Obstetric Paralysis: Who is to blame? A systematic literature review* * Study developed at the Faculdade de Medicina de Marília, Marília, SP, Brazil.

José Antonio Galbiatti Fabrício Luz Cardoso Marília Gabriela Palacio Galbiatti About the authors

Abstract

Obstetric palsy is classically defined as the brachial plexus injury due to shoulder dystocia or to maneuvers performed on difficult childbirths. In the last 2 decades, several studies have shown that half of the cases of Obstetric palsy are not associated with shoulder dystocia and have raised other possible etiologies for Obstetric palsy. The purpose of the present study is to collect data from literature reviews, classic articles, sentries, and evidence-based medicine to better understand the events involved in the occurrence of Obstetric palsy. A literature review was conducted in the search engine PubMed (MeSH - Medical Subject Headings) with the following keywords: shoulder dystocia and obstetric palsy, completely open, boundless regarding language or date. Later, the inclusion criterion was defined as revisions. A total of 21 review articles associated with the themes described were found until March 8, 2018. Faced with the best available evidence to date, it is well-demonstrated that Obstetric palsy occurs in uncomplicated deliveries and in cesarean deliveries, and there are multiple factors that can cause it, relativizing the responsibility of obstetricians, nurses, and midwives. The present study aims to break the paradigms that associate Obstetric palsy compulsorily with shoulder dystocia, and that its occurrence necessarily implies negligence, malpractice or recklessness of the team involved.

Keywords
paralysis, obstetric; shoulder; dystocia; birth injuries

Resumo

A paralisia obstétrica é classicamente definida como a lesão do plexo braquial decorrente da distócia de ombros ou das manobras executadas no parto difícil. Nas 2 últimas décadas, vários estudos comprovaram que metade dos casos de paralisia obstétrica não estão associados à distócia de ombros e levantaram outras possíveis etiologias para a paralisia obstétrica. O objetivo do presente trabalho é colher dados da literatura de revisão, artigos clássicos, sentinelas e da medicina baseada em evidências para compreender melhor os eventos envolvidos na ocorrência de paralisia obstétrica. Foi realizada uma revisão da literatura no motor de busca da PubMed (MeSH - Medical Subject Headings) com as seguintes palavras-chave: shoulder dystocia and obstetric palsy, completamente aberto, sem limites de língua ou data. Posteriormente, definimos como critério de inclusão artigos de revisão. Encontramos 21 artigos de revisão com associação dos temas descritos até 8 de março de 2018. Frente às melhores evidências existentes até o momento, está bem demonstrado que a paralisia obstétrica ocorre em partos não complicados e em partos cesáreos, e são múltiplos os fatores que podem causá-la, relativizando a responsabilidade de médicos obstetras, enfermeiras e parteiras. Procuramos, com o presente estudo, quebrar os paradigmas de que paralisia obstétrica se associa obrigatoriamente à distócia de ombros e que a sua ocorrência necessariamente implica em negligência, imperícia ou imprudência da equipe envolvida.

Palavras-chave
paralisia obstétrica; ombro; distocia; traumatismos do nascimento

Introduction

Obstetric palsy (OP) is defined as a partial or total flaccid paralysis that affects the upper limb of the newborn due to brachial plexus injury occurring in normal delivery, and, more rarely, in cesarean section, often associated with shoulder dystocia (SD). It is also defined as palsy due to injury received at birth, according to the Health Sciences Descriptors (DeCS, in the Portuguese acronym).11 Descritores em Ciências da Saúde (DeCS) [Internet]. ed. 2017. São Paulo (SP): BIREME / OPAS / OMS. 2017 [acesso em 2017 dez 04]. Disponível em: http://decs.bvsalud.org
http://decs.bvsalud.org...

Shoulder dystocia (SD) or bisacromial dystocia occurs when the presentation is cephalic and the cephalic pole is already detached, but the shoulders do not come loose, and no other difficulties are observed22 Francisco RP, Fonseca ES, Sapienza DS. Parto e puerpério. In: Zugaib obstetricía. Barueri: Manole; 2008:307-529 (Figure 1).

Fig. 1
Shoulder dystocia.

