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Erbs Palsy and brain injury: mechanisms and manifestations

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    In our next blog for Erb’s Palsy awareness week, Joachim looks at the connection between shoulder dystocia, Erb’s Palsy and brain injuries.

    By Joachim Stanley

When shoulder dystocia (when the baby’s shoulders become stuck during birth) occurs, Erb’s palsy can result.  This is a permanent injury involving one or more of the nerves in the brachial plexus, which causing differing levels of injury to the arm depending on how severely the nerves are injured.

It seems to be less well recognised that shoulder dystocia can also lead to a brain injury to the baby, as this may not be immediately apparent, whereas an injury to the arm can usually be noticed very shortly following birth. There can be oxygen starvation (either partial or total) during the interval between the delivery of the baby’s head and its body, which is why the occurrence of shoulder dystocia should always be treated as an emergency.   If prompt action to resolve the situation is not taken, the chances of the child suffering a brain injury increase because the baby can be left without oxygen for longer than they are able to cope with.  The increased level of risk of brain damage is broadly in proportion to the length of the delay in their delivery following shoulder dystocia.

My colleagues and I have acted in cases where children have suffered such injury as a result of shoulder dystocia. In such cases we work with independent experts such as neonatologists (a doctor who specialises in caring for newborn babies) and paediatric neurologists, and we are advised that when the oxygen supply to a baby’s brain is compromised, a condition known as hypoxic ischaemic encephalopathy (HIE) may be caused.   Like shoulder dystocia itself, HIE is dangerous, and must be treated promptly.  There are various ways of ascertaining whether oxygen starvation has occurred, including measurements taken from the blood from the umbilical cord.   The interpretation of the blood gas results is complex, but in basic terms, the more acidic the blood samples are, the more likely it is that there has been severe oxygen starvation in the period immediately prior to the baby’s delivery.

Babies who have suffered HIE will suffer fitting or seizures in the first few days of life (fitting is one of the diagnostic criteria for HIE). The correct response to such fitting is to do a brain scan.  This would normally not be performed immediately, but probably after some days had elapsed.  This is because it takes time for a brain injury to manifest itself on imaging.   Usually either an ultrasound scan or an MRI (magnetic resonance imaging) scan is performed.  Unfortunately, a normal scan doesn’t entirely rule out the presence of a brain injury as damage can sometimes be too subtle for the equipment to detect.

The effects of a brain injury

The effects of HIE vary enormously, depending primarily upon the length and degree of oxygen starvation that occurred.

At the extreme end of the spectrum, a very serious brain injury might well occur. The effects of such an injury can be profound. A moderate or mild brain injury may also occur.  The signs of a mild brain injury are often subtle, and may not be detected until some way into the child’s life.

Babies who suffer mild or moderate hypoxic ischaemic encephalopathy will not necessarily develop a permanent brain injury, and indeed one study suggests that only about a quarter of those affected will suffer such an injury. Other children will be left with problems with movement.  Still others may avoid motor dysfunction and manifest quite subtle cognitive impairments.  One study dating from 2010 concluded that in the absence of cerebral palsy, childhood survivors of neonatal encephalopathy are at increased risk of cognitive, behavioural and memory difficulties.  The picture is particularly complex in the case of children with Erb’s, as motor skills would have to be assessed in the presence of a condition that could mask underlying problems.  I will be looking more closely at potential developmental issues in my blog tomorrow.

It is not unusual for children with mild brain injuries to experience additional difficulties at around the time they enter secondary education.   This is partly because educational demands typically increase at this time, and partly because children at this age are expected to manifest a greater degree of independence than was formerly the case.

If a subtle brain injury is suspected, that possibility should always be raised with healthcare professionals.   A prompt diagnosis can facilitate educational and pastoral assistance.  The more rapidly that assistance is provided, the better the child’s chances of maximising his or her potential.

Our experience

From the perspective of pursuing a claim, if there is indication of negligence in the management of shoulder dystocia which may have delayed the baby’s delivery, then it is important that the full extent of the child’s injuries are appreciated when considering the level of compensation that should be paid. Whilst the physical problems associated with Erb’s Palsy are more immediately apparent, it can take longer for the full extent of the problems to be understood until the child reaches an age where they start to become more independent.  If there is indication that the baby may have suffered from oxygen starvation during their birth, then it is equally important that any ongoing injury as a result is recognised, and we may therefore advising postponing concluding a claim until the child is old enough that the full extent of their injuries will be known.  This is something that your legal team will advise you on fully.

 

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