Forensic Identification and Evaluation of 25 Obstetric Brachial Plexus Palsy Medical Damage Cases.

OBJECTIVES: To analyze the high risk factors of obstetric brachial plexus palsy (OBPP), and to explore how to evaluate the relationship between fault medical behavior and OBPP in the process of medical damage forensic identification. METHODS: A retrospective analysis was carried out on 25 cases of medical damage liability disputes related to OBPP from 2017 to 2021 in Beijing Fayuan Judicial Science Evidence Appraisal Center. The shortcomings of hospitals in birth weight assessment, delivery mode selection, labor process observation and shoulder dystocia management, and the causal relationship between them and the damage consequences of the children were summarized. RESULTS: Fault medical behavior was assessed as the primary cause in 2 cases, equal cause in 10 cases, secondary cause in 8 cases, minor cause in 1 case, no causal relationship in 1 case, and unclear causal force in 3 cases. CONCLUSIONS: In the process of forensic identification of OBPP, whether medical behaviors fulfill diagnosis and treatment obligations should be objectively analyzed from the aspects of prenatal evaluation, delivery mode notification, standardized use of oxytocin, standard operation of shoulder dystocia, etc. Meanwhile, it is necessary to fully consider the objective risk of different risk factors and the difficulty of injury prevention, and comprehensively evaluate the causal force of fault medical behavior in the damage consequences.

A five-year retrospective review of infants with Erb-Duchenne's palsy at a teaching hospital in North Trinidad.

Birth injuries are devastating to parents and carers alike. They carry the possibility of residual loss of function to the infant and thus the potential for litigation. The aim of this study was to determine the incidence of Erb-Duchenne's palsy and the identification of any contributing factors. A retrospective review over a five-year period, 2005-2009, was performed and an incidence of 0.94 per 1000 live births was noted. An association between both macrosomia and shoulder dystocia and the development of Erb-Duchenne palsy in the newborn was noted. The authors recommended the use of partograms and improved note documentation in the management of labour.

Impact of obstetrical brachial plexus injury on parents.

BACKGROUND: The aim of this study was to describe the impact of obstetrical brachial plexus palsy (OBPP) on parents and to investigate the effect of the severity of OBPP and the age of the children on parents. METHODS: A total of 106 parents (with a mean age of 30.14 ± 5.01 years) of children with OBPP were included in the study. The functional level of the children was assessed by the Active Movement Scale, whereas the impact of OBPP on the parents was assessed by the Turkish version of the Impact on Family Scale. RESULTS: The parents appeared to be moderately affected by their child's disorder. Financial, social, personal, mastery parameters and total impact values were 52% (27-77%), 65% (46-114%), 49% (31-67%), 51% (28-74%) and 56% (40-72%), respectively. Root involvement and the age of the children did not make a statistically significant difference in the level of impact. CONCLUSIONS: Detailed knowledge of the impact of OBPP on families might provide a chance to support affected families in coping with the situation and decrease their burden in providing care for the children. It is crucial to evaluate and provide social support to parents of children with OBPP.

Traumatic facial nerve palsy in newborns: is it always iatrogenic?

We sought to report an updated incidence, risk factors, and outcome of traumatic facial palsy (TFP) in newborn infants born at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia. We performed a 12-year retrospective study at KAMC. The records of infants with the diagnosis of TFP during the study period were reviewed and compared with 148 healthy term infants born during the same study period. Among 83,067 infants delivered between January 1994 and December 2005, 29 infants were diagnosed with TFP for an incidence of 0.03%. Forceps delivery and maternal primiparity were the only significant risk factors for TFP. Only 7 (24.1%) of these infants were delivered by cesarean section. The other 22 cases of TFP (75.9%) were delivered without any forceps application. Almost all infants (93%) with TFP had spontaneous recovery within 2 months. Only one child suffered from permanent facial weakness when he was last examined at the age of 12 years. Although forceps delivery was considered the most significant risk factor, currently most of the cases occur spontaneously without forceps application. The majority of infants with TFP will recover spontaneously within the first 2 months of life.