Although rare, with an incidence in < 1% of births, it is a serious complication, whose occurrence increases considerably to ∼ 6% in cases of fetuses weighing > 4,000 g.33 Srofenyoh EK, Seffah JD. Prenatal, labor and delivery characteristics of mothers with macrosomic babies. Int J Gynaecol Obstet 2006;93(01):49-50,44 Piasek G, Starzewski J, Chil A, et al. [Analysis of labour and perinatal complications in case of foetus weight over 4000 g]. Wiad Lek 2006;59(5-6):326-331 Factors associated with this complication are maternal obesity, postdatism and gestational diabetes.33 Srofenyoh EK, Seffah JD. Prenatal, labor and delivery characteristics of mothers with macrosomic babies. Int J Gynaecol Obstet 2006;93(01):49-50

4 Piasek G, Starzewski J, Chil A, et al. [Analysis of labour and perinatal complications in case of foetus weight over 4000 g]. Wiad Lek 2006;59(5-6):326-331
-55 Seeho SK, Smith C, Mcelduff A, Morris JM. Diabetes Res Clin Pract 2007;77(02):263-268 Importantly, even in fetuses weighing < 4,000 g, SD may occur, especially when there is some degree of disproportion between the fetus and the maternal pelvis.22 Francisco RP, Fonseca ES, Sapienza DS. Parto e puerpério. In: Zugaib obstetricía. Barueri: Manole; 2008:307-529

Shoulder dystocia is associated with maternal complications, the most commonly described being birth canal lacerations, uterine atony with hemorrhage, pubic symphysis disjunction, and, occasionally, uterine rupture.22 Francisco RP, Fonseca ES, Sapienza DS. Parto e puerpério. In: Zugaib obstetricía. Barueri: Manole; 2008:307-529

Fetal complications are brachial plexus injuries and clavicle and humerus fractures, which may progress to intrapartum or neonatal death. The brachial plexus is formed by joining the anterior branches of the roots of C5, C6, C7, C8 and T1, emerging between the anterior and middle scalene muscles. In many cases, it receives a contribution from C4, when it is called prefixed. The situation in which this contribution is from T2 is called postfixed.66 Galbiatti JA, Falloppa F. Paralisia obstétrica. In: Herbert S, Xavier R, Pardini Junior AG, Barros Filho TEP, eds. Ortopedia e traumatologia: princípios e prática. 3a ed. Porto Alegre: Artmed; 2003:830-838 The brachial plexus is usually injured by excessive traction during labor, which can occur in up to 15% of newborns with bisacromial dystocia.77 Baxley EG,Gobbo RW. Shoulder dystocia. Am Fam Physician 2004;69(07):1707-1714 In most cases, the lesion resolves within 6 to 12 months, but severe cases may require surgery, with risk of permanent damage in up to 10% of occurrences.88 Athukorala C, Middleton P, Crowther CA. Intrapartum interventions for preventing shoulder dystocia. Cochrane Database Syst Rev 2006;(04):CD005543

Galbiatti,99 Galbiatti JA. Paralisia obstétrica. In: Faloppa F, AlbertoniWM,coord. Guia de Medicina Ambulatorial e Hospitalar da UNIFESP-EPM, Ortopedia e Traumatologia. São Paulo: Manole; 2008:273-284 Galbiatti et al66 Galbiatti JA, Falloppa F. Paralisia obstétrica. In: Herbert S, Xavier R, Pardini Junior AG, Barros Filho TEP, eds. Ortopedia e traumatologia: princípios e prática. 3a ed. Porto Alegre: Artmed; 2003:830-838 and Albertoni et al,1010 Albertoni WM, Galbiatti JA, Canedo AC, Merlotti M. Estudo anatômico do plexo braquial na criança até os seis meses de idade. Rev Bras Ortop 1994;29(03):162-169 in studies about OP, comment on anatomical bases and make a brief history of this lesion. The authors point out that this has been recognized since ancient times in the medical literature. It was briefly cited by Smellie in 1764. In 1872, Duchenne de Boulogne, in his “Traité de l'Électrisation Localisée”, used the term obstetric palsy and described upper root paralysis. Erb, in 1874, detailed the clinical picture of upper trunk OP (C5 and C6). In 1885, Klumpke described the rarer plasy of the lower roots (C8 and T1), which may be associated with the Claude Bernard-Horner syndrome.

The incidence of OP ranges from 0.1% to 0.4% of all live births. Despite advances in obstetric care, the incidence of OP may be increasing due to the larger number of newborns with high weight. Several risk factors were identified, including prolonged labor, high-weight newborns, difficult birth, forceps use, and previous deliveries concurrent with OP. Shoulder dystocia is the mechanical factor that results in upper trunk injury.1111 Sawyer JR. Brachial plexus palsy. In: Canale ST, Beaty JH, editors. Campbell's operative orthopaedics. 12th ed. Philadelphia: Elsevier; 2013:1323-1330 Significant risk factors are: child weight > 4,000 g, SD, and breech deliveries.1212 Slooff AC. Obstetric brachial plexus lesions and their neurosurgical treatment. Clin Neurol Neurosurg 1993;95(Suppl):S73-S77

The most common type of OP and which has a better prognosis is the plasy called high, or Erb-Duchenne (90% of cases), in which the roots of C5-C6 are affected and the most frequently involved muscles are the supraspinatus and the infraspinatus (Figure 2). There is also total (mixed) palsy, which presents both motor and sensory palsy of the entire extremity of the affected limb due to injury to all plexus roots; and low plasy, or Klumpke (C8-T1), in which the forearm and hand muscles are the most affected. The severity of the injury depends on the affected roots and its extent.

