Article

Neonatal brachial plexus palsy: An unpredictable injury

Authors:
  • Rotunda Hospital, Children's University Hospital, Temple Street and Royal College of Surgeons in Ireland
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Abstract

Brachial plexus paralysis is a serious form of neonatal morbidity. We determined its incidence and persistence of disability and evaluated whether its occurrence could be predicted by maternal characteristics or partographic analysis in a large cohort of recent cases. During the years 1994 through 1998, all infants with neonatal evidence of obstetric brachial plexus injury were identified and followed 14;>or=1 year. Obstetric details in these maternal-infant pairs were compared with 108 control pairs, matched for maternal and gestational age, parity, and birth weight. Partographs of cases and control subjects were reviewed, in a blinded manner, by 3 obstetricians who were asked to identify likely cases of nerve injury. A risk score comprising eight recognized associated clinical features was assigned. Fifty-four of 35,796 infants (1.5/1000) had evidence of brachial plexus injury; in 10 cases (19%), neurologic deficit persisted to 1 year. Although the risk factor profile was relatively higher in cases compared with control subjects, the highest score was 5 of 8 in six cases (2 cases, 4 control subjects). Obstetricians' partographic assessment identified "likely brachial plexus injury" in 13 of 54 cases (24%) and 16 of 108 control subjects (15%), and in only 3 cases (6%) did the assessors concur (positive predictive value, 7%-17%; negative predictive value, 5%-12%; sensitivity, 24%-50%; specificity, 66%-68%). Risk scores were similar among persistently and transiently injured cases. Our results indicate that brachial plexus injury is not predictable before delivery, either by risk factor scoring or by partographic analysis.

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... [1][2][3][4][5][6] Incidence rates vary with study type and the availability of maternal and fetal care. [7][8][9] NBPP is the result of a closed nerve stretch injury to the brachial plexus, mostly occurring during labour. The mechanisms of injury include maternal, obstetric, and infant factors that apply traction on the anatomically vulnerable plexus. ...
... Twelve were cohort studies 62-73 and 10 were case-control studies. 7,15,[74][75][76][77][78][79][80][81] Only four studies had a prospective design. 7,15,65,70 Nine studies were conducted in Europe, 7,64-67,72,76-78 seven in North America, 62,63,68,69,71,75,81 five in Asia, 15,70,74,79,80 and one in Australia. ...
... 7,15,[74][75][76][77][78][79][80][81] Only four studies had a prospective design. 7,15,65,70 Nine studies were conducted in Europe, 7,64-67,72,76-78 seven in North America, 62,63,68,69,71,75,81 five in Asia, 15,70,74,79,80 and one in Australia. 73 The primary outcome in each study was risk factors for NBPP. ...
Article
Aim: To provide a comprehensive update on the most prevalent, significant risk factors for neonatal brachial plexus palsy (NBPP). Method: Cochrane CENTRAL, MEDLINE, Web of Science, Embase, and ClinicalTrials.gov were searched for relevant publications up to March 2019. Studies assessing risk factors of NBPP in relation to typically developing comparison individuals were included. Meta-analysis was performed for the five most significant risk factors, on the basis of the PRISMA statement and MOOSE guidelines. Pooled odds ratios (ORs), 95% confidence intervals (CIs), and across-study heterogeneity (I2 ) were reported. Reporting bias and quality of evidence was rated. In addition, we assessed the incidence of NBPP. Results: Twenty-two observational studies with a total sample size of 29 419 037 live births were selected. Significant risk factors included shoulder dystocia (OR 115.27; 95% CI 81.35-163.35; I2 =92%), macrosomia (OR 9.75; 95% CI 8.29-11.46; I2 =70%), (gestational) diabetes (OR 5.33; 95% CI 3.77-7.55; I2 =59%), instrumental delivery (OR 3.8; 95% CI 2.77-5.23; I2 =77%), and breech delivery (OR 2.49; 95% CI 1.67-3.7; I2 =70%). Caesarean section appeared as a protective factor (OR 0.13; 95% CI 0.11-0.16; I2 =41%). The pooled overall incidence of NBPP was 1.74 per 1000 live births. It has decreased in recent years. Interpretation: The incidence of NBPP is decreasing. Shoulder dystocia, macrosomia, maternal diabetes, instrumental delivery, and breech delivery are risk factors for NBPP. Caesarean section appears as a protective factor. What this paper adds: The overall incidence of neonatal brachial plexus palsy is 1.74 per 1000 live births. The incidence has declined significantly. Shoulder dystocia, macrosomia, maternal diabetes, instrumental delivery, and breech delivery are the main risk factors. Prevention is difficult owing to unpredictability and often labour-related risk.
... La PBO continúa siendo una de las causas más frecuentes de traumatismo obstétrico, así como de litigio médico, sobre todo cuando los daños son permanentes [2][3][4][5] . ...
... Generalmente se cree que es el resultado de un traumatismo durante el parto, que produce un estiramiento, rotura o avulsión del plexo braquial. En algunos casos, sin embargo, no se encuentran causas obstétricas, proponiéndose una causa prenatal 2,9,10 . Por esto se discute si es más apropiado el término "congénito" frente a "obstétrico", ya que este último conlleva implicaciones de la causa 1 . ...
... Múltiples estudios corroboran que la parálisis del plexo braquial en el período neonatal puede ocurrir antes, durante o después del parto [9][10][11]17,22,23 . En la mayoría de los casos, el alto peso del niño en el nacimiento se considera el principal factor asociado al daño del plexo 2,3,8,13,15,24 . Otros factores estadísticamente significativos son el tipo de presentación, como la distocia de hombros 2,8,13,25,26 , los partos prolongados, los partos vaginales instrumentados y las maniobras empleadas para liberar los hombros 2,8,19,25,27 . ...
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Article
IntroductionObstetric brachial palsy (OBP) is a lesion of the brachial plexus during the neonatal period associated to delivery.
... Obstetric brachial plexus palsy (OBPP) is an injury caused by the straining of the brachial plexus during birth, and it may range from neuropraxia to the complete avulsion of the nerve roots [5,18,26]. Surgery may be prescribed in cases where clinical treatment does not result in an adequate recovery [17]. ...
... (2), median nerve (3) musculocutaneous nerve (4). b We can observe dissection of a fascicule of ulnar nerve (5) and musculocutaneous ready to be sutured (6) We observed that 12 children presented spontaneous usage of the affected limb in their functional activities after 1 year of postoperative follow-up, showing a significant difference between the two points in time (p = 0.005). ...
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Article
Purpose: Most cases of obstetric brachial plexus palsy (OBPP) involve C5 and C6 nerve roots (Erb's palsy). In those cases, re-establishing the elbow flexion is the primary goal of surgery. The partial transfer of the ulnar nerve to the musculocutaneous nerve (Oberlin's procedure) is widely used in adults, but incipient in children. The purpose of this study is to describe the results obtained with such procedure as regards the improvement of the elbow flexion and donor nerve morbidity. Method: Thirteen children aged 9 to 15 months underwent Oberlin's procedure. They were assessed preoperatively and 1 year postoperatively using the active movement scale and also according to the functionality of the affected limb. All of them were evaluated because of the possibility of movement loss resulting from the donor nerve. We used the non-parametric, statistic Wilcoxon signed rank test (α = 0,05) method. Results: There was a significant improvement in the active elbow flexion between pre- and postoperative periods. Eleven children presented functional improvement. All of them maintained negative cookie test 1 year after the surgery. We did not observe any loss related to the donor nerve in terms of wrist flexion. Conclusion: The results suggest that Oberlin's procedure can be an effective and safe alternative to treat elbow flexion in Erb's palsy.
... Otros factores del trabajo de parto, clásicamente relacionados con la distocia de hombros, como la prolongación de la segunda fase del parto y el uso de oxitocina, no se ha podido demostrar que incrementen el riesgo de una parálisis braquial 12,17 . ...
... Por último, la evolución de las lesiones del plexo braquial son generalmente buenas, entre el 50 y el 81,4% tendrán una recuperación total entre los 6 meses y el año del parto 8,17 , y un pequeño porcentaje no se recuperan (aproximadamente el 2%) 8 , el resto tienen una recuperación parcial con alguna secuela, estas cifras son similares a la observadas en nuestro estudio. ...
Article
Objective To evaluate the maternal, neonatal and delivery risk factors that could be associated with brachial plexus palsy in the neonate.
... The relationship between labor disorders and OBPP has been investigated in several studies (40,(57)(58)(59)(60)(61). OBPP occurs more frequently in induced labors (46). ...
... Multiple logistic regression analysis using antenatal, intrapartum, and neonatal factors predicted only 19% of the brachial plexus injuries in the series of Perlow et al (51). Donnelly et al suggested that OBPP is not predictable by risk factor scoring or analysis of the partogram (60). ...
Article
Unlabelled: Obstetric brachial plexus palsy (OBPP), is an injury of the brachial plexus at childbirth affecting the nerve roots of C5-6 (Erb-Duchenne palsy-nearly 80% of cases) or less frequently the C8-T1 nerve roots (Klumpke palsy). OBPP often has medicolegal implications. In the United Kingdom and the Republic of Ireland the incidence is 0.42, in the United States 1.5, and in other western countries 1 to 3 per 1000 live births. Most infants with OBPP have no known risk factors. Shoulder dystocia increases the risk for OBPP 100-fold. The reported incidence of OBPP after shoulder dystocia varies widely from 4% to 40%. Other risk factors include birth weight >4 kg, maternal diabetes mellitus, obesity or excessive weight gain, prolonged pregnancy, prolonged second stage of labor, persistent fetal malposition, operative delivery, and breech extraction of a small baby. OBPP after caesarean section accounts for 1% to 4% of cases. Historically, OBPPs have been considered to result from excessive lateral traction and forceful deviation of the fetal head from the axial plane of the fetal body, usually in association with shoulder dystocia, which increases the necessary applied peak force and time to deliver the fetal shoulders. Direct compression of the fetal shoulder on the symphysis pubis may also cause injury. However a significant proportion of OBPPs occurs in utero, as according to some studies more than half of the cases are not associated with shoulder dystocia. Possible mechanisms of intrauterine injury include the endogenous propulsive forces of labor, intrauterine maladaptation, or failure of the shoulders to rotate, and impaction of the posterior shoulder behind the sacral promontory. Uterine anomalies, such as fibroids, an intrauterine septum, or a bicornuate uterus may also result in OBPP. It is not possible to reliably predict which fetuses will experience OBPP. Future research should be directed in prospective evaluation of the mechanisms of injury, to enable obstetricians, midwives, and other health care professionals to identify modifiable risk factors, develop preventive strategies, and improve perinatal outcomes. Target audience: Obstetricians & Gynecologists, Family Physicians. Learning objectives: After completion of this article, the reader will be able to summarize known risk factors for shoulder dystocia, describe the relationship between shoulder dystocia and obstetrics brachial plexus injuries, and describe three potentail explanantions for brachial plexus injuries other than lateral traction at delivery.
