Brachial Plexus Injuries and Erb’s Palsy Explained for Parents

When a newborn’s arm hangs limp at their side, unable to move naturally while the rest of their body responds normally, it often signals a brachial plexus injury. This type of birth injury affects the network of nerves that controls movement and sensation in the shoulder, arm, and hand. While the image of a newborn with limited arm movement can be frightening, understanding what happened, why it happened, and what comes next can help families navigate the path forward.

What Is the Brachial Plexus and Why Does It Matter in Birth Injuries

The brachial plexus is a complex network of nerves that originates from the spinal cord in the neck and travels through the shoulder to the arm and hand. These nerves carry signals from the brain to the muscles, telling them when and how to move, and they carry sensation back from the skin to the brain.

The network begins with nerve roots emerging from the spine at levels C5, C6, C7, C8, and T1 (the fifth through eighth cervical vertebrae and the first thoracic vertebra). These roots organize themselves into trunks, then divide and recombine into divisions, then form cords, and finally branch into the individual nerves that control specific muscles and skin areas in the arm.

This elaborate organization means that depending on where the injury occurs along this pathway, different muscles and areas of the arm will be affected. The upper portions of the plexus (C5-C6) primarily control shoulder and elbow movement, while the lower portions (C8-T1) control the hand and fingers.

What Is Erb’s Palsy and How Does It Affect Your Baby’s Arm Movement

Erb’s palsy, also called Erb-Duchenne paralysis, specifically refers to injury affecting the upper portion of the brachial plexus, typically involving the C5 and C6 nerve roots, and sometimes extending to include C7. This is the most common type of brachial plexus birth injury, accounting for approximately 45% of all cases.

The condition is named after Wilhelm Erb, a German neurologist who described it in the 1870s. When these upper nerves are damaged, the affected baby loses the ability to move their shoulder away from their body, rotate the shoulder outward, bend the elbow, and turn the palm upward.

Different types of brachial plexus injuries involve different parts of the nerve network. Klumpke’s palsy affects the lower nerves (C8-T1) and primarily impacts hand and finger function. Total brachial plexus palsy involves all the nerves from C5 to T1, resulting in a completely paralyzed arm.

How Common Are Brachial Plexus Injuries in Newborns

Brachial plexus injuries occur in approximately 1.5 out of every 1,000 live births in the United States. This translates to roughly 12,000 babies born each year with this condition. The incidence has been decreasing over recent decades as obstetric practices have evolved and awareness of risk factors has improved.

Studies from 1997 to 2012 documented a statistically significant decline in these injuries. Canadian data shows a similar incidence of about 1.24 per 1,000 births. While these numbers might seem small, for the families affected, the impact is significant and immediate.

The encouraging news is that with modern medical care and early intervention, many children recover substantial or complete function. However, the outcome depends heavily on the severity of the initial injury and how quickly appropriate treatment begins.

Recognizing the Waiter’s Tip Position in Babies with Erb’s Palsy

The classic presentation of Erb’s palsy is distinctive enough that healthcare providers can often recognize it immediately after birth. The affected arm assumes what’s called the “waiter’s tip” position:

• The arm hangs limply at the baby’s side, with the shoulder turned inward toward the body and the elbow straight. 
• The forearm rotates so the palm faces backward or downward, and the wrist and fingers typically curl into a flexed position.
•  The overall appearance resembles a waiter or server discreetly holding their hand behind their back while awaiting a tip.

This characteristic posture results from paralysis of specific muscle groups. The muscles that normally lift the arm away from the body (deltoid and supraspinatus), rotate the shoulder outward (infraspinatus and teres minor), bend the elbow (biceps and brachialis), and turn the palm upward (supinator) are all weakened or paralyzed. Meanwhile, the opposing muscle groups that weren’t injured pull the arm into this distinctive position.

The affected baby will also show an absent or decreased Moro reflex (startle reflex) on the injured side. When startled, babies normally throw both arms outward and then bring them back together, but a baby with Erb’s palsy will only move the unaffected arm.

What Causes Brachial Plexus Injuries During Delivery

Most brachial plexus injuries occur when the baby’s shoulder becomes stuck behind the mother’s pubic bone during delivery, a complication called shoulder dystocia. After the baby’s head delivers, the anterior shoulder (the one facing toward the mother’s front) lodges against the pubic bone instead of passing underneath it. This creates an emergency situation where the baby’s body needs to be delivered quickly, but the shoulder obstruction prevents normal passage.

During efforts to resolve shoulder dystocia, the baby’s head and neck may become stretched laterally as the shoulder remains fixed. This stretching pulls on the brachial plexus nerves, which run from the neck through the shoulder area. The nerves can be stretched beyond their capacity to recover, or in severe cases, torn partially or completely.

What many people don’t realize is that shoulder dystocia itself can cause nerve injury even when delivery is managed perfectly according to established protocols. The baby’s position, the fit between the baby and the birth canal, and the forces involved in delivery all contribute to injury risk. Research shows that 46-55% of infants with brachial plexus palsy have no identifiable risk factors, making these injuries difficult to predict or prevent entirely.