Fig. 2
Erb's obstetric paralysis.

Galbiatti et al66 Galbiatti JA, Falloppa F. Paralisia obstétrica. In: Herbert S, Xavier R, Pardini Junior AG, Barros Filho TEP, eds. Ortopedia e traumatologia: princípios e prática. 3a ed. Porto Alegre: Artmed; 2003:830-838 present the classic brachial plexus anatomy and explain that neural lesions can be classified into three functional categories, according to Seddon1313 Seddon HJ. Three types of nerve injury. Brain Oxford 1943;(66):37:

Neuropraxia: without neural morphological alteration, defined as localized conduction block due to metabolic alteration and clinically represented by motor palsy, mild sensory and sympathetic alteration, showing total recovery over a few weeks.

Axonotmesis: axonal interruption without endoneurial injury, leading to Wallerian degeneration distal to the lesion. Variable axonal regeneration occurs oriented by endoneurium preservation; the recovery time depends above all on the distance from the injury to the effectors (basically to the muscular motor plate).

Neurotmesis: determines a total nerve damage with destruction of internal and external structures. There is no spontaneous regeneration, requiring surgical treatment.

In the clinical practice, it is often difficult to classify lesions, especially axonotmesis. It must be considered also in relation to the brachial plexus injury, avulsions at the spinal cord level, also called preganglionic lesions, because they are proximal to the ganglions of motor neurons, which do not allow repair. In this situation, there is also injury to the posterior branch of the nerve root and it leads to the denervation of the paravertebral musculature of the cervical region.

The authors stress the importance of the most frequent differential diagnoses, which are cerebral palsy, clavicle and humeral shaft fractures, present in 10 to 15% of the cases with cephalic presentation.66 Galbiatti JA, Falloppa F. Paralisia obstétrica. In: Herbert S, Xavier R, Pardini Junior AG, Barros Filho TEP, eds. Ortopedia e traumatologia: princípios e prática. 3a ed. Porto Alegre: Artmed; 2003:830-838 Proximal humeral epiphyseal detachment, neonatal osteomyelitis, pyogenic shoulder arthritis, and congenital syphilis are also differential diagnoses.

Obstetric palsy is one of the complications associated with childbirth that needs to be better studied and understood, as it maintains its international incidence to the present day,1414 Beller FK. [Incidence and etiology of brachial plexus upper arm paralysis in newborn infants. A reviewand basic principles for legal assessment]. Z Geburtshilfe Neonatol 2000;204(05):163-169 taking place all over the world, not distinguishing rich or poor countries, young obstetrician surgeons or surgeons with extensive experience, obstetric nurses or midwives.

Against this background, the medicolegal demands related to unfavorable events related to childbirth, including OP, have been increasing. In this scope, particularly obstetricians are held responsible or blamed for these events that occur during their professional activity. It is set in a classic paradigm that, in the last decade, with the evolution of evidence-based medicine (EBM), is being broken. There are currently new studies proving new etiologies as having congenital or intrauterine origins, and caused by endogenous forces of childbirth, among others. In 1997, Paradiso et al1515 Paradiso G, Grañana N, Maza E. Prenatal brachial plexus paralysis. Neurology 1997;49(01):261-262 had already published an important article dealing with electroneuromyography (ENMG) examination at birth, demonstrating that brachial plexus injury could have occurred inside the uterus. The authors report on an 18-day-old child with a C5-C6 lesion whose ENMG examination was compatible with an old lesion dated before birth. There are cases in which certain children are born with palsy without labor abnormality, without dystocia and without any particular maneuver.

The classic definition bears signs that the cause would be dystocic deliveries or delivery maneuvers performed by the attending physician. This paper aims to gather data from the review literature, classic articles, sentinel data and evidence-based medicine for the professionals involved in these procedures, among them the medical expert, to have sufficient scientific support to better understand the events that occur during childbirth and to identify whose responsibility the OP really is.

With this review, we will, in the light of the latest studies, change the direction, at least partially, of the causes of OP.

