Brachial Plexus-Erb’s Palsy Injury with Shoulder Dystocia During Childbirth

Shoulder dystocia occurs during childbirth when after the head of the child is delivered, the anterior shoulder of the infant cannot pass below the pubic synthysis.  It is diagnosed when the shoulders fail to deliver spontaneously after the fetal head.

It is imperative that during the management of shoulder dystocia that the attending obstetrician not apply excess downward lateral traction, which can cause a brachial plexus injury.  Excess lateral traction is the most common cause of brachial plexus injuries and its utilization fails to meet standards of care and can result in the baby being delivered with Erb’s Palsy.  Traction on the head that is applied by the OBGYN at delivery can cause brachial plexus nerve injury.

Fetal maneuvers can reduce the incidence of bracial plexus palsy and are both safe and effective.  It has been described by Drs. Gurewitsch and Allen of the Johns Hopkins University School of Medicine that fetal manipulation is actually associated with a very low rate of injury compared to maternal maneuvers or traction alone.  Because of this, training in fetal maneuvers should be emphasized and should be prioritized in shoulder dystocia management algorithms.

Drs. Gurewitsch and Allen advised that clinicians need to think counterintuitively – to slow down, but keep track of time and use it wisely.  OBGYNs are advised to wait for a contraction, but not to push or pull, instead allowing the shoulders necessary time to rotate on their own.  They should actively increase their awareness of traction and their tendency to naturally increase it when faced with a difficult delivery.  Use of episiotomy should be only to gain access to perform fetal maneuvers and not as a maneuver in its own right.

Finally, Drs. Gurewitsch and Allen advise that obstetricians are urged not to fear fetal manipulations but rather to become adroit at them, by practicing on all shoulder dystocia delieveries and even on routine deliveries.  Researchers, educators and policy makers need to validate, prioritize and re-emphasize the advantage of fetal maneuvers for management of shoulder dystocia.