Risk Factors: Plexus Birth Injury

Brachial Plexus Injury From Shoulder Dystocia

This article describes what risk factors contribute to traumatic birth injuries to the brachial plexus nerves from shoulder dystocia during birth and other causes.

In recent times, there have been increasing instances of babies suffering from brachial plexus injury during birth. Although most such birth injuries get corrected with time, some may be permanent and can leave your child with a disability for life.

A brachial plexus injury is usually a consequence of a birthing emergency known as shoulder dystocia, where the baby’s shoulders get stuck behind the mother’s pelvis and cannot be delivered without intervention. In trying various maneuvers to resolve the shoulder dystocia so as to deliver the baby, the brachial plexus nerves of the fetus can get stretched and damaged.

Depending on the severity of such damage, different types of brachial plexus injuries such as Erb’s palsy, Klumpke’s palsy, and bracial palsy can occur. All the sensations in the baby’s arm; starting from the shoulder, to the arm, to the wrist and the hand, are controlled by the brachial plexus nerves. Thus, a brachial plexus injury can affect the movement of the arm and may even result in permanent paralysis of the entire arm.

All brachial plexus injuries are not necessarily seen after a shoulder dystocia. Many such injuries can occur even if no shoulder dystocia occurred while delivery. However, since a majority of these injuries do arise from shoulder dystocia; here’s a look at some risk factors that will help you to determine whether or not brachial plexus injury will occur from shoulder dystocia.

Prior births with shoulder dystocia: If there is a history of shoulder dystocia during one or more previous deliveries, then there are higher chances of shoulder dystocia during subsequent deliveries. This does increase the risk of brachial plexus injury to the fetus, even if previous dystocias were resolved successfully without injury.

Prior difficult deliveries: If a woman has had difficult vaginal deliveries in the past, which have ended up with a cesarean delivery, then there are chances that a shoulder dystocia did occur but was not diagnosed properly. In such cases too there is an increased risk of shoulder dystocia and birth injuries. However, since most deliveries after one c-section are also cesareans, the risk of brachial plexus injury is reduced greatly.

Prior births with macrosomic fetus: If there is a history of delivering macrosomic babies (large babies with fetal weight greater than 4500 grams), then the risk of shoulder dystocia and brachial plexus injury is increased significantly. And since majority of brachial plexus injuries are seen with macrosomic fetuses, it is advisable to consult your gynecologist about this increased risk if you are carrying another large baby.

Induction of labor: If labor needs to be induced, different types of labor inducing drugs are used to hasten the labor. Medical studies have shown that such drugs are associated with a higher risk of shoulder dystocia during birth. One theory is that when labor is induced, the fetus does not descend naturally into the birthing canal but does so in an awkward position, which results in shoulder dystocia. And since induction of labor increases the risk of shoulder dystocia, the baby’s risk for brachial plexus injury is also increased.

Prolonged second stage of labor: When the second stage of labor does not progress in a timely fashion but is prolonged, the chances of brachial plexus injury may increase. This is because forceps and vacuum extractors may be used to hasten the second stage of labor. The use of such tools, especially for more than 20 minutes, has shown to increase risk of shoulder dystocia, which in turn increases risk of brachial plexus injury to the fetus.

Increased glucose in urine: If there is an increased content of glucose in the urine of a pregnant woman, this could be sign that the woman has developed gestational diabetes. If such is indeed the case, then the risk for brachial plexus injury is heightened because shoulder dystocia risk is increased.All the above are simply risk factors that may increase chances of brachial plexus injury from shoulder dystocia. But, many cases of erb’s palsy and brachial palsy are seen in babies that did not exhibit any of these risk factors. Thus, all in all, it is very difficult to predict whether a shoulder dystocia will definitely result in a brachial plexus injury or not.

However, since majority of such injuries occur predominantly after a shoulder dystocia, it is best to concentrate on recognizing and minimizing the risk factors for shoulder dystocia. Some of these risk factors are:

• Maternal age
• Maternal obesity
• Diabetes
• Macrosomic fetus
• Post term pregnancy

Thus, if your doctor has studied your complete medical and birthing history, predicting a shoulder dystocia is indeed possible. Once predicted, it is possible to prevent a shoulder dystocia by opting for a cesarean, which also lowers the risk of brachial plexus injury considerably.If you have any concerns regarding shoulder dystocia and brachial plexus injury, make sure you discuss your concerns with your doctor.

If you have reason to believe that your doctor did not take your concerns seriously and if any type of brachial plexus injury was a direct result of a medical mistake, you should get in touch with an Erb’s palsy lawyer to know if you have valid grounds for an Erb’s palsy lawsuit and about compensation due to you.

Obstetric Brachial Plexus Injury

Factors Increasing Risk of Shoulder Dystocia

What factors must doctors and expecting parents consider when assessing the risk of an obstetric brachial plexus injury?

