What is Erb's Palsy?
- What is Erb's Palsy? Is this the same as a shoulder dystocia? Brachial Plexus injury?
- CAUSES OF BRACHIAL PLEXUS INJURY
- RISK FACTORS DURING PREGNANCY
- WARNING SIGNS DURING LABOR
- TREATMENT
- THE FUTURE
What is Erb's Palsy? Is this the same as a shoulder dystocia? Brachial Plexus injury?
The brachial plexus is a group of nerves that run from the spinal cord through the arm to the wrist and hand. These nerves are responsible for movement and sensation in the shoulder, arm, wrist, hand and fingers. Injury to the plexus can cause varying degrees of paralysis to the affected arm. These injuries can limit one's ability to perform various movements (reaching over-head, grasping objects, straightening the arm, etc.) depending on the degree of the injury and the nerves involved. A severe injury may cause complete paralysis and disfiguration, especially if left untreated.
CAUSES OF BRACHIAL PLEXUS INJURY
Stretching of the head away from the shoulder or similar trauma in the area of the brachial plexus can cause damage to the nerves. The most common type of injury is an obstetrical brachial plexus injury. This injury occurs when one or both of the baby's shoulders become impacted or stuck on the mother's pubic bone during delivery. This condition is known as Shoulder Dystocia. Frequently, shoulder dystocia occurs during delivery of large babies, however many injuries occur in average and low birth weight babies. Approximately 3 out of every 1000 children will be born with a brachial plexus injury. Brachial plexus injuries are more common than Down's Syndrome or Muscular Dystrophy. It may not be possible to predict when a shoulder dystocia will happen, but being aware of the risk factors and warning signs could allow the obstetrical team to anticipate a problem and prepare for a safe delivery.
RISK FACTORS DURING PREGNANCY
Some conditions which may be contributing factors in a shoulder dystocia birth are as follows:
- Gestational diabetes
- Advanced maternal age
- Multiple pregnancies
- Excessive maternal weight gain (over 35 lb) or obesity
- Previous delivery of large infant with or without complications
- Previous delivery of infant with brachial plexus injury or broken clavicle (collar bone)
- Previous shoulder dystocia
- Post-term deliveries (overdue babies - past 40 weeks gestation)
- Stalled Labor
WARNING SIGNS DURING LABOR
Labor is monitored carefully, since there are some signals during labor that can alert the doctor or midwife that a shoulder dystocia delivery may be likely. Several maneuvers are available for releasing the trapped shoulder when the situation arises. In some cases a cesarean section will be performed to deliver the baby safely.
These warning signs include:
- Failure of labor to progress - often pitocin is used to make contractions more effective
- Prolonged second stage of labor
- Cephalopelvic disproportion - baby's head is too large for mother's pelvis
- Macrosomia - large baby
- Need for forceps or vacuum extractor
TREATMENT
Babies are usually diagnosed with a brachial plexus injury within the first 24 hours after birth. Often it is obvious immediately after birth because the baby will actively move its arms and legs. An arm with a brachial plexus injury will move very little or not at all.
The baby should be evaluated soon after birth and followed by a doctor or medical team experienced in treating brachial plexus injury. Evaluation should occur regardless of function at the time of injury. It is critical that the parents be taught proper care of the infant and exercises to help in recovery of function of the arm.
In many facilities, a team of specialists will evaluate at regular intervals to be sure that all aspects of the injury are addressed. A brachial plexus team may consist of a combination of plastic surgeons, orthopedic surgeons, neurologists, reconstructive micro surgeons, rehabilitation physicians, occupational therapists, physical therapists and behavioral therapists among others.
- Early treatment should include range of motion exercises to help keep the baby's muscles toned and flexible while waiting for the nerves to heal. The parents can be taught how to properly exercise the arm beginning at about two weeks of age. Stretching and moving the arm, wrist, hand and fingers is important to keep the muscles, tendons and ligaments from shortening and causing a permanent contracture (tightening) of the joints and muscles. Contracture will further limit the child's mobility and recovery of function.
- Physical and occupational therapy is needed to help strengthen the arm and help with coordination and mobility. It may also be necessary to help teach the child alternate methods for day-to-day functions such as brushing their hair or dressing themselves. Various types of splinting, massage therapy, pool therapy and electrical stimulation may be used as well.
- Surgery is needed in some cases to repair injured nerves, reposition muscles or correct bone deformities. Many primary surgeries (nerve repair) are done as early as 3 or 4 months of age to maximize the potential for recovery. Optimal results may not be possible as the child gets older, so it is important to have a surgical consultation early. Even with surgical intervention, a complete recovery may not be possible. The main goal of surgery is to improve function as much as possible in the affected arm.
THE FUTURE
If you are expecting or plan to become pregnant, talk to your obstetrician or midwife about shoulder dystocia and brachial plexus injury. Ask about their experience handling this complication and the hospital protocol that would be followed if shoulder dystocia does occur. Shoulder dystocial drills are practiced by obstetrical staff in some birthing facilities to help prepare for an emergency.
If you have given birth to a child who suffered a brachial plexus injury or have encountered a shoulder dystocia or other trauma during a previous birth, your chances of delivering a child with a brachial plexus injury will be significantly higher. Cesarean delivery may be necessary to prevent injury during a subsequent delivery. Talk to your practitioner about which method of delivery is safest for you and your baby. Your history from previous pregnancies should be carefully reviewed to determine your risk for complications. Your practitioner should be willing to let you take an active role in the decision-making process during pregnancy, labor and delivery.