... Perinatal brachial plexus palsy (PBPP) is a flaccid paresis or paralysis of the upper extremity at birth, occurring in 0.42 to 4.6 per 1000 live births [1][2][3][4][5][6]. It is the second most common birth injury after clavicle fracture [7]. ...
Full-text available
Article
Purpose Perinatal brachial plexus palsy (PBPP) has a wide spectrum of clinical symptoms that can range from incomplete paresis of the affected extremity to flaccid arm paralysis. Although there is a high rate of spontaneous recovery within the first two years of life, it remains challenging to determine which patients will benefit most from surgical intervention. The diagnostic and predictive use of various imaging modalities has been described in the literature, but there is little consensus on approach or algorithm. The anatomic, pathophysiological, and neurodevelopmental characteristics of the neonatal and infant patient population affected by PBPP necessitate thoughtful consideration prior to selecting an imaging modality. Methods A systematic review was conducted using six databases. Two reviewers independently screened articles published through October 2021. Results Literature search produced 10,329 publications, and 22 articles were included in the final analysis. These studies included 479 patients. Mean age at time of imaging ranged from 2.1 to 12.8 months and investigated imaging modalities included MRI (18 studies), ultrasound (4 studies), CT myelography (4 studies), and X-ray myelography (1 study). Imaging outcomes were compared against surgical findings (16 studies) or clinical examination (6 studies), and 87.5% of patients underwent surgery. Conclusion This systematic review addresses the relative strengths and challenges of common radiologic imaging options. MRI is the most sensitive and specific for identifying preganglionic nerve injuries such as pseudomeningoceles and rootlet avulsion, the latter of which has the poorest prognosis in this patient population and often dictates the need for surgical intervention.
... In previous studies, many authors express hope and focus that improved obstetric techniques, including more frequent use of cesarean delivery might lower the occurrence of birth injury. This hope, however, has not been confirmed by previous studies [7]. Despite the association in most cases with traumatic delivery due to obstetric causes, most clavicle fractures occur in normal newborns after uncomplicated deliveries, and so it is an unpredictable complication [8]. ...
Article
Introduction The clavicle is one of the most commonly injured bones during the birth process. The objective of this study was to determine the frequency and outcome of fractured clavicle amongst neonates born in a five-year period at a Secondary Hospital setting and to determine the Maternal and Neonatal Characteristics involved in such cases and compare them with a control group and determine the significance of any factors. Methods All cases of fractured clavicle were retrospectively reviewed in a Secondary care hospital setting during a five-year period from July 2015 to June 2020. Maternal and neonatal factors were determined and then compared to a control group. Results Out of 21,435 live births at our center during the study period, 92 infants were diagnosed to have clavicle fractures, giving an incidence of 4.29 per 1,000 live births (0.43%). 89% cases (n=82) were detected before discharge and 11 % cases (n=10) on routine follow-up visit after discharge. Physical examination identified 77% cases (n=71) whereas 23% cases (n=21) were recognized incidentally on X-ray. All babies with fracture including 3 with Erb's palsy recovered completely without any complications. On logistic regression analysis, spontaneous vaginal delivery, prolonged second stage, vertex presentation, vitamin D deficiency in mothers, birthweight, macrosomia, all were significant risk factors. Conclusion Neonatal clavicular fracture appears to be a transient yet unpredictable and unavoidable event with an overall good prognosis. Only the birth weight was identified as the common risk factor affecting clavicular fracture. Parental concerns and anxiety can be decreased with proper counselling and reassurance.
... Sin embargo, la distocia de hombros resulta el mayor factor de riesgo, aumentado cien veces el riesgo de PBO (1,21). Esta es más frecuente en bebés de más de 4 kg de peso (22,23), pero el mejor predictor de la distocia es el antecedente de una distocia de hombros previa (24,25). La presentación de nalgas suele generar lesiones severas y, frecuentemente, provoca lesiones bilaterales. ...
... When the injury is identified around the time of the birth it is termed brachial plexus birth injury (BPBI). Previous terms for BPBI include birth brachial plexus palsy [1], birth brachial plexus injury, obstetric brachial plexus injury [2], obstetric brachial plexus palsy [3], neonatal brachial plexus injury [4], and neonatal brachial plexus palsy [5]. There is a higher likelihood of BPBI occurring when three or more of the following variables are present at birth: excessive maternal weight gain, labor longer than 61.5 minutes, maternal age greater than 26.4 years, tachysystole, or persistent fetal malpresentation [6]. ...
Article
Background: The brachial plexus is a network of nerves exiting the spinal cord through the fifth, sixth, seventh, and eighth cervical nerves (C5-C8) as well as the first thoracic nerve (T1) to conduct signals for motion and sensation throughout the arm. Brachial plexus birth injuries (BPBI) occur in 1.5 per 1,000 live births. The purpose of this study was to determine the perceived change in musculoskeletal health-related quality of life of brachial plexus patients utilizing the Pediatric Outcomes Data Collection Instrument (PODCI). PODCI scores were examined along with the patient's procedure history (surgical or Botulinum Toxin), extent of involvement and demographics. Patients: A total of 81 patients from two to eighteen years of age from nine different states met the inclusion criteria of having a pre-procedure and post-procedure PODCI score along with a Narakas score from 2002-2017. These patients were seen at the Brachial Plexus Center, which is an interdisciplinary clinic at a large academic medical centerMETHODS: This retrospective study utilized PODCI data collected annually during their regular brachial plexus clinic visits. Upper extremity (UE) and global functioning (GFx) scores pre- and post-procedure were stratified by Narakas Classification. Data were analyzed using paired t-test and ANOVA testing. Results: Patients with a Brachial Plexus Birth Injury (BPBI) had lower PODCI scores for UE and GFx when compared with the pediatric normative scores for age-matched healthy children. Scores in both UE and GFx domains were higher after procedure in the groups of Narakas I and IV. There was significant correlation between UE and GFx scores and documented first PODCI score (2 years of age) and age at intervention (5 years of age). Conclusion: Procedures increased the perceived quality of life for children with a BPBI and increased their overall PODCI scores for both UE and GFx.
... Shoulder dystocia, macrosomia, gestational diabetes, fetal malpresentation, and excessive maternal weight gain have all previously been noted as risk factors [1,2,11,[15][16][17][18][19]. Although statistically sound, most of these risk factors offer little to no potential to aid the obstetrician in attempting to prevent BPBI during delivery [20]. Predictive values do not come from having a commonly-occurring risk factor associated with a rare birth outcome. ...
Full-text available
Article
Over the course of decades, the incidence of brachial plexus birth injury (BPBI) has increased despite advances in healthcare which would seem to assist in decreasing the rate. The aim of this study is to identify previously unknown risk factors for BPBI and the risk factors with potential to guide preventative measures. A case control study of 52 mothers who had delivered a child with a BPBI injury and 132 mothers who had delivered without BPBI injury was conducted. Univariate, multivariable and logistic regressions identified risk factors and their combinations. The odds of BPBI were 2.5 times higher when oxytocin was used and 3.7 times higher when tachysystole occurred. The odds of BPBI injury are increased when tachysystole and oxytocin occur during the mother’s labor. Logistic regression identified a higher risk for BPBI when more than three of the following variables (>30 lbs gained during the pregnancy, stage 2 labor >61.5 min, mother’s age >26.4 years, tachysystole, or fetal malpresentation) were present in any combination.
... Historical reports of perinatal brachial plexus palsy describe incidences ranging from 0.42 to 1.5 per 1000 live births. [1][2][3] Significant disability may persist in the affected limb in about 10-20% of individuals after 2 years. Generally, there is a less favorable prognosis for those with bilateral brachial plexus palsy than for those afflicted in just one limb. ...
Full-text available
Article
Events during delivery of an infant can result in substantial harm to the infant or mother. Common birth injuries consist of traumatic brain injury, seizures, and mental retardation. Brachial plexus palsy, although rare, may result in substantial and chronic impairment. Phrenic nerve palsy is a peripheral nerve disorder caused by excessive cervical extension due to birth trauma. In this report, we describe the case of a newborn with bilateral brachial plexus palsy along with unilateral phrenic nerve paresis. Keywords: Birth injuries, brachial plexus palsy, phrenic nerve paresis
... По данным мировой литературы, вероятность получения травмы ПС во время родов составляет 0,3-3,9 случая на 1000 новорожденных [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21]. Как показывают исследования последних десятилетий с учетом данных крупных акушерских центров Европы и Северной Америки, частота развития АППС, составляет 1-2 на 1000 новорожденных [22][23][24][25][26]. В большинстве опубликованных сообщений причинами повреждения называют патологическое положение плода или трудности при родовспоможении. ...
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Article
The aim of current publication – to present our own experience in use of electromyographic examination in prognosis for children with obstetric brachial plexus injury to practical neurologists and neurophysiologists. Review of literature shows that common approaches to electrotrophysiological diagnosis of obstetric brachial plexus injury do not exist. The aim of this study– to evaluate retrospectively electrophysiological and sonographic parameters of obstetric brachial plexus injury in children, determining the most informative variables. Since 2007 to 2014 we examined 218 children, 74 of them were operated. Electrophysiological investigation in young children have difficulties in performance.We present our algorithm of diagnostic of obstetric brachial plexus injury: 1) testing main muscles, which perform basic movementsin upper limb (needle EMG of supra- and infraspinatus muscles and cutaneous EMG of biceps muscles); 2) localization of injury (paralysis or Duchenne – Erb palsy and electrophysiological criteria of spinal cord root avulsion). We found out that the most crucial role in assessing prognosis plays an examination of motor unit potentials (MUPs) duration. Absence of MUPs within needle EMG from supraspinatus muscle and absence of interference curve from biceps muscle during first 6 months have poor prognosis. After 6 months careful, dynamic study of MUPs duration in infraspinatus muscle and co-contraction of agonist and antagonist muscles is needed. To decide whether reconstructive surgery in a patient with obstetric brachial plexus injury is necessary, surgeon must analyze clinical and instrumental data. The possibility of usage of the ultrasonogrophy in brachial plexus injury requires further investigation.