Current concepts in the management of brachial plexus birth palsy.

Brachial plexus birth palsy, although rare, may result in substantial and chronic impairment. Physiotherapy, microsurgical nerve reconstruction, secondary joint corrections, and muscle transpositions are employed to help the child maximize function in the affected upper extremity. Many present controversies regarding natural history, microsurgical treatment, and secondary shoulder reconstructive surgery remain unresolved in infants with brachial plexus birth palsies. Recent literature has enhanced our understanding of the pathoanatomy and natural history of the injury as well as the surgical indications, expected outcomes, and complications; this literature has led to improved care of these patients. Based on the present evidence, recommendations for both microsurgery and shoulder reconstruction with tendon transfer and arthroscopic and open reductions are presented.

Total obstetric brachial plexus palsy: results and strategy of microsurgical reconstruction.

From 2000 to 2006, 35 infants with total obstetric brachial plexus palsy underwent brachial plexus exploration and reconstruction. The mean age at surgery was 10.8 months (range 3-60 months), and the median age was 8 months. All infants were followed for at least 2.5 years (range 2.5-7.3 years) with an average follow-up of 4.2 years. Assessment was performed using the Toronto Active Movement scale. Surgical procedures included neurolysis, neuroma excision and interposition nerve grafting and neurotization, using spinal accessory nerve, intercostals and contralateral C7 root. Satisfactory recovery was obtained in 37.1% of cases for shoulder abduction; 54.3% for shoulder external rotation; 75.1% for elbow flexion; 77.1% for elbow extension; 61.1% for finger flexion, 31.4% for wrist extension and 45.8% for fingers extension. Using the Raimondi score, 18 cases (53%) achieved a score of three or more (functional hand). The mean Raimondi score significantly improved postoperatively as compared to the preoperative mean: 2.73 versus 1, and showed negative significant correlation with age at surgery. In total, obstetrical brachial plexus palsy, early intervention is recommended. Intercostal neurotization is preferred for restoration of elbow flexion. Tendon transfer may be required to improve external rotation in selected cases. Apparently, intact C8 and T1 roots should be left alone if the patient has partial hand recovery, no Horner syndrome, and was operated early (3- or 4-months old). Apparently, intact nonfunctioning lower roots with no response to electrical stimulation, especially in the presence of Horner syndrome, should be neurotized with the best available intraplexal donor.

[Perinatal brachial plexus palsy]. / Perinatální paréza brachiálního plexu.

Upper limbs palsy as a result of affliction of plexus brachialis nervous bunch is disorder, whose frequency moves among 0.42-5.1 / 1000 liveborn children. Delivery mechanism itself certain weighty, no however only cause rising paralysis. Some way paralysis rise already intrauterinne, some way then at surgical childbirth per sectionem caeseream. Brachial plexus palsy isn't benign disorder. If isn't this disorder in time diagnosed and accordingly treated, child threatens late aftermath, especially significant limitation of limbs movement with functional consequencies.

Diaphragmatic paralysis after phrenic nerve injury in newborns.

