers but the shoulders don't easily follow. Deliveries that are complicated by shoulder dystocia usually are described as the baby getting "stuck" - a function of the baby's shoulder being unable to clear the mother's pubic bone during the final phase of the delivery.
What doctors call the "turtle sign" occurs when the baby's head first appears but then retracts back inside the mother. The turtle sign is a signal to the doctor or midwife that shoulder dystocia has developed.
Shoulder dystocia is a medical emergency because of the potential for compression of the umbilical cord and resulting oxygen deprivation to the baby. However, shoulder dystocia is a known complication of delivery. It is not uncommon. Doctors and midwives learn early in their training (1) how to avoid a shoulder dystocia from occurring; (2) how to diagnose shoulder dystocia as soon as it occurs; and (3) how to effectively deal with shoulder dystocia once the diagnosis is made.
The doctor or midwife can avoid shoulder dystocia by taking a careful history from the mother in the early stages of her pregnancy. It's important to know whether either parent was a very large baby. It's also important to know, if the mother has had prior pregnancies, whether any of those births were complicated by very large babies (macrosomia), shoulder dystocia, a fractured collar bone (clavicles), or a broken arm.
Shoulder dystocia can also be avoided by the doctor or the midwife carefully monitoring the mother's weight gain during her pregnancy. A big weight gain during pregnancy often means a big baby which increases the risk of shoulder dystocia.
The size of your baby can be estimated before birth by ultrasonography. Ultrasounds are safe and noninvasive. Medical technology equips ultrasound machines with computers that measure your baby's body parts, including head size, abdominal circumference, leg length, and compares those measurements to a data bank. From that calculation, the computer can accurately predict whether your baby is large for gestational age and in what percentile it ranks compared to babies of the same gestational age.
Babies that measure in the 90th percentile for size have a very high risk for shoulder dystocia. In those cases, the doctor or midwife should discuss with you the option of a cesarean delivery in order to avoid the risk of shoulder dystocia and brachial plexus injury.
Shoulder dystocia can also be avoided in a gestational diabetes pregnancy. A mother who is diagnosed with diabetes during her pregnancy has a metabolic disorder that may lead to a big baby, or a baby with a particularly broad shoulder girth and chest. Through counseling with a dietician, vigilant blood sugar monitoring, and in severe cases, insulin prescription, gestational diabetes can be well-controlled with little effect on the baby.
Sometimes, shoulder dystocia can't be predicted. When it does occur, there are many accepted maneuvers used to safely dislodge the baby's stuck shoulder so that the delivery occurs gently and without injury to the baby. These maneuvers are reasonably safe for both the mother and the baby, and literally take seconds to accomplish.
One of the most effective maneuvers employed in a shoulder dystocia setting is the McRobert's maneuver - done usually with the help of a nurse or family member. The McRobert's maneuver involves removing the mother's legs from the stirrups and pushing her knees up to her chest. The McRobert's maneuver opens the pelvic diameter and is intended to widen the birth passage.
Another maneuver is called suprapubic pressure. This maneuver may be done by the doctor, midwife or nurse and involves pushing on the mother's belly just above the pubic bone. Sometimes a nurse will use a stool or climb on the delivery table to apply as much suprapubic pressure as possible. Suprapubic pressure is intended to compress the baby's shoulder girdle in order to pop it underneath the pubic bone. This maneuver is often utilized at the same time as the McRobert's maneuver.
Another effective maneuver is the Wood's screw maneuver, where the doctor or midwife reaches into the birth canal and rotates the baby's shoulder away from the pubic bone. This maneuver is intending to rotate the diagonal axis of the baby to align it with the diagonal axis of the mother's pelvis, and providing more space for the baby to move.
Alternatively, the doctor or midwife may try to deliver the baby's arm opposite to the stuck shoulder (called the "posterior arm"), or the doctor may intentionally fracture the baby's clavicle (collar bone) to decrease the size of the shoulder diameter. Shoulder dystocia often includes a very large episiotomy (surgical cut in the vaginal tissue) in order to provide more room to perform all of the various maneuvers.