Methods

A literature search was performed on the PubMed search engine (Medical Subject Headings [MeSH]) with the following keywords: shoulder dystocia and obstetric palsy, completely open, with no language or date limits. We found 87 articles. Subsequently, we defined as the inclusion criterion review articles, of which 22 review articles remained associated with the themes described until March 8, 2018. We excluded 1 article because it was the same study published in a different journal in the form of a compact version, remaining, therefore, 21 articles.

These 21 articles were given order numbers according to the growing chronology of the publication. These articles were characterized according to the main relevant points, with the following descriptors: shoulder dystocia, cesarean section, prevention, history, etiopathogenesis and medicolegal. When we included in the search engine descriptors specifically related to medical expertise, such as the descriptors expert or expert testimony, in addition to a limited number of articles, they fell into themes not included in our scientific proposal.

We performed a manual review of the 21 articles that originated our review and added to our bibliography articles that were cited in most publications and the articles considered classic or sentinel data (for these, the year of publication and language were not considered). With this concept, articles with a medicolegal nature were valued.

Results

A total of 87 articles were included based on the inclusion criteria mentioned above, excluding 66 that did not have review characteristics or were repeated compact-version publications by the same authors published in another journal. Effectively, 21 articles were used, 17 in the English language, 2 in the French language, and 2 in the German language.

The results show that there are no articles with adequate levels of evidence, being mostly literature reviews.

Regarding the year of publication, there was a variable distribution from 2000 to 2016 (Table 1).1414 Beller FK. [Incidence and etiology of brachial plexus upper arm paralysis in newborn infants. A reviewand basic principles for legal assessment]. Z Geburtshilfe Neonatol 2000;204(05):163-169,1616 Sandmire HF, DeMott RK. Erb's palsy without shoulder dystocia. Int J Gynaecol Obstet 2002;78(03):253-256

17 Krause M, Feige A. [Shoulder dystocia from a legal standpoint]. Z Geburtshilfe Neonatol 2005;209(06):201-209

18 Gherman RB, Chauhan S, Ouzounian JG, Lerner H, Gonik B, Goodwin TM. Shoulder dystocia: the unpreventable obstetric emergency with empiric management guidelines. Am J Obstet Gynecol 2006;195(03):657-672

19 Hankins GD, Clark SM, Munn MB. Cesarean section on request at 39 weeks: impact on shoulder dystocia, fetal trauma, neonatal encephalopathy, and intrauterine fetal demise. Semin Perinatol 2006;30(05):276-287

20 Gurewitsch ED. Optimizing shoulder dystocia management to prevent birth injury. Clin Obstet Gynecol 2007;50(03):592-606

21 Allen RH. On the mechanical aspects of shoulder dystocia and birth injury. Clin Obstet Gynecol 2007;50(03):607-623

22 Jevitt CM, Morse S, O'Donnell YS. Shoulder dystocia: nursing prevention and posttrauma care. J Perinat Neonatal Nurs 2008;22(01):14-20

23 Doumouchtsis SK, Arulkumaran S. Are all brachial plexus injuries caused by shoulder dystocia? Obstet Gynecol Surv 2009;64(09):615-623

24 O'Shea TM, Klebanoff MA, Signore C. Delivery after previous cesarean: long-term outcomes in the child. Semin Perinatol 2010;34(04):281-292

25 Doumouchtsis SK, Arulkumaran S. Is it possible to reduce obstetrical brachial plexus palsy by optimal management of shoulder dystocia? Ann N Y Acad Sci 2010;1205:135-143

26 Anderson JE. Complications of labor and delivery: shoulder dystocia. Prim Care 2012;39(01):135-144

27 Abzug JM, Kozin SH. Evaluation and management of brachial plexus birth palsy. Orthop Clin North Am 2014;45(02):225-232

28 Stitely ML, Gherman RB. Shoulder dystocia: management and documentation. Semin Perinatol 2014;38(04):194-200

29 Chauhan SP, Blackwell SB, Ananth CV. Neonatal brachial plexus palsy: incidence, prevalence, and temporal trends. Semin Perinatol 2014;38(04):210-218

30 Ouzounian JG. Risk factors for neonatal brachial plexus palsy. Semin Perinatol 2014;38(04):219-221

31 Legendre G, Bouet PE, Sentilhes L. Place de la simulation pour réduire la morbidité néonatale et maternelle secondaire à une dystocie des épaules. J Gynecol Obstet Biol Reprod (Paris) 2015;44(10):1285-1293

32 Schmitz T. Modalités de l'accouchement dans la prévention de la dystocie des épaules en cas de facteurs de risque identifiés. J Gynecol Obstet Biol Reprod (Paris) 2015;44(10):1261-1271

33 Hill MG, Cohen WR. Shoulder dystocia: prediction and management. Womens Health (Lond) 2016;12(02):251-261
-3434 Sentilhes L, Sénat MV, Boulogne AI, et al. Shoulder dystocia: guidelines for clinical practice from the French College of Gynecologists and Obstetricians (CNGOF). Eur J Obstet Gynecol Reprod Biol 2016;203:156-161

Table 1
Selected Articles

All of the major studies were literature reviews, as this is one of the premises of the method, and the number of articles in their bibliography ranged from 11 to 121 articles reviewed.