BACKGROUND: Phrenic nerve injury (PNI) from birth trauma is a recognized phenomenon, generally occurring with ipsilateral brachial plexus palsy (BPP). In severe cases, PNI results in diaphragm paresis (DP) and respiratory insufficiency. Surgical diaphragmatic plication (SDP) is a potential management strategy for patients with PNI and DP, but timing and outcomes associated with SDP have not been rigorously studied. METHODS: Records from 49 tertiary United States pediatric hospitals in the Pediatric Health Information System from 2004 to 2018 were analyzed. The study cohort included patients diagnosed with BPP from birth trauma who were documented to have PNI or DP. Patients who underwent congenital cardiac operations were excluded. RESULTS: A total of 5832 patients were identified with BPP from birth trauma during the study period, 122 (2%) of whom were found to have concomitant DP. Of those, 65 (53%) were male, 39 (32%) were infants of diabetic mothers, 80 (65%) required mechanical ventilation, and 33 (27%) underwent SDP. SDP was performed at a median (range) age of 36 (7-95) days. Median (range) total and postoperative hospital lengths of stay (LOS) were 34 (6-180) and 15 (4-132) days, respectively. There was also an observed increase in post-operative LOS with increase in age at operation. CONCLUSION: Neonatal DP is rare and is managed with SDP in a minority of instances. Age at repair affects total and postoperative length of stay, proxies for resource utilization and morbidity. Repair prior to 45 days of life appears to result in a shorter postoperative hospital stay. This analysis will help guide surgeons with respect to indications and operative timing for infant DP. TYPE OF STUDY: Retrospective Comparative Study. LEVEL OF EVIDENCE: Level III.

Extremity shortness in obstetric brachial plexus lesion and its relationship to root avulsion.

A total of 73 patients with obstetric brachial plexus palsy and extremity shortness were evaluated clinically, electrophysiologically, and with cervical magnetic resonance imaging. Patients were separated into groups according to age and the level of lesion. The differences of the length of the humerus, ulna, radius, and the second and fifth metacarpal bones were significant between the involved and uninvolved extremities. The difference in shortness increased in relation to the age of the groups and stabilized to approximately 10% in the groups aged 4 to 8 years and 8+ years. A significant relationship was observed between bone length differences and lesion levels. Differences in bone lengths were statistically significant in patients with avulsion in the group aged 8+ years. Extremity shortness appears to be related to avulsion and the level of lesion. The effect of avulsion on extremity shortness gradually increases with age. Finally, root avulsion can be an important factor in extremity shortness of obstetric brachial plexus palsy patients.

What factors are associated with neonatal injury following shoulder dystocia?

OBJECTIVE: To identify factors associated with the development of neonatal injury in the setting of shoulder dystocia. STUDY DESIGN: Medical record ICD-9 codes and a computerized perinatal database were reviewed to identify cases of shoulder dystocia from January 1996 to January 2001 in a tertiary care center. For confirmation of the diagnosis and collection of data, both maternal and neonatal charts were then reviewed and neonatal injuries categorized as either neurological (brachial plexus injury) or skeletal (clavicular fracture, humeral fracture). Shoulder dystocia cases were divided into groups based on the presence of neonatal injury at delivery or at discharge (with or without Erb's palsy). The group with neonatal injury was compared for demographic and obstetrical factors to the group without injury (control). chi (2) test, Mann-Whitney test and logistic regression were used as appropriate. RESULTS: During this 5-year period, there were 25,995 deliveries and 206 (0.8%) confirmed cases of shoulder dystocia. Of these cases, 36 (17.5%) had neonatal injury diagnosed at delivery and 25 (12%) remained with significant residual injury at discharge. Of these there were 19 cases of Erb's palsy and six cases of clavicular fracture. No association was found between neonatal injury and maternal age, ethnicity, diabetes, operative vaginal delivery or number of obstetrical maneuvers. However, maternal body mass index >30 kg/m2, a second stage of labor >20 min and a birth weight >4500 g were all associated with an increased risk of neonatal injury at delivery and at discharge, including Erb's palsy. After logistic regression analysis, only a second stage of delivery >20 min remained significantly associated with neonatal injury at discharge. CONCLUSION: In our population, maternal obesity was associated with an increased risk of neonatal injury after shoulder dystocia. In addition, a short second stage of labor (<20 min) was associated with a lower rate of neonatal injury.

Medical and legal issues related to brachial plexus injuries in neonates.

