By Andrew Needle
Needle & Ellenberg, P.A.
Brachial plexus injuries in newborns can be catastrophic, life altering, life long, physical impairments for the new born. Brachial plexus injuries (commonly described as a “palsy”) have an incidence of 1.5 cases per 1000 live births and have not declined despite recent advances in obstetrics. Brachial plexus injury is the classic injury following shoulder dystocia. In a shoulder dystocia, the fetal shoulder gets stuck under the mother’s pubic symphysis. Birth weight is believed to be the most important fetal factor for shoulder dystocia. A birth weight higher than 4.5 kg carries a ten-fold risk increase for brachial plexus injury. Gestational diabetes is frequently related to this causing a more massive fetus with a thicker body making transit past the pubic symphysis more difficult. Other maternal risk factors include obesity, a short stature, and a history of prior shoulder dystocia deliveries.
Medical description of the brachial plexus injury goes back to ancient times with the modern description dating to the latter part of the 19th Century. The brachial plexus consists of the nerve roots of spinal cord segments C5, C6, C7, C8, and T1. Brachial plexus injuries usually fall into the two major groups of Erb’s palsy and Klumpke’s palsy. The Erb’s Palsy involves injury to the upper trunk of the brachial plexus (nerve roots C5 through C7). This palsy affects the muscles of the upper arm and causes abnormal positioning of the scapula: “winging”. Muscles of the wrist that are controlled by C6 may also be affected. The Klumpke’s palsy involves lower trunk lesions from nerve roots C7, C8, and T1. This is the more severe of the injuries causing the elbow to become flexed and the forearm into a palm up position with a claw like deformity of the hand. Only a limited sense of the degree of injury can be assessed by physical exam and clinical observation of the baby’s movement limitations; and the full extent of the injury and the specific locations of the lesion causing injury can only be determined by surgical exploration of the brachial plexus at the time of a reparative procedure.
There is a school of thought that all brachial plexus injuries during birth are avoidable and are the product of either excessive traction on the baby’s head by the obstetrician or the use of fundal pressure by labor and delivery nurses which further jams the shoulder into the pubic symphysis in combination with excessive traction. Multiple techniques are available to the obstetrician or mid wife to free the shoulder without exerting undue and excessive traction stretching, pulling, and even avulsing the nerve roots.
As a likely response to the avoidability of the brachial plexus injury and the consequent lawsuits for the deviations from the standard of care by the delivering health care professional, beginning in the late 1990s, medical researchers looking for ways to defend against the claims began developing an alternative causation theory for obstetric brachial plexus injuries. This so-called intrauterine causation theory opines that the intrauterine forces during delivery cause the brachial plexus injury—as opposed to the traction used by the health care provider on the fetal head. It has been traditionally thought that most brachial plexus injuries result from stretching of the nerves of the brachial plexus during delivery.
The competing theories have had implications for parents whose child has been delivered with the injury in the form of greater contest of medical malpractice claims and the need by the claimant’s attorney to “de-bunk” this junk science created to excuse the negligent physician or mid-wife. These cases should only be handled by experienced medical malpractice attorneys fully familiar with the injury and its causes.