What is Erb’s Palsy
Possible Causes of Erb’s Palsy
What can be done to predict the occurrence of Erb’s Palsy
Diagnosis
Treatment
Advice
Birth Injuries & Cerebral Palsy
What is Erb’s Palsy
Erb’s palsy or brachial plexus injury is a condition affecting one or more of the five major nerves to the arm. It frequently occurs as a consequence of a birth injury which can affect the shoulder, arm and hand in varying degrees depending on the severity of the injury.
Typically, a child will show weakness and paralysis of the affected shoulder, arm or hand and may not be able to raise the arm fully or bend the arm at the elbow. The arm can be turned towards the body and the hand turned backwards in what is known as a “waiter’s tip” position. In very severe injuries, affecting the whole arm, there can be a complete Brachial Plexus Injury. Horner’s Syndrome, involving a drooping eye lid, may be associated. Sensory loss in the arm is present, as is often torticollis (when the baby will face their good side but cannot face forward for any length of time).
Possible Causes of Erb’s Palsy
Erb’s palsy can occur when a baby’s shoulder becomes lodged behind the mother’s pubic bone in the birth canal (a complication known as shoulder dystocia) and an excessive degree of force is applied to the child’s head. As the head is pulled away from the trapped shoulder, the brachial plexus nerves become distorted and damaged, with effects that can be severe and permanent.
What can be done to predict the occurrence of Erb’s Palsy
Whilst the occurrence of shoulder dystocia is not predictable, good diagnostic antenatal care can detect whether there are predisposing risk factors present. If tests reveal either that the unborn child is particularly big (“macrosomic”), or that the mother’s pelvis is unusually shaped or small, then the risks of shoulder dystocia occurring are likely to be higher. Maternal and gestational diabetes are also known risk factors for shoulder dystocia, as is maternal obesity. It is known that many diabetic mothers will give birth to larger babies, and the risks of this appear to be increased if maternal blood sugars have not been carefully controlled and monitored throughout the pregnancy. A child shown to be lying in the breech position (buttocks or feet first rather than the more usual “head first” presentation) may also be at higher risk of shoulder dystocia. Similarly, if the mother has experienced a previous birth at which shoulder dystocia occurred, then subsequent pregnancies should be treated as high risk.
If one or more of the above factors are noted before the birth, the treating clinicians could be expected to consider whether it is appropriate to take preventative action, which might include delivering the child a few days or weeks early, or perhaps undertaking a caesarean section. Simply monitoring blood sugars in diabetic mothers, and encouraging good control of these through a well-regulated diet can reduce the risk of shoulder dystocia.
Sometimes, however, shoulder dystocia cannot be predicted before labour has started. A prolonged labour is not necessarily something that can be foreseen, and neither is fetal malpositioning within the birth canal. However, both of these circumstances can lead to shoulder dystocia. More rarely, shoulder dystocia can also be caused by the dispensation of drugs such as Syntocinon, which are used to speed up labour. If any of these factors are present, and shoulder dystocia then develops, prompt and correct action on the part of the treating clinicians is essential. There are recognised clinical techniques with which to facilitate a safe birth when shoulder dystocia has occurred, of which an important component is performance of the McRoberts manoeuvre. For this manoeuvre to be performed safely, there should ideally be at least four members of staff present. Two members of staff should press the mother’s legs backwards, towards her abdomen. This will facilitate opening the pelvis. A third member of staff should then apply pressure to the area over the mother’s pubic bone, thereby helping to release the trapped shoulder. If that is not successful, an internal manoeuvre to rotate the baby’s shoulders or deliver the posterior arm may be undertaken.
In the setting of shoulder dystocia, it is highly inadvisable for the staff present to apply fundal pressure (pressure from the vaginal base), because this can have the effect of wedging the trapped shoulder still further into the pubic symphysis. Similarly, caution should also be adopted when attempting delivery: “one or two good, firm tugs” could have disastrous consequences for the child, and will almost certainly not extricate the trapped shoulder.
Whilst it is not completely unacceptable to use traction in the setting of shoulder dystocia, this is an emergency situation in which a great deal of care and judgment are required. A similar degree of caution should be exercised when considering an instruments delivery (i.e. delivery by forceps or ventouse) in these circumstances.
In general, records suggesting an excessive degree of force adds weight to the claim that the injury was caused by negligence.
Erb’s palsy can also occur due to an injury to the clavicle (the collar bone) in the neonatal period, unrelated to the birth itself.
Diagnosis
Once it has occurred, Erb’s palsy will usually be diagnosed by a paediatrician and an x-ray examination may be requested. The purpose of this diagnostic test is to assess whether there is any damage to the bones in the arm, shoulder and neck. The degree of injury to the nerve structures themselves can be assessed by separate tests, which include an electromyogram (EMG) or a nerve conduction study: these should be able to determine not only the injuries sustained, but also the degree of residual function in the affected nerves.
Treatment
Nerve damage can heal on its own over time, but this is not always the case. If no change occurs over the first 3 – 6 months of life, the paediatrician might consider the possibility of undertaking exploratory surgery; this will reveal the extent of the damage, and it may be possible to obtain an improvement in symptoms. However, this, too, is not a certainty.
Advice
Our team of experienced birth injury solicitors have the compassion, understanding and legal skills to take you through the claims process. If you would like to consider a potential claim with us, please make an online enquiry or request a callback using the links above. We will be happy to help you.