... Donnelly et al. have also concluded that OBPP is not predictable by the risk factors or the partogram. 42 Shoulder dystocia, is also largely unpredictable. Statistical models have been developed to estimate this risk using parameters including birthweight, maternal BMI, gestational age and parity. ...
Article
Obstetrical brachial plexus palsies (OBPP) have been historically attributed to the impaction of the fetal shoulder behind the symphysis pubis and to excessive lateral traction of the fetal head during maneuvers to deliver the fetal shoulders in shoulder dystocia. Shoulder dystocia is indeed a major risk factor as it increases the risk for OBPP 100-fold. The incidence of OBPP following shoulder dystocia varies widely from 4% to 40%. However, a significant proportion of OBPPs are secondary to in utero injury. The propulsive forces of labor, intrauterine maladaptation, and compression of the posterior shoulder against the sacral promontory as well as uterine anomalies are possible intrauterine causes of OBPP. Many risk factors for OBPP may be unpredictable. Early identification of risk factors for shoulder dystocia, as well as appropriate management when it occurs, may improve our ability to prevent the occurrence of OBPP in those cases that are caused by shoulder dystocia.
... The incidence of PBPP has been reported to be between 0.42 and 5.1 per 1000 live births. The reports of the largest populations found incidences between 0.42 and 1.5 per 1000 live births (1)(2)(3). ...
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Article
Perinatal brachial plexus palsy (PBPP) is a flaccid paralysis of the arm at birth that affects different nerves of the brachial plexus supplied by C5 to T1 in 0.42 to 5.1 infants per 1000 live births. To identify antenatal factors associated with PBPP and possible preventive measures, and to review the natural history as compared with the outcome after primary or secondary surgical interventions. A literature search on randomized controlled trials, systematic reviews and meta-analyses on the prevention and treatment of PBPP was performed. EMBASE, Medline, CINAHL and the Cochrane Library were searched until June 2005. Key words for searches included 'brachial plexus', 'brachial plexus neuropathy', 'brachial plexus injury', 'birth injury' and 'paralysis, obstetric'. There were no prospective studies on the cause or prevention of PBPP. Whereas birth trauma is said to be the most common cause, there is some evidence that PBPP may occur before delivery. Shoulder dystocia and PBPP are largely unpredictable, although associations of PBPP with shoulder dystocia, infants who are large for gestational age, maternal diabetes and instrumental delivery have been reported. The various forms of PBPP, clinical findings and diagnostic measures are described. Recent evidence suggests that the natural history of PBPP is not all favourable, and residual deficits are estimated at 20% to 30%, in contrast with the previous optimistic view of full recovery in greater than 90% of affected children. There were no randomized controlled trials on nonoperative management. There was no conclusive evidence that primary surgical exploration of the brachial plexus supercedes conservative management for improved outcome. However, results from nonrandomized studies indicated that children with severe injuries do better with surgical repair. Secondary surgical reconstructions were inferior to primary intervention, but could still improve arm function in children with serious impairments. It is not possible to predict which infants are at risk for PBPP, and therefore amenable to preventive measures. Twenty-five per cent of affected infants will experience permanent impairment and injury. If recovery is incomplete by the end of the first month, referral to a multidisciplinary team is necessary. Further research into prediction, prevention and best mode of treatment needs to be done.
Chapter
Electrodiagnostic (EDX) medicine and EDX testing are an extension of the history and physical examination tailored to the clinical scenario. A wide range of tests are available, and it is incumbent on the electrodiagnostician to select those relevant to the clinical circumstances. The testing procedure may change as data are acquired and new findings interpreted. High-quality consultations are rendered by physicians with experience and technical competence coupled with an understanding of the peripheral nervous system. This chapter provides an overview of EDX tests, the extent of such testing for different clinical scenarios based on guidelines, and the types of abnormalities one can expect to find with different neuromuscular disorders.
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Article
The abilities of children diagnosed with Obstetric Brachial Palsy (OBP) are limited by brachial plexus injuries. Thus, their participation in the community is hindered, which involves a lower quality of life due to worse performance in activities of daily living as a consequence of the functional limitations of the affected upper limb. Conventional Mirror Therapy (Conventional MT) and Virtual Therapy improve the affected upper limb functionality. Therefore, the aim of this study was to compare the effects of Conventional MT and Virtual Reality MT on the spontaneous use of the affected upper limb and quality of life of children with upper Obstetric Brachial Palsy between 6 and 12 years of age. A randomized pilot study was performed. Twelve children were randomly assigned to perform Conventional Mirror Therapy or Virtual Reality Mirror Therapy for four weeks. Ten children completed the treatment. Two assessments (pre/post-intervention) were carried out to assess the spontaneous use of the affected upper limb and the quality of life using the Children's Hand-use Experience Questionnaire (CHEQ) and the Pediatric Quality of Life Inventory Generic Core Scales (PedsQL TM 4.0), respectively. There was a statistically significant increment in spontaneous use, observed in independent tasks (p = 0.02) and in the use of the affected hand with grasp (p = 0.04), measured with the CHEQ, for the Virtual Reality MT group. There were no statistically significant changes (p > 0.05) for the Conventional MT group in the spontaneous use of the affected upper limb. Regarding the quality of life, statistically significant changes were obtained in the Physical and Health activity categories of the parents' questionnaire (p = 0.03) and in the total score of the children's questionnaire (p = 0.04) in the Virtual Reality MT group, measured using the PedsQL TM 4.0. Statistically significant changes were not obtained for the quality of life in the Conventional MT group. This study suggests that, compared to Conventional MT, Virtual Reality MT would be a home-based therapeutic complement to increase independent bimanual tasks using grasp in the affected upper limb and improve the quality of life of children diagnosed with upper OBP in the age range of 6-12 years.
Article
Objective: To analyze the origins and consequences of cases of brachial plexus injuries and their relationship to shoulder dystocia. Methods: We conducted a retrospective cohort study and identified all neonates with brachial plexus injury delivered at our institution between March 2012 and July 2019. A review was performed of the maternal and neonatal records of each neonate to identify obstetric antecedents, including the occurrence of shoulder dystocia and persistence of the injury. Experience of the delivering clinician was also examined. Statistical analysis was performed with the Fisher exact test, χ test for trends, and two-tailed t tests. Results: Thirty-three cases of brachial plexus injury were identified in 41,525 deliveries (0.08%). Fourteen (42%) of these cases were not associated with shoulder dystocia; three (9%) followed cesarean delivery. Brachial plexus injury without shoulder dystocia was related to the absence of maternal diabetes, lower birth weights, and a longer second stage of labor. Persistent brachial plexus injury at the time of discharge was seen with equal frequency among neonates with (17/19, 89%, 95% CI 0.52-100%) and without shoulder dystocia (10/14, 71%, 95% CI 34-100%), P=.36). Whether brachial plexus injury was transient or persistent after shoulder dystocia was unrelated to the years of experience of the delivering clinician. Despite ongoing training and simulation, the already low incidence of brachial plexus injury did not decrease over time at our institution. Conclusion: Brachial plexus injury and shoulder dystocia represent two complications of uterine forces driving a fetus through the maternal pelvis in the presence of disproportion between the passage and the shoulder girdle of the passenger. Either or both of these complications may occur, but often are not causally related.
Article
Objectives: To establish the incidence of obstetric neonatal brachial plexus and facial nerve injuries in a tertiary maternity hospital in the United Kingdom and to identify associated risk factors with an emphasis on the time of delivery. Study design: From our hospital electronic data bases we identified all live births born between 2000 and 2016 and those neonates who sustained a nerve injury during delivery. We performed a logistic regression analysis linking "facial nerve injury" and "brachial plexus injury" with variables for which we had complete cohort data including "breech", "gestation", "sex", "birthweight", "day of week", "time of delivery", "method of delivery", "singleton/multiple deliveries" and "number of deliveries per day". Significance level was set at 5%. Results: We identified 87,461 live births of which 29 had sustained a facial nerve and 45 a brachial plexus injury. Logistic regression showed a significant positive association between "facial nerve injury" and "forceps delivery" (95% CI: 25-1398), "Ventouse delivery" (95% CI: 1.7-207) and "emergency Caesarean section" (95% CI: 1.7-148) and between "brachial plexus injury "and "birthweight" (95% CI: 1.001-1.003), "forceps delivery" (95% CI: 3.4-14) and "Ventouse delivery" (95% CI: 2.5-13). There was no increased risk for weekend and out of hours deliveries. All babies with a nerve injury made a full recovery. Conclusions: Our obstetric neonatal nerve injury rate (0.085%) was low with our brachial plexus injury rate (0.051%) being about one third of a historical rate from Ireland (0.15%) and half of the rate recently reported from the United States (0.12%) which could be linked to our staff dealing with many high risk pregnancies. Neonatal birth injury data should be included as a clinical safety marker for delivery units.
Article
Objective: Although Caesarean section (CS) is protective for brachial plexus birth injury (BPBI), the incidence is not zero. A trial of labour with unfavourable intrauterine positioning is hypothesized to result in excessive force on the brachial plexus. The purpose of this study was to determine the risk of BPBI in emergent CS versus elective CS. Methods: This was a retrospective cohort study. The authors used a nationwide demographic sample of all infants born in Canada from 2004 to 2012. BPBI diagnoses, risk factors, and national incidence data were obtained from the Canadian Institute for Health Information Discharge Abstract Database and Hospital Morbidity Database. The primary outcome was risk of BPBI in emergent CS versus elective CS. Results: BPBI incidence was 1.24 per 1000 live births. Known biases may have underestimated the incidence. CS (elective and emergent) was protective for BPBI as compared with vaginal delivery (odds ratio [OR] 0.15; 95% confidence interval [CI] 0.13-0.18, P < 0.0001). Emergent CS was a moderately strong risk factor for BPBI versus elective CS (OR 3.14; 95% CI 1.79-5.10, P = 0.0001). Conclusion: Emergent CS is a moderate risk factor for BPBI compared with elective CS. Intrauterine positioning with a trial of labour may provide an antenatal etiology in these distinct cases.
