A template for reviewing the strength of evidence for obstetric brachial plexus injury in clinical negligence claims

Abstract

Obstetric brachial plexus injury (OBPI) is uncommon but accounts for a significant proportion of obstetric clinical negligence claims. There is debate in the medical literature and in legal proceedings regarding the causation of OBPI, particularly whether OBPI is caused by the accoucheur applying excessive traction or simply through the forces of labour itself.This paper reviews the medical literature and legal case law surrounding OBPI and presents a template for reviewing the strength of evidence for OBPI in clinical negligence claims. The template contains factors more likely to be present if the OBPI was caused by the maternal forces of labour 'propulsion injury' (injury to the posterior arm, no documented evidence of shoulder dystocia, up-todate training, appropriate shoulder dystocia management, no evidence of excessive traction, correct number of birth attendants, precipitous second stage, temporary injury) and factors more likely if the injury is iatrogenic (injury to the anterior arm, shoulder dystocia, no recent training, incorrect shoulder dystocia resolution manoeuvres used, evidence of excessive traction, insufficient birth attendants, fundal pressure, permanent injury). Each factor does not, in itself, establish causation, but the template may provide a useful aid to legal teams reviewing medical notes.

Causation of permanent brachial plexus injuries to the anterior arm after shoulder dystocia – Literature review

“…The publication of clinical templates for CP has helped provide a framework to understand causation for affected individuals more accurately, 5,27 and there was a similar template published for NBPI in 2008. 1 However, since the ACOG document, new data have changed our understanding of causation for permanent, anterior arm NBPI after SD and the application of the template should also be reconsidered and updated.…”

“…Both the 2008 clinical template 1 and the recent ACOG report 6 suggest that posterior NBPIs are likely to be caused by impaction of the posterior shoulder on the sacral promontory where the uterine forces continue to push the baby down the birth canal, which stretches the foetal brachial plexus. In particular, the head travelling along the curve of carus could cause the necessary widening of the angle between the shoulder and head to cause the injury.…”

“…See for example, Croft However, the Courts did find some assistance from a template which provided indicators for determining between a propulsion and iatrogenic injury, published in 2008. 1 In Croft, Mr Justice Hickinbottom described the template as follows:…”

Shoulder dystocia: analysis from a risk management perspective

“…It is important to note which shoulder is anterior during delivery, as injury to the posterior shoulder is not believed to be the fault of the obstetrician. 9,10 A review paper by Draycott et al 11 introduces a template which can be used in legal cases to ascertain the cause of the brachial plexus injury. It compares the findings at delivery in cases caused by propulsive forces during birth or those caused by the attending obstetrician or midwife.…”

“…9,10 A review paper by Draycott et al . 11 introduces a template which can be used in legal cases to ascertain the cause of the brachial plexus injury. It compares the findings at delivery in cases caused by propulsive forces during birth or those caused by the attending obstetrician or midwife.…”