Advice for Healthcare Professionals
This page is intended for obstetricians, midwives, neonatologists and other clinicians involved in maternity and paediatric care. Its purpose is to support thoughtful, evidence‑based clinical practice and to help guide conversations with parents following a difficult delivery in which an obstetric brachial plexus injury (OBPI), including Erb’s palsy, is suspected or diagnosed. We recognise that these situations are challenging for clinicians as well as for families, and that the manner in which care and communication are provided in the hours, days and weeks after birth can have a lasting impact.
What is obstetric brachial plexus injury?
Obstetric brachial plexus injury refers to injury to the network of nerves that supply movement and sensation to the shoulder, arm and hand, occurring in temporal association with birth. Erb’s palsy is the most commonly recognised pattern and typically affects the upper roots of the brachial plexus, resulting in weakness or paralysis of shoulder abduction, external rotation and elbow flexion. The severity of injury varies widely, ranging from transient neuropraxia with spontaneous recovery to permanent paralysis involving nerve rupture or avulsion.
How does the injury arise?
The contemporary clinical and biomechanical literature consistently demonstrates that permanent OBPI most commonly arises in the setting of shoulder dystocia, where the fetal shoulders become impacted after delivery of the head. The fundamental problem is bony impaction and relative fetopelvic disproportion, not soft‑tissue resistance. Injury occurs when excessive, misdirected or repeated traction is applied to the fetal head and neck before the shoulders have been realigned into a physiological position within the pelvis.
Large population‑based studies show that while the recorded incidence of shoulder dystocia has increased over time, the incidence of permanent OBPI has declined. This divergence is widely understood to reflect improved recognition of dystocia and better intrapartum management, particularly the limitation of traction and the timely use of appropriate rotational and fetal manipulation manoeuvres. These findings strongly support the conclusion that permanent OBPI is, in most cases, a preventable traction‑mediated injury rather than an unavoidable consequence of maternal pushing or uterine forces.
It is also well recognised that shoulder dystocia is frequently under‑recognised or under‑documented at the time of delivery. The absence of a contemporaneous label does not exclude the presence of shoulder impaction. Clinically, the need for more than customary traction to deliver the shoulders is the practical indicator that dystocia has occurred.
Initial presentation after birth
Newborns with OBPI typically present with reduced or absent movement of one arm shortly after birth. Common features include an asymmetric Moro reflex, the arm held adducted and internally rotated, reduced elbow flexion, and preserved hand movement in upper‑plexus injuries. In more extensive injuries, hand and wrist function may also be affected. Sensory changes are difficult to assess in the neonate, but pain responses may be altered.
It is important to appreciate that the early clinical picture does not reliably predict ultimate outcome. Some infants will show rapid improvement over weeks, while others may have more severe injuries that only become fully apparent with time. Early reassurance should therefore be carefully balanced with honesty about uncertainty.
Immediate clinical priorities
From a clinical perspective, early priorities include a careful neurological examination, documentation of findings, and prompt referral to appropriate paediatric and physiotherapy services. Early physiotherapy guidance is important to maintain joint mobility and to support families in safe handling and positioning. Where recovery is incomplete or delayed, timely referral to a specialist brachial plexus service is essential so that surgical options, if indicated, are not missed.
Clear, accurate and contemporaneous documentation of the delivery and neonatal findings is important both for ongoing clinical care and for later understanding of events. This should be undertaken in a factual, reflective manner.
Communicating with parents: an empathic approach
For parents, the discovery that their baby is not moving an arm normally is often distressing and frightening. Many parents describe the immediate postnatal conversations as shaping their trust in clinicians and their ability to cope in the months that follow.
Helpful principles include:
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Acknowledge the parents’ concern and distress openly, rather than minimising it.
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Explain, in clear and non‑technical language, what has been observed and what it may mean, while avoiding speculation or premature conclusions.
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Be honest about uncertainty and the range of possible outcomes, emphasising that further assessment over time is needed.
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Avoid attributing blame, either to the parents, the baby, or members of the clinical team.
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Reassure parents that appropriate steps will be taken to assess, monitor and support their child.
Where questions arise about how or why the injury occurred, it is appropriate to explain that these injuries are most commonly associated with difficulty delivering the shoulders and that further review of the delivery and the baby’s progress will inform understanding over time. Defensive or dismissive explanations can be deeply damaging and are best avoided.
Supporting families in the weeks and months ahead
Ongoing support is as important as the initial response. Parents benefit from clear follow‑up plans, written information, and signposting to specialist services and peer support organisations. Many families value being told explicitly that it is appropriate to ask questions, seek second opinions and request copies of records.
Clinicians should also be mindful that some parents will later seek medicolegal advice, not out of hostility, but as part of trying to understand what happened and to secure resources for their child’s future. A transparent, respectful approach from the outset is entirely consistent with good clinical care and professionalism.
A shared goal
The shared aim of clinicians and families is the best possible outcome for the child. Evidence‑based intrapartum management, early recognition of injury, timely referral, and empathic, honest communication all contribute to that goal. By combining technical skill with compassionate care, clinicians play a central role not only in reducing the incidence of obstetric brachial.