Chapter
This chapter is focused on injuries of extracranial, cranial, intracranial, spinal cord, and peripheral nervous system structures, with emphasis on those disorders that appear to be related primarily to mechanical trauma. Extracranial hemorrhage consists of three major lesions: caput succedaneum, subgaleal hemorrhage, and cephalhematoma. These lesions are generally not serious, except for several uncommon complications. Skull fracture, the principal bony lesion of the newborn, may be linear, be depressed, or consist of occipital osteodiastasis. Intracranial hemorrhage, not unexpectedly, may result from mechanical factors, although among all types of intracranial hemorrhage, trauma per se is a prominent pathogenetic factor principally only for epidural and some cases of subdural hemorrhage. Subdural hemorrhage is discussed in Chapter 22. Spinal cord injury is the most serious CNS parenchymal lesion related primarily to mechanical factors. Two major sites of injury are upper to mid-cervical, occurring mainly in cephalic deliveries and relating primarily to torsional factors, and lower cervical to upper thoracic, occurring mainly in breech deliveries and relating primarily to longitudinal or lateral tractional factors. MRI has proven valuable for both diagnosis and prognosis. Improvements in obstetrical practice have led to declines in incidence. Management is difficult, but new pharmacological, cellular, and rehabilitative interventions are on the horizon. Traumatic injury to peripheral nervous system structures is particularly dominated by brachial plexus injury. The mechanical forces underlying most cases are usually some combination of exogenous factors, such as downward lateral traction involving delivery of the head in a breech delivery or of the shoulder in cephalic deliveries and endogenous factors, such as very strong maternal expulsion forces. Other injuries to peripheral nervous system structures individually are uncommon but collectively are relatively common.
Article
Purpose: This study aimed to: 1) evaluate the prevalence of cranial asymmetry (positional plagiocephaly) in infants with neonatal brachial plexus palsy (NBPP); 2) examine the association of patient demographics, arm function, and NBPP-related factors to positional plagiocephaly; and 3) determine percentage of spontaneous recovery from positional plagiocephaly and its association with arm function. Methods: Infants < 1 year of age with NBPP and no previous exposure to plagiocephaly cranial remolding therapy or surgical intervention were recruited for this prospective cross-sectional study. Positional plagiocephaly (diagonal difference) measurements were captured using a fiberglass circumferential mold of the cranium. Included infants were divided into 2 groups: 1) those with positional plagiocephaly at most recent evaluation (plagio group), including infants with resolved positional plagiocephaly (plagio-resolved subgroup); and 2) those who never had positional plagiocephaly (non-plagio group). Standard statistics were applied. Results: Eighteen of 28 infants (64%) had positional plagiocephaly. Delivery type might be predictive for plagiocephaly. Infants in the non-plagio group exhibited more active range of motion than infants in the plagio group. All other factors had no significant correlations. Conclusions: A high prevalence of positional plagiocephaly exists among the NBPP population examined. Parents and physicians should encourage infants to use their upper extremities to change position and reduce chance of cranial asymmetry.
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The article presents the current literature devoted to the problem of delivery of pregnant women with gestational diabetes mellitus (GDM). Analyzed issues related to the definition of the optim-al timing and mode of delivery of women with GDM. On the basis of these data revealed that the principles of tactics and delivery of pregnant women with GDM worldwide ambiguous and require further research. Thus, the development of common standards for best tactics, methods and timing of delivery of pregnant women with gestational diabetes mellitus is a challenging and important task for modern medicine and requires further investigation.
Article
Birth injuries of the brachial plexus are fairly common, but most affected newborns make quick recoveries without any specific intervention. A minority suffer more severe injuries that lead to varying degrees of life-long disability. Modern microsurgical techniques permit reconstruction of certain plexus injuries and, in carefully selected patients, can restore Voluntary activity to target muscle groups. The degree to which reanimation of paralyzed muscles improves function and quality of life for these children is a more important matter that has not yet been addressed using 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.
Chapter
Definition Hypoglycemia in neonates is a relatively common, heterogenous and potentially serious problem. A consistent definition of hypoglycemia does not exist in the literature or in clinical practice. Epidemiology Hypoglycemia is a frequent concern in neonatology For the majority of healthy term infants, low glucose levels reflect metabolic adaptation to extrauterine life If the first feeding is delayed by 3–6 h, 10% of healthy neonates are not able to maintain their blood glucose level above 30 mg/dl (1.7 mmol/l). After 12 h of life (and feeding) the risk for symptomatic hypoglycemia declines, but still exists for the term infant with low birth weight (<2500 g; SGA), with high birth weight (LGA), and postasphyxic newborns. Diagnosis The diagnosis of hypoglycemia may be made in the symptomatic neonate with a low blood glucose concentration and resolving symptoms after normalization of the blood glucose concentration. Transient hypoglycemia in the first few hours after birth is relatively frequent. Hypoglycemia that is persistent requires further investigation. WHO guidelines – hypoglycemia of the newborn (continued on p. 262) • Healthy term newborns who are breastfeeding on demand do not need to have their blood glucose routinely checked and need no supplementary foods or fluids • Healthy term newborns do not develop “symptomatic” hypoglycemia as a result of simple underfeeding. If an infant develops signs suggesting hypoglycemia, look for an underlying cause. This usually means drawing a blood sample (serum tube, better: sodium fluoride tube) at the time of hypoglycemia prior to treatment. Detection of the cause is as important as immediate correction of the blood glucose level • Thermal protection (the maintenance of normal body temperature) in addition to breastfeeding is necessary to prevent hypoglycemia […]
Chapter
What are the initial steps in managing a vigorous term newborn infant – and which measures should be avoided? See p. 221. When are advanced resuscitative measures indicated in newborns? Keywords: meconium, asphyxia, premature birth/prematurity, special events. See p. 227. Why is endotracheal intubation in very small preterm infants difficult? Explain the anatomical features. See p. 236. Estimate the birth weight for the following tube sizes (inner diameter) for endotracheal intubation: 2.0-, 2.5-, or 3.0-mm-ID tube. See p. 85, Table 2.2 What would you tell the parents: how high is the rate of brain damage (IVH, PVL) in preterm infants <1500 g? See p. 238. What could be the reasons for deterioration in spite of assuredly correct endotracheal intubation? See p. 222, p. 236, p. 340, p. 392, p. 410, p. 417. Below which gestational age is viability of the fetus not probable? See pp. 185–6. Is it legitimate to discontinue life-saving resuscitative measures once started in extreme prematurity? See p. 184, p. 235. What are the possible complications of monochorial twin pregnancies? See p. 240. What samples need to be collected prior to an emergency transfusion? See Table 3.1, p. 241. What are the clinical signs of a twin–twin transfusion syndrome (TTTS)? See Table 3.1, p. 240. What is in the differential diagnosis when the newborn presents with pallor and increased respiratory rate? See Table 3.2, p. 243. When infection of the newborn is suspected what diagnostic tests should be performed in the delivery room? See Table 3.2, p. 244, p. 280. […]
Article
Brachial plexus injuries (BPI) are usually apparent at or shortly after birth. Many cases of BPI are transient, with the recovering full function in the first week of life. A smaller percent of children continue to have weakness and may contribute to life - long neuromuscular dysfunction for the infant BPI is reported in the medical literature at the rate of 0.2 to 4 per thousand live births. BPI continues to occur despite an increasing awareness of risk factors. BPI can be classified by their anatomic location: Erb duchenne Palsy Upper Root injury (C5C6); Klumpke's Palsy Lower Root injury (C8T1) and Erb - Klumpke Paralysis Complete or Total Injury (C5T1). Clinical presentation depend of the degree of nerve injury or by their anatomic location. A systematic examination should take place as soon as possible to establish diagnosis to assess the degree of injury, differentiate BPI from other conditions and document a baseline functional assessment (posture, motor function, spontaneous movements, primitive reflexes, ROM active and passive) and associated injuries. During the first weeks of life serial assessments is necessary Several classification systems have been described to categorize and evaluate motor et sensor function which is extremely difficult to assess in neonates and infants. Some authors recommended Electromyography studies. MRI is not routinely. Alter assessment, team of experts makes establishment of goals and approaches to rehabilitation for patients with BPI. Therapy is based on each child's unique needs. Initial therapy involves protection of the joint from stress. Physiotherapist mast be capable of assessing nerve damage and providing parents with information to avoid possible complications (handling). An intensive physical therapy is essential. Physical therapy is used to maintain passive range of movement, to stimulate activity in muscles whose nerve supply is disconnected, to prevent syndrome of neglect, to prevent contractures and bony deformity and habituation of incorrect movements and body posture. Electrical stimulation can be used for stimulation of innervated musculature but the efficacy ES on injured nerve and denervated muscle has been questioned. Some authors believe that if the infant does not show recovery of neurologic function by age 4 months, surgical intervention should be scheduled but physical therapy is still elemental. Instructing parents and family in a home exercise program and emotional support to the family is necessary for success of Rehabilitation program.