That said, certain factors do increase risk significantly. Some relate to the mother’s health and pregnancy, while others involve characteristics of the baby or the delivery process itself.

Medical and Delivery Risk Factors That Increase Brachial Plexus Injury Risk

Understanding risk factors doesn’t mean these injuries are always preventable, but it does help healthcare providers identify situations requiring extra vigilance or altered delivery plans.

Maternal factors that increase risk include gestational diabetes, which increases the likelihood of a larger baby and raises injury risk about sixfold. Maternal obesity (BMI between 25-29.99) and excessive weight gain during pregnancy both contribute to having a larger baby. Maternal age of 35 or older carries increased risk, as does having previously delivered a large baby.

Baby-related factors center primarily on size. Macrosomia, defined as birth weight over 4,000 grams (about 8 pounds, 13 ounces), increases risk approximately 14-fold. Male babies have higher risk than female babies, partly because they tend to be larger. Babies in breech position (feet or bottom first) face increased risk if delivered vaginally. Post-term pregnancies beyond 42 weeks also carry elevated risk.

Delivery factors matter significantly. Shoulder dystocia is the strongest predictor, increasing risk roughly 100-fold. The use of operative vaginal delivery instruments dramatically raises risk—forceps increase risk about ninefold, and vacuum extraction also elevates risk substantially. Prolonged labor, particularly when the active pushing phase extends unusually long or when labor stops progressing, increases the likelihood of both shoulder dystocia and brachial plexus injury.

Among all these factors, shoulder dystocia stands out as the most significant and most directly connected to brachial plexus injury. But shoulder dystocia itself is notoriously difficult to predict. It occurs in about 0.2-3% of all deliveries, and while risk factors help identify higher-risk situations, most cases occur in deliveries without warning signs.

How Doctors Diagnose Brachial Plexus Injuries in Newborns

Diagnosis typically begins in the delivery room or newborn nursery when healthcare providers notice that a baby isn’t moving one arm normally. The initial assessment involves carefully observing the baby’s spontaneous movements and testing reflexes.

During physical examination, the provider gently moves the baby’s arm through its full range of motion, checking which movements are possible and which are absent or weak. They test the Moro reflex by supporting the baby’s head and body, then allowing a sudden, controlled dropping sensation—healthy babies will throw their arms out symmetrically, but a baby with brachial plexus injury will only move the unaffected arm.

The provider checks for associated injuries that sometimes occur alongside brachial plexus damage, including clavicle (collarbone) fractures, which are relatively common because both injuries can result from the same difficult delivery circumstances.

Important warning signs during examination include Horner’s syndrome, a collection of symptoms consisting of a drooping eyelid (ptosis), a smaller pupil (miosis), and decreased sweating (anhidrosis) on the affected side of the face. These symptoms indicate that the injury extends to include the lower nerve roots (C8-T1) and has likely caused an avulsion injury where the nerve root tore away from the spinal cord. This finding suggests a poor prognosis with little chance of spontaneous recovery.

Another concerning associated condition is phrenic nerve palsy, which occurs in about 1-2% of brachial plexus injuries. The phrenic nerve controls the diaphragm muscle used for breathing. When it’s damaged, one side of the diaphragm becomes paralyzed, which can cause respiratory difficulties requiring careful monitoring and sometimes breathing support.

Medical Tests Used to Evaluate Brachial Plexus Injuries in Infants

Beyond the initial physical examination, several assessment tools and tests help doctors understand the severity of injury and track recovery over time.

The Active Movement Scale (AMS) provides a standardized way to measure how much the baby can move their arm. It grades movement from 0 (no muscle contraction at all) to 7 (full range of motion against gravity with additional resistance). This scale works for infants from birth through age 15 and offers a consistent language for describing recovery progress.

For children over age three, the Mallet Classification evaluates shoulder function specifically. It scores the child’s ability to lift their arm away from their body (global abduction), rotate the shoulder outward (external rotation), and complete functional movements like touching the back of their neck, their spine between their shoulder blades, and their mouth. Each movement receives a grade from I (no function) to V (normal function).

Electrodiagnostic studies measure the electrical activity in nerves and muscles. Electromyography (EMG) records the electrical signals that muscles produce, revealing whether the nerve signals are reaching the muscles and how well the muscles respond. Nerve conduction studies measure how fast and how well electrical signals travel through the nerves themselves.

These electrical studies are typically performed 6-12 weeks after birth because it takes that long for the changes from nerve injury to become measurable. Testing earlier often gives unclear results. The studies are repeated every three months to monitor recovery progress and help determine whether surgery might be needed.

One limitation of electrodiagnostic testing is that it’s less reliable in newborns and young infants compared to adults. The developing nervous system in babies sometimes makes interpretation challenging.

Imaging studies provide visual information about the nerves and surrounding structures. X-rays rule out bone fractures that might have occurred during delivery, particularly clavicle fractures which are common in difficult deliveries.

