What is Erb’s Palsy?

Erb’s Palsy is a nerve injury that effects the movement of a child’s shoulder, arm, and hand. The injury usually happens when too much force is used when the delivery staff pulls on the baby’s head in an effort to remove a baby stuck in the birth canal. The baby may be too large to fit easily through the birth canal. When the baby’s shoulder gets stuck in the birth canal, it is called “shoulder dystocia.”

Pulling on the baby’s head stretches and injures the nerves in the baby’s shoulder. The injured nerves are between the shoulder and the neck. These nerves carry signals from the spinal cord to move the baby’s arm, hand, and fingers. This collection of nerve fibers is called the “brachial plexus,” or “Erb’s Point” (hence the name Erb’s Palsy, or Brachial Plexus Palsy).

Most of the time these nerves are only mildly injured, and the baby may regain movement in a few months. Unfortunately, about 20% of the time, the injury is so severe, or the nerves are actually avulsed (torn from their points of attachment to the spine), or they may be ruptured, so that paralysis of the arm and shoulder is permanent.

How can I tell if my baby might have suffered an injury to his brachial plexus?

This injury may result in varying degrees of weakness or paralysis of the shoulder, arm, or hand. Which part of the arm is involved depends on which nerves in this big network, or plexus, of nerves is injured. A baby with this injury typically holds his limp arm down by his side with forearm turned inward and wrist bent. The child can’t lift the arm up and doesn’t bring it up even when she or he is startled. A baby with a very bad injury may also have a droopy eyelid on the side that was injured (a condition called “ptosis”), in addition to an injury to his arm. Ptosis is one of the signs of “Horner’s Syndrome,” another condition known to result from injuries to some of the nerves making up the brachial plexus.

What tests can be done to diagnose this injury?

Your baby’s physician may order an x-ray of the neck -- an MRI -- and maybe even nerve conduction tests (abbreviated as NCV/EMG’s). A pediatric neurologist may be asked to evaluate the degree of injury; therapists might be also be called in to design slings or splints, to perform and teach the parents to do exercises to keep the arm limber and to be part of a rehabilitation process. In some cases, surgeries performed in the baby’s first few months have been helpful to restore some function to the affected arm and hand.

Is Erb’s Palsy Avoidable?

Sadly, the answer is yes. Most Erb’s Palsies can be prevented.

So how can this injury be prevented?

1. It can be avoided by having good health care during pregnancy such as:
   
   1. Blood sugars of mothers with diabetes mellitus or gestational diabetes require vigilant monitoring. They also require good dietary teaching, and tight control of blood sugars through diet or medication administration throughout the pregnancy. We know that high blood sugars (blood glucose levels) “overnourish” the baby and make it gain weight faster than an average fetus. Babies born to mothers with gestational diabetes are also thought to have broader shoulders, in addition to generally increased birth weights, and larger babies are more likely to get stuck in the birth canal.
   2. Your obstetrician or midwife should be evaluating whether you have risk factors, and whether they should consider recommending that the parents consider a cesarean delivery rather than vaginal delivery.

   Risk factors that are more likely to result in difficult deliveries, brachial plexus injuries and Erb’s Palsy include:

   • Larger babies (especially those weighing over 8 1/2 pounds at birth)
   • Larger babies, predictably, are born to mother’s with diabetes, or gestational diabetes, particularly if the blood sugars have not been carefully monitored and managed;
   • Mothers with smaller pelvises or smaller pelvic openings;
   • Mothers who have had multiple births or who delivered another child with high birth weight;
   • Mothers who have had a prior child with shoulder dystocia, regardless of whether the previous child had a brachial plexus injury;
   • Mothers whose own birth weight was above normal or who were obese before conception or who had excessive weight gain during pregnancy;
   • Mothers who give birth at the age of 30 or older;
   • Prolonged labors;
   • Breech position;
   • Fetal malposition in the birth canal;
   • A Post-term pregnancy;
   • Mothers who have had their labor induced and
   • Mothers who had their labor speeded up with drugs like Cervadil, Pitocin, or Cytotec or where the baby’s delivery was assisted by the obstetrician using a vacuum or forceps.


2. Good advance planning by your obstetrician can lead to an earlier delivery in the event your baby is thought to be too big for an easy, safe delivery. A large baby can be delivered a few days or weeks early, before s/he becomes too large for delivery vaginally. (A large baby is called “macrosomic”). This is a situation where an ounce of prevention is worth several pounds of cure.

   Risk factors that are known to result in difficult deliveries often can and should lead the midwife or obstetrician to deliver by cesarean section.

3. Parents should be informed and involved in anticipatory decision-making, not last minute crises during delivery.
   • Parents deserve to be informed of the risks that could lead to a difficult delivery with shoulder dystocia. Together with their obstetrician or midwife, they should explore the options, such as an earlier induction or a planned delivery by cesarean section, in the event that risk factors are present.


4. In the event that a baby’s shoulder becomes wedged behind the mother’s pubic bone (shoulder dystocia), there are several techniques and maneuvers to dislodge the stuck shoulder safely. A team of nurses and doctors with current knowledge and skill in the techniques for these deliveries are less likely to deliver an injured baby.

   Below are the McRoberts’ Maneuver on the left, and the Woods’ Screw Maneuver on the right, which are two of the most common techniques to dislodge the baby when it has gotten stuck.

   Your birthing facility has a duty to be sure that their obstetrics teams have continuing education and skill training, so that they have current knowledge and skills to deal with these challenges when they occur.

Bottom Line: Erb’s palsy is almost always a preventable birth defect.

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