Article
OBJECT The aim of this study was to determine the volume and timing of referrals for obstetrical brachial plexus injury (OBPI) to multidisciplinary centers in a national demographic sample. Secondarily, we aimed to measure the incidence and risk factors for OBPI in the sample. The burden of OBPI has not been investigated in a publicly funded system, and the timing and volume of referrals to multidisciplinary centers are unknown. The incidence and risk factors for OBPI have not been established in Canada. METHODS This is a retrospective cohort study. The authors used a demographic sample of all infants born in Canada, capturing all children born in a publicly funded, universal healthcare system. OBPI diagnoses and corresponding risk factors from 2004 to 2012 were identified and correlated with referrals to Canada’s 10 multidisciplinary OBPI centers. Quality indicators were approved by the Canadian OBPI Working Group’s guideline consensus group. The primary outcome was the timing of initial assessment at a multidisciplinary center, “good” if assessed by the time the patient was 1 month of age, “satisfactory” if by 3 months of age, and “poor” if thereafter. Joinpoint regression analysis was used to determine the OBPI incidence over the study period. Odds ratios were calculated to determine the strength of association for risk factors. RESULTS OBPI incidence was 1.24 per 1000 live births, and was consistent from 2004 to 2012. Potential biases underestimate the level of injury identification. The factors associated with a very strong risk for OBPI were humerus fracture, shoulder dystocia, and clavicle fracture. The majority (55%–60%) of OBPI patients identified at birth were not referred. Among those who were referred, the timing of assessment was “good” in 28%, “satisfactory” in 66%, and “poor” in 34%. CONCLUSIONS Shoulder dystocia was the strongest modifiable risk factor for OBPI. Most children with OBPI were not referred to multidisciplinary care. Of those who were referred, 72% were assessed later than the target quality indicator of 1 month that was established by the national guideline consensus group. A referral gap has been identified using quality indicators at clinically relevant time points; this gap should be addressed with the use of knowledge tools (e.g., a clinical practice guideline) to target variations in referral rates and clinical practice. Interventions should guide the referral process.
Article
Notfälle im Kreißsaal sind eher seltene Ereignisse, bedrohen aber zumeist zwei oder mehrere Leben gleichzeitig. Nicht immer sind sie vorhersehbar oder kündigen sich langfristig an. „Seltenes“ muss nachweislich geübt werden, am besten in Teamtrainings. Dieses Training ist nicht nur in der Luftfahrt Pflicht, sondern auch für Katastropheneinsatzteams ständiges Thema. Geübt werden muss das „management of the unexpected“. Gut sichtbare Schautafeln erleichtern kompetentes und konstruktives Handeln. Der Beitrag erhebt keinen Anspruch auf Vollständigkeit, sondern soll Impulse setzen und zur Entwicklung von Notfallplänen anregen. Abstract Neonatal or maternal emergencies are rare events in clinical practice, although threatening for both mother and child. Obviously, most emergencies cannot be foreseen but clinicians must be aware of their possible occurrence. For situations, such as shoulder dystocia, risk factors are established like elevated body-mass index (BMI) of the mother, estimated birth weight more than 4000 g, macrosomia and diabetes. All emergencies have in common that they need a defined emergency communication pathway. Emergency strategies and emergency reactions are essential to cope with rare situations. Team training which is obligatory in aviation, needs to be implemented in any guidelines provided. The so-called management of the unexpected needs to be part of routine medical education for the students, residents and for the staff.
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Article
Objective: To identify risk factors, particularly modifiable, associated with brachial plexus injury. Study design: A retrospective case-control study conducted at a single hospital between the years 1993 and 2012. All neonates who were diagnosed of brachial plexus injury were included. A control group matched at a ratio of 1:2 was randomly selected. Demographic and obstetric data were obtained from the hospital discharge register with ICD-9 codes and crosschecked with the labor medical records. All medical files were manually checked and validated. A stepwise logistic regression model was performed to identify independent predictors for brachial plexus injury before delivery among those found significant in the univariate analysis. Results: Of all 83 806 deliveries that took place during this period, 144 cases of brachial plexus injury were identified (1.7/1000 deliveries). Overall, 142 cases and 286 controls had available data. Among the study group, 41 (28.9%) had documented shoulder dystocia compared with 1 (0.4%) among the controls (P<0.0001). Logistic regression analysis revealed that maternal age above 35 years (P=0.01; odds ratio (OR) 2.7; 95% confidence interval (CI) 1.3 to 5.7), estimated fetal weight before delivery (P<0.0001; OR 2.5; 95% CI 1.7 to 3.8, for each 500 g increase), vaginal birth after cesarean (P=0.02; OR 3.3; 95% CI 1.2 to 8.8) and vacuum extraction (P=0.02; OR 3.6; 95% CI 1.2 to 10.3) were all found to be independent predictors for developing brachial plexus injury. When stratifying the analysis according to parity, vacuum delivery was found to be an independent risk factor only among primiparous women (OR 6.0; 95% CI 1.7 to 21.6). Conclusions: The findings suggest that very few factors contributing to brachial plexus injury are modifiable. For that reason, it remains an unpredictable and probably an unavoidable event.
Article
Epidemiological knowledge of the incidence, prevalence, and temporal changes of neonatal brachial plexuses palsy (NBPP) should assist the clinician, avert unnecessary interventions, and help formulate evidence-based health policies. A summary of 63 publications in the English language with over 17 million births and 24,000 NBPPs is notable for six things. First, the rate of NBPP in the US and other countries is comparable: 1.5 vs. 1.3 per 1000 total births, respectively. Second, the rate of NBPP may be decreasing: 0.9, 1.0 and 0.5 per 1,000 births for publications before 1990, 1990-2000, and after 2000, respectively. Third, the likelihood of not having concomitant shoulder dystocia with NBPP was 76% overall, though it varied by whether the publication was from the US (78%) vs. other countries (47%). Fourth, the likelihood of NBPP being permanent (lasting at least 12 months) was 10-18% in the US-based reports and 19-23% in other countries. Fifth, in studies from the US, the rate of permanent NBPP is 1.1-2.2 per 10,000 births and 2.9-3.7 per 10,000 births in other nations. Sixth, we estimate that approximately 5000 NBPPs occur every year in the US, of which over 580-1050 are permanent, and that since birth, 63,000 adults have been afflicted with persistent paresis of their brachial plexus. The exceedingly infrequent nature of permanent NBPP necessitates a multi-center study to improve our understanding of the antecedent factors and to abate the long-term sequela.
Article
Neonatal brachial plexus palsy (NBPP) is an unpredictable complication of childbirth. Historic risk factors for the occurrence of NBPP have included shoulder dystocia, fetal macrosomia, labor abnormalities, operative vaginal delivery, and prior NBPP. However, whether studied alone or in combination, these risk factors have not been shown to be reliable predictors. The majority of NBPP cases occur in women with infants <4500 g who are not diabetic and have no other identifiable risk factors. Furthermore, cesarean section reduces but does not completely eliminate the risk for NBPP. In this section, the relationship of these historic obstetric risk factors to the occurrence of NBPP is further explored.
Article
Objectives To provide management guidelines for labor and delivery in women with gestational diabetes. Materials and methods A literature search was performed using the Pubmed and Cochrane database. Foreign societies guidelines were also consulted. Results There is no additional information from recent studies that may suggest changing current French guidelines about timing of delivery in gestational diabetes. The incidence of shoulder dystocia is increased in women with gestational diabetes, especially when infants are weighing more than 4500g. Elective cesarean section when the fetal weight was greater than or equal to 4250 to 4500g may reduce the risk of shoulder dystocia. Meticulous attention to avoiding maternal hyperglycemia during labor can prevent neonatal hypoglycemia. There is no significant role for x-ray pelvimetry in the management of gestational diabetes. Conclusion Management of labor and delivery in women with gestational diabetes will mainly depend on estimated fetal weight, especially when macrosomia is present.
Article
Objective: The objective was to determine the rate of neonatal brachial plexus palsy (NBPP) among women with vaginal birth after cesarean delivery (VBAC) and to compare the peripartum characteristics with control subjects. Study design: The Maternal-Fetal Medicine Unit cesarean registry data were used to identify nonanomalous singleton pregnancies with VBAC and NBPP at gestational age of ≥37 weeks (term) and 4 control subjects (matched for gestational age and diabetes mellitus status but without brachial injury). Odds ratio (OR) and 95% confidence intervals (CIs) were calculated. Results: Among 11,313 VBACs at term, there were 23 women with NBPP (rate of 2.0/1000 women). Newborn infants with NBPP, compared with control infants, were significantly more likely to weigh ≥4000 g (48% vs 10%, respectively; OR, 8.45; 95% CI, 2.58-28.44) and to require admission to the neonatal intensive care unit (30% vs 13%; OR, 12.98; 95% CI, 2.61-72.18). Conclusion: Women who desire VBAC should be informed about the low rate of NBPP and, if eligible, encouraged to have a trial of labor after cesarean delivery.
Chapter
The rate of injury can be reduced. Prediction of the complication is not the solution. Prevention does not require prediction. The foundations of the science of medicine were laid down by Hippocrates not Nostradamus! Keywordsinjury–prediction–prevention–risk factors
Chapter
Identification of risk factors and discussion of these with the patient is critical to satisfactory outcomes. Keywordsdystocia–legal–palsy–traction
Article
The management of obstetrical brachial plexus injury, often called birth palsy, remains one of the most controversial topics in pediatric neurosurgery. Most birth palsies have acceptable spontaneous recoveries, whereas only a minority require surgical intervention. A selective approach for surgery was used in this Louisiana State University Health Sciences Center (LSUHSC) series, for which the operative rate was 9%. At LSUHSC, the patient with obstetrical brachial plexus injury is followed for 6 to 9 months before surgery, which is performed if there is no satisfactory biceps and/or shoulder function. This is a retrospective analysis of 169 patients with 171 palsies referred to LSUHSC for possible surgery. There were 76 patients with 77 birth palsies managed operatively and nonoperatively at LSUHSC between 1975 and 1991. An additional 93 patients with 94 palsies who were managed between 1992 and 2003 were included in this analysis. The results of initial and follow-up examinations using Eng's criteria for impairment ratings (IRs) were available for 151 of 171 (88%) nonoperative and operative obstetrical brachial plexus injuries managed between 1975 and 2001. Fifty-two percent of the nonoperative patients evaluated at an initial visit had an IR of 4 or 5, which represents very poor function by comparison to IR of 1 in the Eng scale, which represents almost no abnormality. The percentage of patients in this category (4-5) improved to 30% after follow-up visits. For the 16 operative cases, the initial and follow-up percentages of patients with IRs of 4 or 5 were 67% and 22%, respectively. Ultimately, 47% of the nonoperative patients achieved a grade 2 IR after follow-up compared with 17% of the operative patients. Using this selective approach at LSUHSC, in which the operative rate was 9%, acceptable outcomes were obtained both in patients not having surgery and also in those having surgical intervention.
