Cause and Effect of Obstetric (Neonatal) Brachial Plexus Palsy

Mehlman

Journal of Children's Orthopaedics

et al. 2009

Purpose The spontaneous recovery rate of neonatal brachial plexus palsy (NBPP) is often cited as 75-95%. However, recent reports have found the recovery rate to be much lower. The purpose of this study was to perform an evidence-based review aimed at summarizing the available English language information regarding prognosis following NBPP based on the Narakas classification. Methods A Medline database search was performed to identify articles that focused on the natural history, outcome, prognosis, or conservative treatment of neonatal brachial plexus birth injury from 1966 to 2006. Twentyfour articles were identified. The articles were graded according to the Oxford Evidence Based Grading Scale and data regarding sample size, follow up, study purpose, Narakas grouping, Mallet scale, and recovery of function at 3 and 6 months were extracted. Of the 24 articles, 11 were included for review. Data analysis included odds ratios and percent recovery. Results Of the 11 studies, only one was given a grade of a Level I study, three were given a grade of Level II, and seven were given a grade of Level IV. Sixty-four percent of infants classified as Narakas I and II had spontaneous recovery of biceps function at 3 months of age and only 9% of the Narakas III and IV group had recovery. Sixtyfive percent of the Narakas I and II group had complete recovery at 6 months of age and only 14% of the Narakas III and IV group had recovery. The odds of biceps recovery at 3 months of age for the Narakas I and II group was 19 times higher compared to the III and IV group. The odds of complete recovery were 11 times higher for the Narakas I and II group compared to the III and IV group. Conclusion The quality of the literature regarding the prognosis of neonatal brachial plexus injury is poor. Based on the Narakas classification, recovery better for NBPP classified as Narakas I and II.

“…Forty-eight children were identified with NBPP [11]. Thirteen (27%) of these children had permanent sequela and four (8%) were considered to be 'almost well' by 12-18 months of age [11].…”

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Prognosis following neonatal brachial plexus palsy: An evidence-based review

Mehlman

Journal of Children's Orthopaedics

et al. 2009

Acta Obstet Gynecol Scand

“…The incidence of OBPP is between 0.5% and 5 ‰ in countries with well developed obstetric services (6)(7)(8)(9)(10)(11)(12). Reduction in incidence from 1.56 per 1000 live births in 1938 to 0.28 per 1000 in 1962 was reported in New York.…”

Section: Incidencementioning

confidence: 99%

“…The authors ascribed the reduction to improved obstetric practice (13). Subsequent reports, including two population-based studies from Sweden (10,11), have suggested an increase in the incidence, possibly due to an increase in mean birth weight (10,11,(14)(15)(16). However, the incidence in the United Kingdom and Ireland has not changed in nearly 40 years (17).…”

Section: Incidencementioning

confidence: 99%

High birthweight and shoulder dystocia: the strongest risk factors for obstetrical brachial plexus palsy in a Swedish population‐based study

Mollberg

Hagberg

Bager

et al. 2005

137

Background: Obstetric brachial plexus palsy (OBPP) at birth is one important cause of neurological disability in children and adults; the incidence has increased substantially in Sweden over the past decade. Several risk factors for OBPP have been identified, e.g. high birth weight and shoulder dystocia, but it remains difficult to predict based on antenatally available information. Despite extensive research on OBPP, there is no generally accepted strategy for prevention. The overall objective of this thesis is to study predisposing risk factors for OBPP in vaginally delivered infants and to identify specific obstetric procedures that are strongly associated with OBPP. Based on this knowledge, our ultimate aim is to develop a prevention strategy with respect to manual assistance in the second stage of labour. Methods: Paper I reports on a retrospective case-control study aimed at investigation of the incidence and risk factors for OBPP in a large population studied in 1987-1997. All deliveries recorded in the Swedish Medical Birth Register during the period were investigated. Cases of OBPP were compared with all cases without OBPP. Paper II describes a retrospective casecontrol study, the purpose of which was to identify risk factors for OBPP, specifically in women delivered by vacuum extraction. The groups with and without OBPP were compared with regard to possible risk factors, including those linked to the vacuum extraction procedure. The aim of the prospective population-based case-control study presented in Paper III was to evaluate the association between OBPP and obstetric manoeuvres during the second stage of delivery. Obstetric management in OBPP cases was compared to management in a randomly selected control group. Paper IV and Paper III are based on the same cases. The aims of the study presented in Paper IV were a) to describe neurological deficits in children with remaining OBPP at 18 months of age; b) to compare maternal, infant and obstetric data in infants with and without OBPP at 18 months of age and c) to evaluate if differences in force applied in downward traction of the head (ranked on a 100-point visual analogue scale) correlated to the number of affected nerve roots (C5-C6, C5-C7, C5-Th1). Results:The incidence of OBPP in Sweden increased from 0.17% to 0.27% between 1987 and 1997. Infants with high birth weight, especially >4500 g, were at increased risk of shoulder dystocia and OBPP. However, high birth weight was not or only weakly overrepresented among children with persistent OBPP, compared with those who recovered, suggesting that other factors are important. Hence, many factors related to prolonged second stage and difficulties in delivering the shoulders were overrepresented in the OBPP group, compared to controls. In particular, forceful downward traction applied to the head after the fetal third rotation represented an important risk factor for OBPP in cephalic-presentation vaginal deliveries. Downward traction of the head had been applied more often and with greater force in the...