The data regarding the number order, type of study, number of bibliographies used for each article, the most important points and conclusions of the study are shown in Table 2.

Table 2
Detailed data of the articles

Discussion

Obstetric palsy is classically defined as partial or total flaccid palsy that affects the upper limb due to brachial plexus injury in childbirth. This concept is present in both orthopedic and obstetric textbooks22 Francisco RP, Fonseca ES, Sapienza DS. Parto e puerpério. In: Zugaib obstetricía. Barueri: Manole; 2008:307-529,66 Galbiatti JA, Falloppa F. Paralisia obstétrica. In: Herbert S, Xavier R, Pardini Junior AG, Barros Filho TEP, eds. Ortopedia e traumatologia: princípios e prática. 3a ed. Porto Alegre: Artmed; 2003:830-838; however, the literature of the last 2 decades has shown that more than half of the cases are not associated with shoulder dystocia.1414 Beller FK. [Incidence and etiology of brachial plexus upper arm paralysis in newborn infants. A reviewand basic principles for legal assessment]. Z Geburtshilfe Neonatol 2000;204(05):163-169,2323 Doumouchtsis SK, Arulkumaran S. Are all brachial plexus injuries caused by shoulder dystocia? Obstet Gynecol Surv 2009;64(09):615-623,3535 Sandmire HF, DeMott RK. Erb's palsy causation: a historical perspective. Birth 2002;29(01):52-54 Other etiologies have been considered, such as congenital and intrauterine origin, and those caused by endogenous forces of childbirth, among others.

We currently have ample evidence that many other factors may be involved in the cause of OP, unrelated to the delivery maneuvers performed by obstetricians.

Zaki et al,3636 Zaki MSI, el Sabbagh MH, Aglan MS. Familial congenital brachial palsy: a report of two affected Egyptian families. Genet Couns 2004;15(01):27-36 in a study on congenital familial injury of brachial plexus palsy present a two-level report on Egyptian families affected at birth, characterized it as relatively uncommon and almost a sporadic disorder. Mollica et al3737 Mollica F, Li Volti S, Grasso A, De Simone D. Familial congenital brachial palsy. Am J Med Genet 1991;41(03):322-324 describe a Sicilian family with congenital severe brachial plexus injury and suggest that the gene has autosomal dominant inheritance with reduced penetrance. The authors report that X-linked inheritance with expression in heterozygous women cannot be ruled out.

Uterine malformations and propulsive forces in the second phase of childbirth are the main etiological factors for plexus injuries,1616 Sandmire HF, DeMott RK. Erb's palsy without shoulder dystocia. Int J Gynaecol Obstet 2002;78(03):253-256,1818 Gherman RB, Chauhan S, Ouzounian JG, Lerner H, Gonik B, Goodwin TM. Shoulder dystocia: the unpreventable obstetric emergency with empiric management guidelines. Am J Obstet Gynecol 2006;195(03):657-672,2525 Doumouchtsis SK, Arulkumaran S. Is it possible to reduce obstetrical brachial plexus palsy by optimal management of shoulder dystocia? Ann N Y Acad Sci 2010;1205:135-143,3535 Sandmire HF, DeMott RK. Erb's palsy causation: a historical perspective. Birth 2002;29(01):52-54,3838 McAbee GN, Ciervo C. Medical and legal issues related to brachial plexus injuries in neonates. J Am Osteopath Assoc 2006;106(04):209-212,3939 Gherman RB, Ouzounian JG, Goodwin TM. Obstetric maneuvers for shoulder dystocia and associated fetal morbidity. Am J Obstet Gynecol 1998;178(06):1126-1130 especially in cases without shoulder dystocia.