Article
The nationwide incidence of neonatal brachial plexus palsy in the United States is unknown. The purpose of this study was to determine the incidence of this condition in the United States and to identify potential risk factors for neonatal brachial plexus palsy. Data from the 1997, 2000, and 2003 Kids' Inpatient Database data sets were utilized for this study. Patients were identified with use of the International Classification of Diseases, Ninth Revision (ICD-9), code 767.6 for neonatal brachial plexus palsy. Previously reported risk factors for this condition, including shoulder dystocia, instrumented delivery, breech delivery, an exceptionally large baby (>4.5 kg), heavy infant weight for gestational dates, multiple birth mates, and cesarean delivery, were also identified with use of ICD-9 codes. Multivariate logistic regression analysis was utilized to assess the association of neonatal brachial plexus palsy with its risk factors, after adjusting for sociodemographic characteristics, such as gender, race, and payer status; hospital-based characteristics, such as number of hospital beds, hospital location, region, type, and teaching status; and the effect of time. Over eleven million births were recorded in the database, and 17,334 had a documented brachial plexus injury in the total of three years, yielding a nationwide mean and standard error of incidence of neonatal brachial plexus palsy in the United States of at least 1.51 +/- 0.02 cases per 1000 live births. The incidence of this condition has shown a significant decrease over the years (p < 0.01). In the multivariate analysis, shoulder dystocia had a 100 times greater risk, an exceptionally large baby (>4.5 kg) had a fourteen times greater risk, and forceps delivery had a nine times greater risk for injury. Having a twin or multiple birth mates and delivery by cesarean section had a protective effect against the occurrence of neonatal brachial plexus palsy. Forty-six percent of all children with neonatal brachial plexus palsy had one or more known risk factors, and fifty-four percent had no known risk factors. This nationwide study of neonatal brachial plexus palsy in the United States demonstrates a decreasing incidence over time. Shoulder dystocia poses the greatest risk for brachial plexus injury, and having a twin or multiple birth mates and delivery by cesarean section are associated with a protective effect against injury. Most children with neonatal brachial plexus palsy did not have known risk factors.
Article
We sought to compare the incidence and antecedents of neonatal brachial plexus injury (BPI) in 2 different 5-year epochs a decade apart following the introduction of specific staff training in the management of shoulder dystocia. All infants with BPI were prospectively identified during 2004 through 2008. Injuries were correlated with maternal details and intrapartum events and compared with the earlier series. Of 41,828 deliveries during 2004 through 2008, 72 infants with BPI were identified (1.7/1000), compared to 54 cases (1.5/1000) from 1994 through 1998 (P = .4); 9 injuries (12.5%) were persistent from 2004 through 2008, compared with 10 (18.5%) earlier (P = .4). There were no significant differences between the 2 time periods with respect to maternal parity, obesity, or prolonged pregnancy, although the cesarean section rate had increased from 10.7 to 18.4%. Despite training in the management of shoulder dystocia and a rising institutional cesarean section rate, the incidence of BPI has remained unchanged compared with 10 years earlier.
Full-text available
Article
Obstetrical Brachial Plexus Palsy (OBPP) is a complication of difficult delivery and resulted from excessive traction on the brachial plexus during delivery. Erb palsy, klumpke paralysis and panplexus palsy reported in 46, 0.6 and 20% of patients, respectively. Unilateral injury is more common than bilateral injury. Risk factors include macrosomia, multiparity, prior delivery of a child with OBPP, breech delivery shoulder dystocia, vacium and forceps assisted delivery and excessive maternal weight gain. The recovery rate is usually reported to be between 80 and 90%. We evaluated 42 children with OBPP. Out of them, we could follow only 28 cases during two years. Poor to moderate recovery occurred in 13 cases. Good to complete (expected) recovery occurred in 15 cases. Most of the patients were females. Right side palsy was more prevalent than left side palsy. Vaginal delivery without forceps was the most mode of delivery. Vertex was the most common presentation. Most of the patients were term. The mean weight of the birth was 3.8 kg. Erb palsy and pan-plexus palsy consisted of 71.4 and 28.6% of lesions. In patients with Erb palsy, there were preganglionic palsy in 3 (15.8%) and postganglionic palsy in 16 (84.2%) cases, while all the patients with panplexus palsy had postganglionic palsy. All patients with complete recovery (9 of 15) had Erb palsy and postganglionic lesion. Erb palsy was present in 71.4% and panplexus palsy was present in 28.6% of cases. Also, 23.8% of cases had preganglionic and 76.2% of cases had postganglionic injures.
Article
Few studies exist with regard to the ability of electromyography (EMG) and volumetric magnetic resonance imaging (MRI) of the infraspinatus muscle to complement the physical assessment of active global shoulder external rotation (GER) in the neonatal brachial plexus palsy (NBPP) population. Therefore, the purpose of this study was to evaluate the relationships of EMG and MRI with active GER based on analysis of the infraspinatus muscle. Seventy-four NBPP patients (mean age, 5 y 1 m; range, 1 y 1 m to 13 y 3 m) who had undergone physical examination of the shoulder, EMG evaluation of the infraspinatus muscle, and shoulder MRI were included in this study. The outcome variable active GER was dichotomized into <0 degree active GER (poor) and ≥0 degree active GER (good). The interference pattern on EMG of the infraspinatus muscle was graded on a 6-point scale and dichotomized into ≤4 and ≥5. On shoulder MRI, infraspinatus muscle volume was measured. The infraspinatus muscle interference pattern and volume were compared with active GER. Interference pattern on EMG of the infraspinatus muscle was significantly related to the Mallet Score (P=0.0022), with a poor interference pattern associated with an approximately 7 times higher likelihood [odds ratio=7.391; 95% confidence interval (2.054, 26.588)] of poor active GER. Infraspinatus muscle volume decrease on MRI was also significantly related to active GER (P=0.0413), with each percent volume decrease corresponding to an increase of 0.094 in the odds of having a poor Mallet Score for active GER [odds ratio=1.094; 95% confidence interval (1.004, 1.193)]. The interference pattern of the infraspinatus muscle on EMG and the infraspinatus muscle volume on MRI are strongly related to active GER as assessed by the Mallet Score. Integrating clinical assessment with electrophysiological and imaging findings may improve the accuracy in evaluating shoulder dysfunction in NBPP and provide improved guidance in selecting interventions specific to the patient's pattern of deficits. Diagnostic study, level II.
To provide management guidelines for labor and delivery in women with gestational diabetes. A literature search was performed using the Pubmed and Cochrane database. Foreign societies guidelines were also consulted. There is no additional information from recent studies that may suggest changing current French guidelines about timing of delivery in gestational diabetes. The incidence of shoulder dystocia is increased in women with gestational diabetes, especially when infants are weighing more than 4500 g. Elective cesarean section when the fetal weight was greater than or equal to 4250 to 4500 g may reduce the risk of shoulder dystocia. Meticulous attention to avoiding maternal hyperglycemia during labor can prevent neonatal hypoglycemia. There is no significant role for x-ray pelvimetry in the management of gestational diabetes. Management of labor and delivery in women with gestational diabetes will mainly depend on estimated fetal weight, especially when macrosomia is present.
Article
To provide management guidelines for labour and delivery in women with gestational diabetes. A literature search was performed using the PubMed and Cochrane databases. Foreign societies guidelines were also consulted. There is no additional information from recent studies that supports changing current French guidelines about timing of delivery in gestational diabetes. The incidence of shoulder dystocia is increased in women with gestational diabetes, especially when infants weigh more than 4500 g. Elective caesarean-section when the foetal weight is greater than or equal to 4250 to 4500 grams may reduce the risk of shoulder dystocia. Meticulous attention to avoiding maternal hyperglycaemia during labour can prevent neonatal hypoglycaemia. There is no significant role for x-ray pelvimetry in the management of gestational diabetes. Management of labour and delivery in women with gestational diabetes will mainly depend on estimated foetal weight, especially when macrosomia is present.