“…Although other studies found multiparity to be a significant risk factor, 15,16 its high prevalence in our population was found equally in both groups. Although the association with high birthweight, cephalic presentation and dystocia was found in other studies, [15][16][17] the association with maternal diabetes was only reported in one other study, 16 and no previous reports have shown a correlation with fetal distress, meconium-stained liquor, neonatal depression, maternal perineal lacerations or episiotomy, factors that might indicate difficult labor and fetal hypoxic-ischemic compromise. The great majority of infants (97.3%) recovered normal brachial plexus function except one (2.7%), who has persistent weakness after four years.…”

Section: Brachial Plexus Palsymentioning

confidence: 80%

Clavicle Fracture and Brachial Plexus Palsy in the Newborn: Risk Factors and Outcome

Narchi

Kulaylat²,

Ekuma-Nkama³

1996

Ann Saudi Med

H Narchi, N Kulaylat, E Ekuma-Nkama, Clavicle Fracture and Brachial Plexus Palsy in the Newborn: Risk Factors and Outcome. 1996; 16(6): 707-710 Since first reported in 1764, brachial plexus palsy and fractured clavicle in the newborn have been the subject of many publications aiming at defining their causes and looking at their prognosis, with varied and sometimes conflicting findings. [1][2][3][4][5][6][7][8][9][10][11][12]18 We undertook this study in a primary care setting of a developing country, in a population with high parity and a high incidence of diabetes in pregnancy, aiming to determine the incidence of these injuries in infants born in our hospital, to identify possible risk factors in our population and to determine the prognosis for full recovery of affected babies. Material and MethodsThe study included all infants who were born at our medical center between January 1991 and December 1993. All neonates were examined by pediatricians soon after birth and prior to discharge home any time after the first 24 hours. Weakness of the upper extremity during examination was looked for and the type of palsy (upper or lower brachial plexus involvement) was defined; loss of continuity or tender swelling over the clavicle, presence or absence of Horner syndrome or phrenic nerve palsy were sought, and x-rays were carried out to rule out a fracture of the clavicle in all affected infants.All affected infants were regularly followed up at two weeks, one and two months, and thereafter as indicated. Some cases of fractured clavicle were diagnosed a few weeks after birth when a visible callus, often first noticed by the mother, was seen. In cases of brachial plexus palsy, parents were instructed to passively mobilize the infant's affected limb through a full range of motion several times a day. Affected infants who did not recover within six months were referred to the orthopedist or neurologist and physical therapist.Maternal and neonatal data were collected, and peripartum events were analyzed. For infants with brachial plexus palsy, the age of recovery of normal function on follow-up was sought.Data was compared between the affected population and the rest of the nonaffected infants over the same period of the study. The t-test was used to compare means and the corrected chi-squared test was used to compare proportions (Fisher's exact test for small values). Results Brachial Plexus PalsyOf the 8855 live births at our medical center during the period of the study, 37 infants were diagnosed to have brachial plexus palsy, giving an incidence of 4.17 per 1000 live births. Of these, there were 24 (64.8%) left, 13 (35.2%) right and no bilateral palsies. All were upper brachial plexus palsies (Erb's), four had associated homolateral fractured clavicle, and none had Horner syndrome or phrenic nerve palsy.There were 22 affected males (59.5%) and 15 females (40.5%). All but three infants were delivered vaginally (92%); one singleton and a set of twins were delivered by cesarean section for breech position. The average...