Injuries to the brachial plexus in neonates present a malpractice dilemma not only for physicians who provide obstetric care, but also for those who administer immediate postnatal treatment for newborns who have these injuries and comorbid medical conditions. Although trauma remains the probable etiology for many brachial plexus injuries, other, nontraumatic etiologies need to be considered. The authors review current medical and legal principles related to brachial plexus injuries-principles that are of concern to all practitioners who provide obstetric and newborn care. They also make a number of recommendations for practitioners to reduce the risk of malpractice lawsuits related to these injuries. Among these recommendations are increasing one's awareness of nontraumatic origins; making sure that appropriate testing (eg, electromyography) is performed for infants whose conditions fail to improve within several months after birth; and taking a proactive role in discussing brachial plexus injuries with patients' families.

Shoulder Function and Bone Mineralization in Children with Obstetric Brachial Plexus Injury After Neuromuscular Electrical Stimulation During Weight-Bearing Exercises.

OBJECTIVE: The purpose of this study was to evaluate the effects of neuromuscular electrical stimulation during weight-bearing exercises on shoulder function and bone mineral density (BMD) in children with obstetric brachial plexus injury (OBPI). DESIGN: This study was a randomized controlled trial. Forty-two children with OBPI were recruited. Their ages ranged from 3 to 5 years. They were randomly assigned either to control group (received a selected program) or study group (received the same program as the control group and neuromuscular electrical stimulation during weight bearing). Mallet grading system and dual-energy x-ray absorptiometry were used to evaluate shoulder function and BMD respectively at entry and after intervention (3 months later). RESULTS: No significant differences of the outcome measures were detected at entry. Significant differences were observed within both groups when the pre and post treatment scores within each group were compared. Finally, significant differences favoring the study group were recorded when their post treatment scores were compared. CONCLUSION: Neuromuscular electrical stimulation during weight bearing exercises is an effective and simple method to improve shoulder function and BMD in children with OBPI.

Birth injuries of the brachial plexus.

Birth injuries of the brachial plexus are fairly common, but the majority of affected newborns make quick recoveries without any specific intervention. A minority suffer more severe injuries that lead to varying degrees of life-long disability. Happily, modern microsurgical techniques permit reconstruction of certain plexus injuries and, in carefully selected patients, can restore voluntary activity to target muscle groups. To what degree reanimation of paralyzed muscles improves function and quality of life for these children is a more important matter that has not yet been addressed at the level of modern standards of evidence. Brachial plexus reconstruction is only a first step in the multidisciplinary process needed to optimize long-term functional outcomes for severely affected infants.

Permanent Erb palsy: a traction-related injury?

Historically, the primary risk factor attributed to brachial plexus injury during birth has been excessive traction applied at delivery to an entrapped anterior shoulder. However, recent evidence has suggested that not all cases of brachial plexus palsy are attributable to traction. We have encountered several cases of permanent Erb palsy associated with birth that were not attributable to traction applied at delivery. We reviewed cases of neonates with documented permanent Erb palsy that occurred either in the absence of shoulder dystocia or in the neonate's posterior arm in the presence of anterior shoulder dystocia. We identified four cases that occurred in the absence of shoulder dystocia and four cases that occurred in the posterior arm of infants with anterior shoulder dystocia. These data further support the notion that the etiology of permanent brachial plexus palsy associated with birth may not be related to traction.

Risk factors for Erb-Duchenne palsy.

The risk factors associated with the occurrence of Erb-Duchenne palsy were examined. Of 22 palsies, 18 were noted among 32,088 nondiabetic gravidas (0.56 per 1000) compared with four among 380 diabetic gravidas (10.5 per 1000), a statistically significant difference. One in six infants of diabetic gravidas who sustained shoulder dystocia experienced an Erb-Duchenne palsy. The incidence of precipitate second-stage labors was high (31.8%) among those infants who experienced the neurologic complication. This labor abnormality is not preventable and may contribute, in many ways, to the neurologic complication. Although recently graduated (less than four years' postresidency training) obstetricians, especially if placed in a high-volume practice, were more likely to experience this adverse outcome than more experienced physicians, even the most senior clinicians delivered infants who were affected.