Article
Background: Brachial plexus birth palsy (BPBP) most often occurs as a result of foetal-maternal disproportion. The C5 and C6 nerve roots of the brachial plexus are most frequently affected. In contrast, roots from the C7 to Th1 that result in total injury together with C5 and C6 injury, are affected in fewer than half of the patients. BPBP was first described by Smellie in 1764. Erb published his classical description of the injury in 1874 and his name became linked with the paralysis that is associated with upper root injury. Since then, early results of brachial plexus surgery have been reasonably well documented. However, from a clinical point of view not all primary results are maintained and there is also a need for later follow-up results. In addition most of the studies that are published emanate from highly specialized clinics and no nation wide epidemiological reports are available. One of the plexus injuries is the avulsion type, in which the nerve root or roots are ruptured at the neural cord. It has been speculated whether this might cause injury to the whole neural system or whether shoulder asymmetry and upper limb inequality results in postural deformities of the spine. Alternatively, avulsion could manifest as other signs and symptoms of the whole musculoskeletal system. In addition, there is no available information covering activities of daily living after obstetric brachial plexus surgery. Patients and methods: This was a population-based cross-sectional study on all patients who had undergone brachial plexus surgery with at least 5 years of follow-up. An incidence of 3.05/1000 for BPBP was obtained from the registers for this study period. A total of 1706 BPBP patients needing hospital treatment out of 1 717 057 newborns were registered in Finland between 1971 and 1997 inclusive. Of these BPBP patients, 124 (7.3%) underwent brachial plexus surgery at a mean age of 2.8 months (range: 0.4―13.2 months). Surgery was most often performed by direct neuroraphy after neuroma resection (53%). Depending on the phase of the study, 105 to 112 patients (85-90%) participated in a clinical and radiological follow-up assessment. The mean follow up time exceeded 13 years (range: 5.0―31.5 years). Functional status of the upper extremity was evaluated using Mallet, Gilbert and Raimondi scales. Isometric strength of the upper limb, sensation of the hand and stereognosis were evaluated for both the affected and unaffected sides then the differences and their ratios were calculated and recorded. In addition to the upper extremity, assessment of the spine and lower extremities were performed. Activities of daily living (ADL), participation in normal physical activities, and the use of physiotherapy and occupational therapy were recorded in a questionnaire. Results: The unaffected limb functioned as the dominant hand in all, except four patients. The mean length of the affected upper limb was 6 cm (range: 1-13.5 cm) shorter in 106 (95%) patients. Shoulder function was recorded as a mean Mallet score of 3 (range: 2―4) which was moderate. Both elbow function and hand function were good. The mean Gilbert elbow scale value was 3 (range: -1―5) and the mean Raimondi hand scale was 4 (range:1―5). One-third of the patients experienced pain in the affected limb including all those patients (n=9) who had clavicular non-union resulting from surgery. A total of 61 patients (57%) had an active shoulder external rotation of less than 0° and an active elbow extension deficiency was noted in 82 patients (77%) giving a mean of 26° (range: 5°―80°). In all, expect two patients, shoulder external rotation strength at a mean ratio 35% (range: 0―83%) and in all patients elbow flexion strength at a mean ratio of 41% (range: 0―79%) were impaired compared to the unaffected side. According to radiographs, incongruence of the glenohumeral joint was noted in 15 (16%) patients, whereas incongruence of the radiohumeral joint was found in 20 (21%) patients. Fine sensation was normal for 34/49 (69%) patients with C5-6 injury, for 15/31 (48%) with C5-7 and for only 8/25 (32%) of patients with total injury. Loss of protective sensation or absent sensation was noted in some palmar areas of the hand for 12/105 patients (11%). Normal stereognosis was recorded for 88/105 patients (84%). No significant inequalities in leg length were found and the incidence of structural scoliosis (1.7%) did not differ from that of the reference population. Nearly half of the patients (43%) had asynchronous motion of the upper limbs during gait, which was associated with impaired upper limb function. Data obtained from the completed questionnaires indicated that two thirds (63%) of the patients were satisfied with the functional outcome of the affected hand although one third of all patients needed help with ADL. Only a few patients were unable to participate in physical activities such as: bicycling, cross-country skiing or swimming. However, 71% of the patients reported problems related to the affected upper limb, such as muscle weakness and/or joint stiffness during the aforementioned activities. Incongruity of the radiohumeral joints, extent of the injury, avulsion type injury, age less than three months of age at the time of plexus surgery and inexperience of the surgeon was related to poor results as determined by multivariate analyses. Conclusions: Most of the patients had persistent sequelae, especially of shoulder function. Almost all measurements for the total injury group were poorer compared with those of the C5-6 type injury group. Most of the patients had asymmetry of the shoulder region and a shorter affected upper limb, which is a probable reason for having an abnormal gait. However, BPBP did not have an effect on normal growth of the lower extremities or the spine. Although, participation in physical activities was similar to that of the normal population, two-thirds of the patients reported problems. One-third of the patients needed help with ADL. During the period covered by this study, 7.3% BPBP of patients that needed hospital treatment had a brachial plexus operation, which amounts to fewer than 10 operations per year in Finland. It seems that better results of obstetric plexus surgery and more careful follow-up including opportunities for late reconstructive procedures will be expected, if the treatment is solely concentrated on by a few specialised teams. Olkahermopunos koostuu viidestä hermojuuresta (C5-C8 ja Th1), jotka lähtevät kaularangan alueen selkäytimestä ja hermottavat yläraajan lihaksia ja tuntoa. Lapsen olkahermopunos voi vaurioitua synnytyksen yhteydessä, jos hermorakenteisiin kohdistuu liiallinen venytys lapsen hartioiden ja äidin synnytyskanavan epäsuhteen seurauksena. Olkahermopunoksen syntymävauriota kutsutaan usein Erbin pareesiksi. Erb kuvasi vuonna 1874 hermovaurion sijainnin olkahermopunoksen C5 ja C6 hermojuurten risteämiskohdassa. Sittemmin Erbin pareesi ja olkahermopunoksen syntymävaurio ovat muodostuneet synonyymeiksi arkikielessä; osin virheellisesti, sillä Erbin pareesissahan on kyse olkahermopunoksen yläosan vauriosta eikä laajemmasta C5-C7 juurten tai ns. totaalivauriosta (C5-C8/Th1). Vaurio voidaan lisäksi luokitella yksittäisen hermon lievästä venyttymästä aina sen irtirepeytymiseen selkäytimestä. Vaikeammat hermon repeytymät aiheuttavat pysyviä muutoksia hartian ja yläraajan lihasten toimintaan ja raajan tuntoon. Lihastoiminnan epätasapaino johtaa nivelten liikerajoituksiin ja virheasentoihin. Joillakin potilailla esiintyy myös kipuja yläraajassa. Suomessa syntyy vuosittain noin 200 lasta, joilla todetaan olkahermopunoksen syntymävaurio. Keskimäärin alle kymmenellä vaurio on niin vaikea, että hermopunoksen leikkaus on perusteltu 3-9 kk. iässä. Suomessa ensimmäinen vastasyntyneen/ imeväisen olkahermopunoksen korjausleikkaus tehtiin vuonna 1971. Vasta 1980-luvun aikana leikkaushoito vakiintui ja samaan aikaan julkaistiin korjausleikkauksesta myönteisiä tuloksia. Toistaiseksi ei ole julkaistu yhtään epidemiologista, väestöön pohjautuvaa yli viiden vuoden seurantatutkimusta. Mahdollisia kasvun myötä kehittyviä ja aikuisikään vaikuttavia pysyviä haittoja ei ole voitu arvioida aikaisemmissa tutkimuksissa lyhyiden seuranta-aikojen vuoksi. Tutkimuksen tavoite oli saada kattava käsitys Suomessa leikattujen potilaiden nykyisestä tilasta sekä selvittää hoidon lopputulokseen vaikuttavia tekijöitä. Pyrin saamaan tutkimukseen kaikki ne potilaat, joilla seuranta-aika olkahermopunoksen korjausleikkauksen jälkeen oli yli viisi vuotta. Potilaita oli yhteensä 124, joista tutkimukseen osallistui 112 (90%). Seuranta-aika leikkauksesta oli keskimäärin 13,5 vuotta, pisimmillään 31,5 vuotta. Potilaiden vaurioituneen puolen yläraajan toiminta, lihasvoimat, nivelten liikelaajuudet ja käden tunto tutkittiin ja näistä saatuja mittaustuloksia verrattiin terveeseen raajaan. Vanhemmat kysyvät usein, vaikuttaako hermovaurio mahdollisesti muutenkin lapsen kehitykseen. Tätä asiaa selvitettiin tutkimalla potilaiden selän ryhtiä, alaraajojen ja kävelyn mahdollisia poikkeavuuksia, liikunnallista aktiivisuutta ja kipujen esiintyvyyttä. Osalla potilaista vamma oli niin vaikea, että päivittäisten asioiden hoito oli hankalaa. Päivittäisistä askareista selviytymistä arvioitiin kyselytutkimuksella. Noin puolella potilaista olkahermopunoksen vaurio sijoittui kahteen ylimpään olkahermopunoksen hermojuureen (C5-6), vajaalla kolmanneksella kolmeen ylimpään (C5-7) ja neljänneksellä kaikkiin hermopunoksen hermojuuriin (totaalivaurio). Kolmasosalla koko tutkimusryhmästä todettiin hermojuuren irtirepeytymä selkäytimestä. Leikkaukset tehtiin keskimäärin kolmen kuukauden iässä. Leikanneita lääkäreitä oli kymmenen, joista kaksi oli tehnyt yli puolet kaikista leikkauksista. Yleisin toimenpide oli hermoarven poisto ja hermojen päiden yhdistäminen toisiinsa joko suoralla ompelulla tai alaraajasta otetulla hermosiirteellä. Reilun 13 vuoden seurannan aikana 63 potilaalle tehtiin raajan korjausleikkaus, joista yleisimpiä olivat olkanivelet liikelaajuutta vapauttavat leikkaukset. Potilaan kätisyys määräytyi vahvasti vamman mukaan - vain neljällä potilaalla kätisyys oli vaurioituneella puolella. Vammautunut raaja oli keskimäärin 6 cm tervettä raajaa lyhyempi. Olkanivelen aktiiviset liikkeet olivat rajoittuneet noin 50% terveeseen puoleen verrattuna ja noin 30% kyynärnivelen ja käden liikelaajuuksien osalta. Potilaat, joilla vaurio käsitti koko olkahermopunoksen, liikelaajuus oli tätäkin huonompi. Näistä potilaista noin kolmasosalla käden puristusvoima oli nolla. Havaitsin saman jakauman potilasryhmien välillä myös tuntomittauksissa. Potilaista, joilla oli kahden ylimmän hermojuuren vaurio, kolmanneksella havaittiin poikkeava tunto. Sen sijaan potilailla, joilla oli todettu koko hermopunoksen vaurio, poikkeava tunto oli kaksi kertaa yleisempää. Tahattomia vammoja, kuten palovammat, estävä suojatunto puuttui jopa kolmannekselta näistä potilaista. Kolmannes kaikista potilaista tarvitsi apua päivittäisissä askareissaan, kuten pukeutumisessa ja ruoan paloittelussa. He harrastivat kuitenkin liikuntaa yhtä paljon kuin saman ikäiset terveet henkilöt, mutta suurella osalla (71%) vammautuneen puolen yläraajan heikkous tai liikerajoitus aiheutti ongelmia. Yli puolet (56%) tutkituista oli saanut fysioterapiaa seurannan aikana. Kolmannes potilaista valitti kipua joko leikkausalueella tai yläraajassa. Tutkimukseni mukaan olkahermopunoksen syntymävaurio ei aiheuttanut muutoksia potilaiden selän tai alaraajojen kehitykseen. Kaiken kaikkiaan laajempi vaurio, yksittäisen hermon irtirepeytymä selkäytimestä ja leikanneen kirurgin kokemattomuus heikensivät lopputulosta. Olkahermopunoksen syntymävaurio on suhteellisen harvinainen vamma. Sen vaikeampi, leikkausta vaativa muoto aiheuttaa pysyvän haitan, vaikka varhaisvaiheen leikkaus onnistuisikin. Vaikeiden vaurioiden keskittäminen 1-2 yksikköön Suomessa todennäköisesti parantaisi hoidon tuloksia ja potilaiden elämänlaatua.