Among the uterine causes, we can highlight uterine malformations such as fibroids, intrauterine septum or bicornuate uterus.2525 Doumouchtsis SK, Arulkumaran S. Is it possible to reduce obstetrical brachial plexus palsy by optimal management of shoulder dystocia? Ann N Y Acad Sci 2010;1205:135-143 Intrauterine maladaptation (e.g. oligohydramnios) may be related to decreased resistance of brachial plexus nerve bundles or scapular girdle structures, leading to plexus injury.4040 Alfonso DT. Causes of neonatal brachial plexus palsy. Bull NYU Hosp Jt Dis 2011;69(01):11-16

Regarding vaginal delivery, we can divide it didactically into three phases: the first is dilation and corresponds to the lowering of the fetus to the fitting axis of the bone pelvis. The second phase is expulsion, which lasts between 30 minutes and 2 hours.

The second phase is subdivided into two stages: the first is the completion of the descent and rotation of the presentation, and the second is the actual descent, in which the abdominal pressure must be controlled and directed with the uterine contractions to expel the fetus.22 Francisco RP, Fonseca ES, Sapienza DS. Parto e puerpério. In: Zugaib obstetricía. Barueri: Manole; 2008:307-529 In the second stage, shoulder dystocia and plexus injuries may occur due to compression of the posterior shoulder against the sacral promontory during uterine contractions. According to mathematical models, the expulsive forces are four to nine times greater than the traction exerted by the obstetrician.2525 Doumouchtsis SK, Arulkumaran S. Is it possible to reduce obstetrical brachial plexus palsy by optimal management of shoulder dystocia? Ann N Y Acad Sci 2010;1205:135-143,3535 Sandmire HF, DeMott RK. Erb's palsy causation: a historical perspective. Birth 2002;29(01):52-54

The third and last phase of labor begins at birth and ends when the placenta is delivered.

Due to this new knowledge, Gherman et al3939 Gherman RB, Ouzounian JG, Goodwin TM. Obstetric maneuvers for shoulder dystocia and associated fetal morbidity. Am J Obstet Gynecol 1998;178(06):1126-1130 as early as 1998, in their review, stated that indirect evidence established maternal driving forces as the most likely cause of Erb palsy, both in cases with associated SD and in cases without it, since direct fetal manipulation techniques for SD resolution were not associated with higher rates of plexus injury, humerus or clavicle fractures. Sandmire et al1616 Sandmire HF, DeMott RK. Erb's palsy without shoulder dystocia. Int J Gynaecol Obstet 2002;78(03):253-256 in 2002, Gherman et al1818 Gherman RB, Chauhan S, Ouzounian JG, Lerner H, Gonik B, Goodwin TM. Shoulder dystocia: the unpreventable obstetric emergency with empiric management guidelines. Am J Obstet Gynecol 2006;195(03):657-672 in 2006, Doumouchtsis et al2525 Doumouchtsis SK, Arulkumaran S. Is it possible to reduce obstetrical brachial plexus palsy by optimal management of shoulder dystocia? Ann N Y Acad Sci 2010;1205:135-143 in 2010 and Abzug et al2727 Abzug JM, Kozin SH. Evaluation and management of brachial plexus birth palsy. Orthop Clin North Am 2014;45(02):225-232 in 2014, respectively, evidenced this knowledge in their reviews, giving enough information to conclude that the recent emphasis on EBM undermined many of the myths and misconceptions surrounding shoulder dystocia. Therefore, the influence attributed to the attending physician during delivery, in relation to brachial plexus injury, needs to be revised.

The main risk factors for brachial plexus injury are: fetal macrosomia (fetal weight > 4,000 g), pelvic presentation and shoulder dystocia.22 Francisco RP, Fonseca ES, Sapienza DS. Parto e puerpério. In: Zugaib obstetricía. Barueri: Manole; 2008:307-529,66 Galbiatti JA, Falloppa F. Paralisia obstétrica. In: Herbert S, Xavier R, Pardini Junior AG, Barros Filho TEP, eds. Ortopedia e traumatologia: princípios e prática. 3a ed. Porto Alegre: Artmed; 2003:830-838,1111 Sawyer JR. Brachial plexus palsy. In: Canale ST, Beaty JH, editors. Campbell's operative orthopaedics. 12th ed. Philadelphia: Elsevier; 2013:1323-1330,1212 Slooff AC. Obstetric brachial plexus lesions and their neurosurgical treatment. Clin Neurol Neurosurg 1993;95(Suppl):S73-S77,1919 Hankins GD, Clark SM, Munn MB. Cesarean section on request at 39 weeks: impact on shoulder dystocia, fetal trauma, neonatal encephalopathy, and intrauterine fetal demise. Semin Perinatol 2006;30(05):276-287,2121 Allen RH. On the mechanical aspects of shoulder dystocia and birth injury. Clin Obstet Gynecol 2007;50(03):607-623,2626 Anderson JE. Complications of labor and delivery: shoulder dystocia. Prim Care 2012;39(01):135-144,3535 Sandmire HF, DeMott RK. Erb's palsy causation: a historical perspective. Birth 2002;29(01):52-54 Maternal obesity, maternal or gestational diabetes, excessive weight gain during pregnancy, male fetus, prematurity, previous history of fetal macrosomia, anterior dystocic deliveries, multiparity, forceps instrumentation, advanced maternal age and post-term birth are considered secondary risk factors.1818 Gherman RB, Chauhan S, Ouzounian JG, Lerner H, Gonik B, Goodwin TM. Shoulder dystocia: the unpreventable obstetric emergency with empiric management guidelines. Am J Obstet Gynecol 2006;195(03):657-672,2121 Allen RH. On the mechanical aspects of shoulder dystocia and birth injury. Clin Obstet Gynecol 2007;50(03):607-623,3939 Gherman RB, Ouzounian JG, Goodwin TM. Obstetric maneuvers for shoulder dystocia and associated fetal morbidity. Am J Obstet Gynecol 1998;178(06):1126-1130,4040 Alfonso DT. Causes of neonatal brachial plexus palsy. Bull NYU Hosp Jt Dis 2011;69(01):11-16 Ouzounian3030 Ouzounian JG. Risk factors for neonatal brachial plexus palsy. Semin Perinatol 2014;38(04):219-221 argues that caesarean section reduces but does not completely eliminate the risk of brachial plexus injury.