Modified Zavanelli maneuver for the alleviation of shoulder dystocia.

BACKGROUND: The Zavanelli maneuver has typically been instituted when conventional maneuvers have failed to alleviate shoulder dystocia. Previously reported cases involving the Zavanelli maneuver have described cephalic replacement followed by immediate cesarean delivery. CASE: We encountered a case in which, despite the McRoberts maneuver, suprapubic pressure, Wood's corkscrew manuever, and attempted extraction of the posterior fetal arm, the baby could not be delivered. The fetal vertex was partially reinserted into the vagina, and this dislodged the impacted shoulders. With expulsive efforts the mother was then able to achieve vaginal delivery of a 3870 g female infant. CONCLUSION: The modified Zavanelli maneuver may be used to successfully alleviate shoulder dystocia.

A comparison of shoulder dystocia-associated transient and permanent brachial plexus palsies.

OBJECTIVE: To estimate differences between shoulder dystocia-associated transient and permanent brachial plexus palsies. METHODS: We performed a retrospective case-control analysis from national birth injury and shoulder dystocia databases. Study patients had permanent brachial plexus palsy and had been entered into a national birth injury registry. Cases of Erb or Klumpke palsy with documented neonatal neuromuscular deficits persisting beyond at least 1 year of life were classified as permanent. Cases of transient brachial plexus palsy were obtained from a shoulder dystocia database. Non-shoulder dystocia-related cases of brachial plexus palsy were excluded from analysis. Cases of permanent brachial plexus palsy (n=49) were matched 1:1 with cases of transient brachial plexus palsy. RESULTS: Transient brachial plexus palsy cases had a higher incidence of diabetes mellitus than those with permanent brachial plexus palsy (34.7% versus 10.2%, odds ratio [OR] 4.68, 95% confidence interval [CI] 1.42, 16.32). Patients with permanent brachial plexus palsies had a higher mean birth weight (4519+/-94.3 g versus 4143.6+/-56.5 g, P<.001) and a greater frequency of birth weight greater than 4500 grams (38.8% versus 16.3%, OR, 0.31, 95% CI 0.11, 0.87). There were, however, no statistically significant differences between the two groups with respect to multiple antepartum, intrapartum, and delivery outcome measures. CONCLUSION: Transient and permanent brachial plexus palsies are not associated with significant differences for most antepartum and intrapartum characteristics.

Management of facial palsy caused by birth trauma.

We present a newborn with a unilateral complete facial palsy caused by birth trauma, and discuss the differential diagnosis, pathophysiology, and management of this common, usually benign, condition. This child made a rapid, complete, spontaneous recovery despite a severe initial injury. Surgical exploration of the facial nerve should be considered only for infants with complete paralysis, clinically and electrophysiologically, who demonstrate no improvement by 5 weeks of age.

Review of obstetrical palsies. Nonoperative treatment.

For the majority of patients with obstetrical brachial plexus palsy, present-day conservative management yields good results. We now must direct our efforts toward improving the 10 to 15 per cent of patients who do not do well. Presently the role of microsurgical reconstruction of these injuries is undergoing evaluation. We must identify the patients with poor prognosis early: Babies should be examined at monthly intervals to document functional return, to supervise the child's exercise program, and to provide parental support. Babies who do not improve rapidly within the first 2 to 3 months should have an electromyogram and nerve conduction study. If this shows evidence of a severe lesion, these patients should be referred to a physician with a special interest in this area.

Indications and results of brachial plexus surgery in obstetrical palsy.

This article presents the first series with long-term results of a large number of patients. As a result, it is difficult to compare these results with anything but spontaneous recovery. In most cases, the end result after surgical treatment will be better than spontaneous recovery.