Brachial Plexus Birth Injuries (OBPI)
Brachial plexus birth injuries are a regular part of pediatric practice both in the delivery room and newborn surgery. Unlike other birth injuries of the nervous system, their prognosis is better.

The incidence of birth injury of the plexus has been reported as between 0.13 and 3.6 cases per 1,000 live births. Recent, prospective studies report incidences clustering around 1 per 1,000 live births or somewhat lower if only severe injuries are counted. Many have expressed the hope that improved obstetric techniques, including the more frequent use of caesarian section, might lower this figure but recent data have not substantiated this. Elective cesarean section provides some protection but does not completely eliminate the risk of brachial plexus injury.

Brachial Plexus Problems: Old and New
In practical terms shoulder dystocia is not a difficult diagnosis to make. After the baby’s head is delivered over the mother’s perineum, it appears to snap back against her vulva. The head becomes congested and cyanotic. It becomes clear that the shoulders are stuck in the pelvic area.

The first thing an obstetrician does is apply downward pressure to the head – sometimes forcefully. The gentle downward tug is a standard maneuver, however, just because it is done frequently doesn’t mean that it’s the correct thing to do.

Experts recommend that when shoulder dystocia is evident, one must not touch the head even gently until after the shoulder impaction is corrected. Pulling on the head – even gently – increases the risk of brachial plexus injury.

Fifty percent of the babies who have shoulder dystocia problems weigh less than 8 pounds 14 oz. The vast majority of these babies recover with no permanent brachial injuries. Five to 25 percent of shoulder dystocia may result in brachial plexus injuries. The key to avoiding brachial injury is gentle traction not excessive or medium force.

Healthcare providers whether they are midwives or specialists must have expertise to manage shoulder dystocia because the condition is not known until it appears. Inappropriate excessive tractions can deliver 50 to 75 pounds of pressure to the fetal head as compared to 2 to 3 pounds of pressure from gentle traction.

Erb’s Palsy is not an impact injury in labor; it is a stretch injury. The shoulder doesn’t reach the pubic bone until the head is out. Damage to the brachial plexus will only occur after the nerves have been stretched 25 percent. Such stretching doesn’t occur in labor.

Risk Factors and Causes
Maternal diabetes, large birth weight for other reasons, prolongation of the second stage of labor, the use of forceps, shoulder dystocia, and older maternal age are all risk factors.

Early doctrines held that plexus injury was caused by clavicular compression, by fracture of the proximal humerus, or by the neurotoxic effects of effusions escaping from the torn capsule of an injured glenohumeral joint.

The anterior shoulder becomes impacted against the pubic bone and a downward force applied to the head to dislodge the shoulder puts the brachial plexus on the stretch. Shoulder dystocia is noted in the obstetric record in about 50 percent of brachial plexus injuries incurred in the course of vertex vaginal deliveries. One possibility is that shoulder dystocia actually occurs in these cases but that the attendants fail to record it.

Without known reason, the authors concluded that shoulder dystocia had been under- recorded, but logic and subsequent commentators agree that the correct conclusion is that the injury-without-dystocia births were different phenomena from the dystocia-with-injury births; likewise, obstetric factors such as birth weight, maternal age, and parity distinguished injuries associated with shoulder dystocia from injuries not associated with shoulder dystocia. Injuries without dystocia were more severe, took longer to resolve, were more frequently associated with a clavicular fracture, and more frequently affected the posterior arm. They concluded that injuries with and without associated dystocia were qualitatively different. Thus the obstetrician’s efforts to relieve shoulder dystocia are not the whole explanation for brachial plexus birth injuries. The last word on the brachial plexus injury matter has not been spoken.

Sources:
Joseph H. Piatt, St. Christopher’s Hospital for Children, Philadelphia, PA & Textbook of Pediatrics, Chapter 7, the Newborn Infant

Fixing the Social Security Disability System for Children with Disabilities and Others

The Tuscaloosa News in Alabama has weighed in on the Social Security Disability backlog.

In an editorial, the newspaper decried the backlog and urged the federal government to appropriate money to address the problem.

“Over the past decade, the backlog of Social Security Administration cases awaiting hearings has more than doubled - even as the agency has lost 10 percent of its administrative law judges.Congress and President Bush have provided money to help cut the backlog. But the aid, though welcome, is inadequate; and hundreds of thousands of Americans are having to wait unconscionably long times for their disability hearings. An article in Tuesday's edition of The Tuscaloosa News told the story of one of these people who spent 18 months navigating the SSA maze before she finally received the benefits due her. And she was one of the more fortunate local claimants. Recent statistics from the Birmingham SSA appeals office show a backlog of 14,266 cases with an average waiting time of almost 20 months.There also was a substantial backlog at the state's three other Office of Disability Adjudication and Review offices in Florence, Mobile and Montgomery.”

Coming Soon!