Despite multiple risk factor analyses in the literature, shoulder dystocia cannot be predicted or avoided, because the precise methods to identify which fetuses will experience this complication do not exist. Prenatal and prelabor data have low predictive value.1818 Gherman RB, Chauhan S, Ouzounian JG, Lerner H, Gonik B, Goodwin TM. Shoulder dystocia: the unpreventable obstetric emergency with empiric management guidelines. Am J Obstet Gynecol 2006;195(03):657-672,2222 Jevitt CM, Morse S, O'Donnell YS. Shoulder dystocia: nursing prevention and posttrauma care. J Perinat Neonatal Nurs 2008;22(01):14-20,2424 O'Shea TM, Klebanoff MA, Signore C. Delivery after previous cesarean: long-term outcomes in the child. Semin Perinatol 2010;34(04):281-292,2626 Anderson JE. Complications of labor and delivery: shoulder dystocia. Prim Care 2012;39(01):135-144 Ultrasound examination performed late in pregnancy also has low sensitivity, with poor accuracy in estimating birthweight – there is a general tendency to overrate it. It should also be noted that SD most commonly occurs in patients without risk factors.2626 Anderson JE. Complications of labor and delivery: shoulder dystocia. Prim Care 2012;39(01):135-144

As the risk of shoulder dystocia is directly proportional to the increased fetal weight,3939 Gherman RB, Ouzounian JG, Goodwin TM. Obstetric maneuvers for shoulder dystocia and associated fetal morbidity. Am J Obstet Gynecol 1998;178(06):1126-1130 prophylactic cesarean section has been proposed in selected cases.3232 Schmitz T. Modalités de l'accouchement dans la prévention de la dystocie des épaules en cas de facteurs de risque identifiés. J Gynecol Obstet Biol Reprod (Paris) 2015;44(10):1261-1271,3333 Hill MG, Cohen WR. Shoulder dystocia: prediction and management. Womens Health (Lond) 2016;12(02):251-261 According to the American College of Obstetricians and Gynecologists (ACOG) and Schmitz,3232 Schmitz T. Modalités de l'accouchement dans la prévention de la dystocie des épaules en cas de facteurs de risque identifiés. J Gynecol Obstet Biol Reprod (Paris) 2015;44(10):1261-1271 we must consider it in fetuses of diabetic mothers with estimated weight > 4,500 g or in fetuses with > 5,000g of mothers with no risk factors. Other authors, like Hankins et al,1919 Hankins GD, Clark SM, Munn MB. Cesarean section on request at 39 weeks: impact on shoulder dystocia, fetal trauma, neonatal encephalopathy, and intrauterine fetal demise. Semin Perinatol 2006;30(05):276-287 recommend it for fetuses of diabetic mothers with weight estimates between 4,000 to 4,250 g or > 4,000g in pregnancies of nondiabetic women.