It is very important to note that none of the above described maneuvers, if properly done, should result in a brachial plexus injury. If the doctor or midwife, when confronted with shoulder dystocia, panics and pulls hard on the baby's head while the baby's shoulder is stuck under the pubic bone, the brachial plexus nerves in the baby's neck may be injured. This is called "excessive traction," and relates to the amount of pulling and stretching forces exerted on the baby's brachial plexus during delivery.
RISK FACTORS FOR SHOULDER DYSTOCIA AND BRACHIAL PLEXUS INJURIES
Shoulder dystocia may occur in normal, uncomplicated pregnancies. However, certain factors suggest that some deliveries face a higher risk of shoulder dystocia than others. Some known risk factors for shoulder dystocia and brachial plexus injuries include:
- Fetal macrosomia - a very large baby weighing over 8 lbs. 14 oz. at birth;
- Gestational (maternal) diabetes;
- Obesity in the mother;
- Pregnancy that exceeds beyond 40 weeks;
- Short maternal stature;
- Contracted or flat pelvis;
- Maternal weight gain of 35 lbs. or more;
- History of shoulder dystocia in previous deliveries;
- Forceps or vacuum-assisted delivery.
TREATMENT OPTIONS FOR BIRTH-RELATED BRACHIAL PLEXUS INJURIES
Most babies born with brachial plexus injuries recover spontaneously without any medical or surgical treatment. Those babies whose brachial plexus injuries do not heal on their own often benefit from physical and occupational therapy.
Some babies do not respond to therapy and require surgery to repair their brachial plexus injuries. Current research recommends primary repair of a brachial plexus injury within 5 to 12 months from birth. The primary repair surgery has been less effective in children over the age of one year.
Even after surgery, children with brachial plexus injuries require long-term occupational and physical therapy, and home daily exercises to maintain function and strength. Some children require additional surgeries and therapy as they grow older to treat muscle contractures, shoulder dislocations and other secondary problems that occur as a result of the permanent brachial plexus injury.
Unfortunately, notwithstanding the best medical and surgical treatment, permanent deficits may remain as a consequence of the child's brachial plexus injury. These permanent injuries include partial or total loss of arm or hand movements, reduced arm size and strength, facial paralysis, chronic shoulder dislocation, drooping of the shoulder or chest, winging of the scapula (shoulder blade), and the emotional and psychological impact of being able to fully participate in sports, jobs, and other physical activity.
WHAT CAN FAMILY MEMBERS DO?
Knowledge is power. You should educate yourself about all of your risk factors for shoulder dystocia. If you're pregnant and suspect that because you have gestational diabetes or some other risk factor for shoulder dystocia, you should talk to your doctor or midwife about the risk of shoulder dystocia and the option of delivery by cesarean section.
If you have a prior history of shoulder dystocia and are pregnant again, it is very important to remind your obstetrician or midwife of your previous shoulder dystocia. Obstetricians and midwives should fully disclose the increased risk of repeat shoulder dystocia to women who have a previous history, and should offer those women delivery by cesarean section.
If your baby is diagnosed with Erb's palsy or a brachial plexus injury at birth, you should immediately obtain your medical records from your obstetrician or midwife, and from the hospital where your baby was born. It is important for you as parents to understand what happened at the delivery in order to provide a complete and accurate history to your baby's doctors and therapists.
The internet has excellent research resources to help you understand what happened to your child and to put you in contact with other families and health care professionals who want to share information concerning what medical and surgical treatment options are available to you. Here are just a few:
www.brachialplexuspalsyfoundation.org
http://www.wikipedia.org/wiki/Erb's_palsy
If your baby's brachial plexus injury does not heal within the first year of life, there is a very real likelihood that the injury is permanent and will require ongoing evaluation and care. In order to maximize your child's recovery and limit the disability, it is very important that you stay in close contact with your pediatrician, pediatric orthopedic and neurosurgeon, and occupational and physical therapists.
It is also very important that you follow the recommendations of your therapists concerning outpatient and home exercise programs. Children with brachial plexus injuries who are not actively involved in formal, structured daily therapy programs are at increased risk for loss of function in the injured arm and painful muscle contractures.