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We devised a method to predict risk of neonatal Erb palsy using variables ascertainable before delivery. Multiple logistic regression modeling was used to construct an Erb palsy risk score from a case-control study of 45 consecutive Erb palsy cases and 90 controls. Receiver-operator characteristics identified a range of scores for which likelihood ratios were determined for calculation of predictive values across a range of prior probabilities. In the final model, large estimated fetal weight, gestational diabetes, large maternal body mass index, large weight gain, and black race were associated with 2.3-4.8 times greater odds of Erb palsy. A long second stage had a modest effect on the odds (OR=2.7, P=0.13), unless preceded by a long deceleration phase, which combination increased the odds of Erb palsy to 20.1 (P=0.001). A risk score of 0.72 had a sensitivity of 36% and a specificity of 99%. In a theoretical population with a birth prevalence of brachial plexus palsy of 2.5/1000, application of the risk score would prevent 36% of cases and result in about 14 cesareans for every nerve injury prevented. We conclude that risk scoring using multiple logistic regression coefficients of variables that can be known in time to affect decision-making about mode of delivery has the potential to guide intervention to prevent some Erb palsies.
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Shoulder dystocia is a rare, unpredictable complication of delivery which can have disastrous consequences for the baby. It is a common source of litigation since parents and their advisers find it difficult to accept that the problem could not have been predicted and circumvented. This article reviews recent cases reported to the Medical Defence Union and describes one case in detail which was successfully defended in court.
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Objective To determine whether the anatomy of an obstetric brachial plexus lesion (OBPL) is causally related to the preceding obstetric history. Design Anatomical classification of the OBPL during reconstructive neurosurgical treatment in consecutive infants who had surgery for OBPL between 1986 and 1994 and relating these findings with the characteristics of the preceding birth. Setting De Wever Hospital, Heerlen, The Netherlands. Subjects All infants who had surgical treatment for OBPL between 1 April 1986 and 1 January 1994 (n= 130). Results An Erb's C546 injury was preceded more frequently by a difficult breech birth (19/26 cases or 73 YO). In contrast, the more extensive forms of Erb's palsy classified as a C547 injury or a total palsy with a C5–Tl injury were observed more frequently after complicated cephalic birth (52/59 or 88%, and 43/45 or 96%, respectively). The extent of anatomical damage as expressed by the incidence of an avulsion of one or more spinal nerves was 18/26 (69 %) in Erb C5–C6, 13/59 (22%) in Erb C547 and 21/45 (47%) in total C5–T1 palsy. Conclusion The Erb's CS-C6 palsy, occasionally bilateral and/or complicated by phrenic nerve injury, was the most frequent form of OBPL after a breech birth. The more extensive form of Erb's palsy and the total palsy were observed more frequently after delivery in a cephalic presentation. The pure form of Erb's palsy and the total palsy were characterised by a higher incidence of nerve avulsions than the extensive form of Erb's palsy.
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It is an almost assumption in obstetric literature that brachial palsy is due to extreme lateral traction on the fetal head during the last phase of delivery. In contrast, there have been reports in the neurologic literature of probable intrauterine origin of brachial plexus palsy. Data to dispute or support the latter view were sought. With this overview in mind, our perinatal data base was searched for all instances of shoulder dystocia and independently for all diagnoses of brachial plexus impairment. Seventeen instances of brachial plexus impairment associated with shoulder dystocia were found. Twenty-two instances of brachial plexus impairment without mention of shoulder dystocia were ascertained. The characteristics of the two groups were remarkably different, especially in birth weight and in maternal age and parity. The data are strongly suggestive that intrauterine maladaptation may play a role in brachial plexus impairment. Brachial plexus impairment should not be taken as prima facie evidence of birth process injury.
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Methods of delivery, maternal and neonatal characteristics were examined to determine their role in the occurrence of Erb/Duchenne's palsy. Data from 210,947 Washington state birth certificates from 1980 through 1982 were examined. The incidence was 50.2 cases of Erb's palsy per 100,000 live births. A case control study design was used to analyze 106 cases and 386 controls by both univariable and multivariable analysis. Birth weight was shown to be a significant risk factor regardless of which method of delivery was used. A high birth weight infant (4001-4500 g) had 2.5 times the risk of incurring an upper brachial plexus injury compared with normal size infants (2501-4000 g). The risk for infants greater than 4500 g increased another tenfold (OR = 21.0). When birth weight was controlled for in the analysis, midforceps (OR = 18.3), vacuum extraction (OR = 17.2), and low forceps (OR = 3.7) remained significantly associated with the Erb's palsy. Delivery by cesarean section was associated with a significant protective effect (OR = 0.5) compared with instrumental vaginal delivery. These data demonstrate a high risk for serious birth injury associated with instrumental midpelvic delivery.
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To determine whether the anatomy of an obstetric brachial plexus lesion (OBPL) is causally related to the preceding obstetric history. Anatomical classification of the OBPL during reconstructive neurosurgical treatment in consecutive infants who had surgery for OBPL between 1986 and 1994 and relating these findings with the characteristics of the preceding birth. De Wever Hospital, Heerlen, The Netherlands. All infants who had surgical treatment for OBPL between 1 April 1986 and 1 January 1994 (n = 130). An Erb's C5-C6 injury was preceded more frequently by a difficult breech birth (19/26 cases or 73%). In contrast, the more extensive forms of Erb's palsy classified as a C5-C7 injury or a total palsy with a C5-T1 injury were observed more frequently after complicated cephalic birth (52/59 or 88%, and 43/45 or 96%, respectively). The extent of anatomical damage as expressed by the incidence of an avulsion of one or more spinal nerves was 18/26 (69%) in Erb C5-C6, 13/59 (22%) in Erb C5-C7 and 21/45 (47%) in total C5-T1 palsy. The Erb's C5-C6 palsy, occasionally bilateral and/or complicated by phrenic nerve injury, was the most frequent form of OBPL after a breech birth. The more extensive form of Erb's palsy and the total palsy were observed more frequently after delivery in a cephalic presentation. The pure form of Erb's palsy and the total palsy were characterised by a higher incidence of nerve avulsions than the extensive form of Erb's palsy.
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The study was undertaken to test the hypothesis that shoulder dystocia might be suspected and reliably identified from the labor partogram. A retrospective analysis of 52 consecutive patients with shoulder dystocia was performed. The 52 controls were the next consecutive parturient matched for maternal age, gestational age at delivery, parity, presentation, and infants weight at delivery. The mean dilation rate was 2.1 +/- 1.9 cm/hr in shoulder dystocia group compared to 2.4 +/- 1.5 cm/hr in the control group. The incidence of protracted rate of less than 1 cm/hr was 14.3% in shoulder dystocia group and 13.5% in the control group. The mean duration of second stage was 38.3 +/- 30.7 minutes in the shoulder dystocia group compared to 35.5 +/- 32.5 minutes in the control group. Only 1.9% have had a prolonged second stage (more than 2 hours) in the shoulder dystocia group compared to 1.9% in the control group. The difference between the groups regarding the length of labor was not statistically significant. We conclude that protracted labor does not seem to be a risk factor for shoulder dystocia.
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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.
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To examine the outcome of trial second labor after a first cesarean performed because of cephalopelvic disproportion, defined according to strict diagnostic criteria. Obstetric details of nulliparous women delivering at 37 or more weeks' gestation by cesarean for cephalopelvic disproportion, between 1975 and 1990, were recorded prospectively. The diagnostic criteria for cephalopelvic disproportion were cervical dilation arrested after 5 cm, unresponsive to oxytocin augmentation, after active dilatation of 2 cm or more in 2 hours. Fetal malpresentations and malpositions were excluded. The outcome of next delivery in our hospital by each woman enrolled was then examined. Eighty-four of 42,793 women met the criteria for disproportion, and 40 with cephalic presentations delivered their next baby in our hospital. All 40 underwent a trial of labor and 27 (68%) delivered vaginally, comprising seven (47%) women with larger second and 20 (80%) with smaller second babies. Of 15 women previously delivered by cesarean at full dilatation, 11 (73%) delivered vaginally with no serious maternal or neonatal morbidity. The strictly defined diagnosis of nulliparous cephalopelvic disproportion should not constitute an automatic "recurrent" indication for elective cesarean delivery, because 68% of patients in our series had successful vaginal deliveries in their next pregnancies. This rate is similar to those reported after all nulliparous cesareans for dystocia.
Article
To identify risk factors associated with brachial plexus injury in a large population. A computerized data set containing records from hospital discharge summaries of mothers and infants and birth certificates was examined. The deliveries took place in more than 300 civilian acute care hospitals in California between January 1, 1994, and December 31, 1995. Cases of brachial plexus injury were evaluated for additional diagnoses and procedures of pregnancy, such as mode of delivery, gestational diabetes, and shoulder dystocia. Those complications were stratified by birth weight and analyzed, using bivariate and multivariate techniques to identify specific risk factors. Among 1,094,298 women who delivered during the 2 years, 1611 (0.15%) had diagnoses of brachial plexus injury. The frequency of diagnosis increased with the addition of gestational diabetes (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.7, 2.1), forceps delivery (OR 3.4, 95% CI 2.7, 4.3), vacuum extraction (OR 2.7, 95% CI 2.4, 3.1), and shoulder dystocia (OR 76.1, 95% CI 69, 84). In cases of brachial plexus injury, the frequency of shoulder dystocia increased from 22%, when birth weight ranged between 2.5 and 3.5 kg, to 74%, when birth weight exceeded 4.5 kg. The frequency of diagnosis of other malpresentation (nonbreech) (OR 73.6, 95% CI 66, 83) was increased for all birth weight categories. Severe (OR 13.6, 95% CI 8.3, 22.5) and mild (OR 6.3, 95% CI 3.9, 10.1) birth asphyxia were increased. Prematurity (OR 0.8, 95% CI 0.67, 0.98) and fetal growth restriction (OR 0.1, 95% CI 0.03, 0.40) were protective against brachial plexus injury. In macrosomic newborns, shoulder dystocia was associated with brachial plexus injury, but in low- and normal-weight infants, "other malpresentation" was diagnosed more frequently than shoulder dystocia. Our study findings suggest that brachial plexus injury has causes in addition to shoulder dystocia and might result from an abnormality during the antepartum or intrapartum period.
Article
Acquired brachial plexus injury historically has been linked with excessive lateral traction applied to the fetal head, usually in association with shoulder dystocia. Recent reports in the obstetric literature, however, have suggested that in utero forces may underlie a significant portion of these injuries. Brachial plexus palsies may therefore precede the delivery itself and may occur independent of the actions of the accoucheur. Thus we propose that the long-held notions of a traction-mediated pathophysiologic mechanism for all brachial plexus injuries warrant critical reappraisal.