A better understanding of the causes of OP is necessary, since the medicolegal demands have increased worldwide, and, in most cases where there is permanent loss of upper limb function, the attending physician is required to indemnify the family of the child for malpractice. According to the Health Insurance Association of America, from January 1985 to December 2001, the average amount paid for indemnities related to brachial plexus injury was US$301,000.00 (∼ 4x more than the average amount paid due to malpractice for other causes in the same period), in a total value of US$54 million. The indemnity values were higher for medical assistants of educational institutions.3838 McAbee GN, Ciervo C. Medical and legal issues related to brachial plexus injuries in neonates. J Am Osteopath Assoc 2006;106(04):209-212

To avoid these contentious situations, Noble4141 Noble A. Brachial plexus injuries and shoulder dystocia: medico legal commentary and implications. J Obstet Gynaecol 2005;25(02):105-107 advises to make accurate and detailed records for a successful defense. However, the fundamental thing remains the doctor-patient relationship. Hickson et al4242 Hickson GB, Clayton EW, Githens PB, Sloan FA. Factors that prompted families to file medical mal practice claims following perinatal injuries. JAMA 1992;267(10):1359-1363 demonstrated in their study that 70% of the mothers who sued obstetricians for perinatal injuries in their newborns complained that these professionals did not adequately inform them about possible permanent injuries in the neuropsychomotor development of their children. Informing the risks inherent in childbirth, such as the fact that brachial plexus injuries are not necessarily due to birth trauma, and trying to understand the fears and anxieties of the patient, is essential to minimize medicolegal issues.3636 Zaki MSI, el Sabbagh MH, Aglan MS. Familial congenital brachial palsy: a report of two affected Egyptian families. Genet Couns 2004;15(01):27-36

The training of the surgical team and the full understanding of the pelvic and fetal anatomy, as well as mechanisms, algorithms and maneuvers by which dystocia can be resolved, epidemiological knowledge of the incidence, prevalence and temporal changes of neonatal brachial plexus paralysis, are of fundamental importance for the proper management of an obstetric center.1919 Hankins GD, Clark SM, Munn MB. Cesarean section on request at 39 weeks: impact on shoulder dystocia, fetal trauma, neonatal encephalopathy, and intrauterine fetal demise. Semin Perinatol 2006;30(05):276-287,2929 Chauhan SP, Blackwell SB, Ananth CV. Neonatal brachial plexus palsy: incidence, prevalence, and temporal trends. Semin Perinatol 2014;38(04):210-218,3232 Schmitz T. Modalités de l'accouchement dans la prévention de la dystocie des épaules en cas de facteurs de risque identifiés. J Gynecol Obstet Biol Reprod (Paris) 2015;44(10):1261-1271,3333 Hill MG, Cohen WR. Shoulder dystocia: prediction and management. Womens Health (Lond) 2016;12(02):251-261,3434 Sentilhes L, Sénat MV, Boulogne AI, et al. Shoulder dystocia: guidelines for clinical practice from the French College of Gynecologists and Obstetricians (CNGOF). Eur J Obstet Gynecol Reprod Biol 2016;203:156-161 Legendre et al,3131 Legendre G, Bouet PE, Sentilhes L. Place de la simulation pour réduire la morbidité néonatale et maternelle secondaire à une dystocie des épaules. J Gynecol Obstet Biol Reprod (Paris) 2015;44(10):1285-1293 advocate in their study the initial and ongoing practical training of the various actors in the birth room using mannequins, that according to the authors is associated with more improvements in shoulder dystocia management than training using a video tutorial.

Final considerations

We believe that, with this literature review, we can undoubtedly help to break the paradigm established since ancient times that this injury would be caused solely and exclusively by medical malpractice. The literature is changing its direction, demonstrating that there are other multiple causes or co-causes for the occurrence of obstetric paralysis, some of them without any involvement of the medical team.

Therefore, on the question of who is responsible for OP, there is currently indirect evidence that establishes that maternal (endogenous) driving forces may be the most likely cause of brachial plexus paralysis at birth, births without SD and children weighing < 4,000 g. Obstetric palsy may have intrauterine, genetic or postural origin, and it is important for medicolegal protection not only the fulfillment of medical records, as well as electroneuromyography examination up to 21 days after birth to determine if it occurred inside the uterus or at birth. There is still a need for new well-based and prospective publications with EBM to better define which is (or are) the real responsible for the occurrence of OP.

  • *
    Study developed at the Faculdade de Medicina de Marília, Marília, SP, Brazil.

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Publication Dates

  • Publication in this collection
    15 May 2020
  • Date of issue
    Mar-Apr 2020

History

  • Received
    12 Mar 2018
  • Accepted
    06 Aug 2018
Sociedade Brasileira de Ortopedia e Traumatologia Al. Lorena, 427 14º andar, 01424-000 São Paulo - SP - Brasil, Tel.: 55 11 2137-5400 - São Paulo - SP - Brazil
E-mail: rbo@sbot.org.br