Understanding Infant Brachial Plexus Injuries

Learning that your newborn has sustained a nerve injury during delivery can be overwhelming for any parent. This guide is designed to help families understand brachial plexus injuries, recognize how medical errors during labor can cause nerve damage, and explore their legal options.

What is a brachial plexus injury?

A brachial plexus injury occurs when the network of nerves surrounding the neck and shoulders—known as the brachial plexus—is stretched, compressed, or torn during childbirth. These vital nerves transmit signals from the spinal cord down through the shoulders, arms, hands, and fingers, allowing for movement and sensation throughout the upper limbs.

During difficult or impacted deliveries, excessive lateral traction applied to the infant’s head and neck can stretch these sensitive nerve fibers beyond their physical limits. Depending on the location and severity of the nerve damage, brachial plexus injuries can range from temporary weakness to permanent paralysis of the arm, including specific clinical conditions such as Erb’s Palsy or Klumpke’s palsy.

Signs and symptoms of brachial plexus

Physical indicators of brachial plexus damage are often noticeable immediately after delivery or within the first few days of life. Symptoms parents and care providers should monitor include:

• Limp or motionless arm: An arm that hangs loosely beside the infant’s body with little to no spontaneous movement.
• Asymmetric startle reflex: Lack of an asymmetric Moro (startle) reflex on the affected side when startled or moved.
• Weakened grip strength: Inability to grasp objects or hold a finger with the hand on the affected side.
• Decreased sensation and reflexes: Reduced response to touch or stimulation in the shoulder, arm, hand, or fingers.
• Abnormal arm positioning: The affected arm held turned inward toward the body with the wrist flexed, commonly known as the “waiter’s tip” posture.
• Facial drooping or Horner’s syndrome: A drooping eyelid or constricted pupil on the same side as the nerve injury in severe lower plexus damage.

What causes brachial plexus injuries during childbirth?

Brachial plexus injuries typically occur when physical impaction or obstruction complicates the delivery process. Common underlying causes and risk factors include:

• Shoulder dystocia: An obstetric complication where the baby’s shoulder becomes lodged behind the mother’s pubic bone after the head delivers.
• Fetal macrosomia: Unusually large birth weight (often exceeding 8 pounds, 13 ounces), increasing the likelihood of physical impaction in the birth canal.
• Cephalopelvic disproportion (CPD): A structural mismatch where the baby’s head or shoulders are too large to pass safely through the mother’s pelvic opening.
• Breech or abnormal fetal presentation: Deliveries where the baby presents feet or buttocks first, placing unique physical strain on the neck and shoulder nerves.
• Misuse of extraction instruments: Improper placement or excessive pulling applied via vacuum extractors or forceps during delivery.
• Prolonged or difficult labor: Extended periods of labor causing repetitive physical compression against the birth canal.

When a brachial plexus injury may be medical malpractice

Not every brachial plexus injury is the result of medical malpractice. Complex anatomical challenges during labor can arise unexpectedly, and some physical pressure is inherent to childbirth. However, obstetric professionals are trained to recognize delivery risk factors, perform standard obstetrical maneuvers, and avoid applying excessive lateral traction to an infant’s head and neck.

When healthcare providers fail to adhere to established delivery standards, severe nerve damage can result. Scenarios that may point to medical negligence include:

• Application of excessive traction: Pulling or twisting too forcefully on the infant’s head or neck when attempting to free an impacted shoulder during shoulder dystocia.
• Failure to perform standard dystocia maneuvers: Failing to execute accepted clinical techniques (such as the McRoberts maneuver or suprapubic pressure) before resorting to excessive force.
• Improper instrument usage: Applying excessive force or misapplying forceps or vacuum extractors during delivery.
• Failure to plan an emergency C-section: Delaying or failing to recommend a C-section when known risk factors like severe fetal macrosomia or CPD are present.
• Failure to monitor fetal progress: Overlooking non-reassuring fetal heart tracings or failing to recognize labor progress arrest.
• Delayed diagnosis and referral: Failing to promptly diagnose nerve damage after birth or failing to refer the infant to a pediatric nerve specialist for timely evaluation.

Determining whether a medical provider’s actions fell below accepted standards of care requires a thorough medical investigation. At Wais, Vogelstein, Forman, Koch & Norman, LLC, our firm works closely with leading medical experts across the country to review labor records, analyze delivery documentation, and determine whether medical negligence caused a child’s injury.

Treatment and long-term outlook

Treatment for a brachial plexus injury depends on the specific type and severity of nerve damage. Mild stretching injuries (neuropraxia) may heal on their own within a few months through conservative management, including specialized physical therapy and gentle range-of-motion exercises to prevent joint stiffness.

For more severe injuries involving torn or avulsed nerves, surgical intervention—such as nerve grafts, nerve transfers, or muscle transfers—may be required within the first three to six months of life to restore limb function. Long-term outlook varies, but early medical evaluation and intervention give children the best opportunity for recovery.