SHOULDER DYSTOCIA, BRACHIAL PLEXUS INJURIES AND THE LAW
There are two reasons why a birth-related brachial plexus injury may be the foundation for a meritorious lawsuit. The first reason is that sometimes the baby should have been delivered by cesarean section and not by vaginal birth due to the mother's known risk factors. There may also be warning signs during labor that should prompt serious consideration of a cesarean delivery: delay of descent or dilation, arrest of descent or dilation, a change in the baby's heart rate (bradycardia or tachycardia), or cephalopelvic disproportion (CPD).
The second reason is that often, evidence surrounding the delivery may show that the doctor or midwife negligently managed the shoulder dystocia by failing to use careful maneuvers to dislodge the stuck shoulder or by using excessive force during the delivery. Evidence of excessive force on the newborn may include extensive petechiae, bruising, abrasions, swelling or malformation of the baby's head, neck, chest, back or arms.
Medical negligence cases involving brachial plexus injuries usually involve one or more of the following issues:
- Failure to diagnose and treat gestational diabetes;
- Failure to perform routine, late-trimester ultrasounds to estimate fetal size and weight;
- Failure to diagnose a small or abnormally shaped maternal pelvis;
- Failure to appreciate fetal macrosomia or a very large baby;
- Failure to inform parents of the dangers and risks inherent in vaginally delivering a very large baby;
- Failure to take a complete an accurate history of previous, difficult or complicated deliveries;
- Failing to inform a mother with a previous history of shoulder dystocia about the risks of recurrence;
- Failure to offer the mother the option of delivery by a cesarean section (informed consent);
- Failure to perform appropriate delivery techniques to manage shoulder dystocia;
- Applying forceps or a vacuum extractor prematurely or in an attempt to dislodge a stuck shoulder;
- Applying inappropriate delivery techniques to manage shoulder dystocia;
- Applying unnecessary and excessive force during the delivery.
SHOULDER DYSTOCIA, BIRTH-RELATED BRACHIAL PLEXUS INJURIES AND THE BURDEN OF PROOF
In general, in order to prove a meritorious medical malpractice case, a plaintiff must establish that the defendant doctor or midwife failed to exercise the degree of care, skill, and diligence exercised by reasonably careful, skillful, and prudent practitioners acting under the same or similar circumstances. In the case of brachial plexus injury, this may require a showing that a competent doctor or midwife (1) should have anticipated the shoulder dystocia, (2) should have employed safe maneuvers that would have prevented the brachial plexus injury, and (3) should have avoided the excessive force in the delivery.
Most states, including Ohio, require the plaintiff to produce expert testimony to prove the standard of care and the violation of the standard of care. This medical testimony is usually offered by a qualified, licensed obstetrician/gynecologist or certified nurse midwife.
The plaintiff must also prove that as a result of the negligence of the doctor or midwife, the plaintiff suffered damages. In the case of a brachial plexus injury, damages can include medical and surgical expenses for treatment, pain and suffering, future earnings, and any other economic and non-economic damages that the plaintiff might suffer.
Most states, including Ohio, require the plaintiff to produce expert testimony on the nature and extent of the injury, likely necessary surgeries or therapies, and the permanency of the injury. It is not unusual for a plaintiff in a brachial plexus injury case to offer the expert testimony of pediatric neurologists, pediatric neurosurgeons or orthopedic surgeons, occupational and physical therapists, and vocational rehabilitation specialists.
The statute of limitations limits the amount of time a person may have to file a lawsuit. Each state has its own statutes of limitations. In Ohio, babies with permanent brachial plexus injuries have until their 19th birthday to file a lawsuit related to their injuries.
Parents also have causes of action related to their child's brachial plexus injury. Parents' statutes of limitations may be different from the child's. In Ohio, parents are limited to one year from the date of the injured baby's birth. Therefore, it is extremely important that parents fully investigate their rights under the law before their baby's first birthday.
Contact Becker & Mishkind at 1-800-826-2433 for a free case evaluation by compassionate and capable attorneys.