MRI (magnetic resonance imaging) is the preferred imaging method for seeing the soft tissues, including the nerves themselves. Advanced MRI techniques like magnetic resonance neurography and diffusion tensor imaging can show nerve swelling, areas of damage, and even track nerve fiber pathways. These specialized imaging methods continue to improve as technology advances.

CT myelography remains the gold standard for diagnosing the most severe type of injury: nerve root avulsion. During this procedure, contrast dye is injected into the spinal fluid, and CT imaging reveals whether any nerve roots have torn away from the spinal cord. A collection of spinal fluid outside the normal spinal canal (called a pseudomeningocele) indicates where a nerve root has torn free.

Understanding the Different Types and Severity of Nerve Damage in Erb’s Palsy

Not all brachial plexus injuries are equally severe. The type and extent of nerve damage determines both the prognosis and the treatment approach.

The classification system doctors use is based on how deeply the nerve structure is damaged:

Neuropraxia represents the mildest form of injury, essentially a stretch or bruise to the nerve. The nerve remains structurally intact but temporarily can’t transmit signals properly. Think of it like stepping on a garden hose—the hose isn’t broken, but water can’t flow through until the pressure is removed. This is the most common type of brachial plexus injury and has the best prognosis, with most cases recovering completely within weeks to months.

Neuroma occurs when the nerve tears partially or completely but then heals. Unfortunately, as the nerve heals, scar tissue forms at the injury site. This scar tissue can compress the nerve and prevent signals from passing through normally. While recovery is possible, it’s often incomplete, and the scar tissue itself can cause ongoing problems by putting pressure on the healing nerve.

Rupture means the nerve has torn completely at some point between the spinal cord and the muscles, but the tear didn’t occur right where the nerve roots connect to the spinal cord. These injuries don’t heal on their own—the gap is too large for the nerve to bridge naturally. Surgical intervention is typically required to restore any function.

Avulsion is the most severe injury type. The nerve root tears away from the spinal cord itself. Because the injury occurs inside the spinal canal at the point where the nerve emerges from the spinal cord, it cannot be directly repaired. These injuries have the poorest prognosis, and while surgical techniques exist to restore some function, complete recovery isn’t possible.

A single brachial plexus injury often involves a combination of these damage types. One nerve root might be avulsed while another is ruptured and yet another is stretched but intact. This combination of injury types is why recovery patterns vary so much from one child to another.

How Doctors Classify Brachial Plexus Injuries from Mild to Severe

Beyond describing nerve damage type, doctors also classify brachial plexus injuries by which nerves are affected. The Narakas Classification system, developed specifically for birth-related brachial plexus injuries, divides cases into four groups:

Group I is classic Erb’s palsy affecting C5-C6. The baby can’t lift the arm away from the body, can’t rotate the shoulder outward, has difficulty bending the elbow, and can’t turn the palm upward. However, wrist and hand function remain normal.

Group II is extended Erb’s palsy involving C5-C6-C7. In addition to the shoulder and elbow problems seen in Group I, these babies also have weakness extending the wrist and fingers backward. The hand grip may remain functional, but the baby can’t cock the wrist back or straighten the fingers fully.

Group III involves all nerve roots from C5 through T1, resulting in total paralysis of the entire arm. The limb hangs completely limp with no movement at shoulder, elbow, wrist, or fingers.

Group IV also involves complete paralysis (C5-T1) but includes the added finding of Horner’s syndrome, indicating damage to the sympathetic nerve chain as well. This strongly suggests that avulsion injuries are present and predicts a poor prognosis.

The classification system helps doctors communicate about injury severity, predict likely outcomes, and make treatment decisions. Generally, Group I injuries have the best prognosis, while Groups III and IV have the most challenging recovery paths.

Recovery Timeline and What to Expect After a Brachial Plexus Injury

The question every parent asks immediately is whether their baby will recover. The answer depends on multiple factors, but there is reason for genuine hope in many cases.

Research shows that 70-96% of infants with Erb’s palsy experience complete recovery within the first year of life, particularly when recovery begins within the first four weeks. These numbers sound encouraging, and they should—most children do recover substantial function. However, more recent research suggests the picture may be somewhat less optimistic than earlier studies indicated, with up to 36% of children experiencing lasting deficits of varying degrees.

Several factors help predict outcomes:

Early recovery is the strongest positive indicator. If biceps function (the ability to bend the elbow) returns by three months, the prognosis is generally excellent. In babies with Group I or II injuries (upper and extended Erb’s palsy), 64% who recover biceps function by three months typically go on to achieve full recovery. For babies with extended Erb’s palsy specifically, early return of wrist extension before two months of age strongly predicts good outcomes.

Horner’s syndrome predicts poor outcomes because it indicates avulsion injury affecting the lower nerve roots. Children with Horner’s syndrome have little chance of spontaneous recovery and almost certainly require surgical intervention.

The speed of recovery in the first few weeks provides crucial information. Babies who show rapid improvement in the first two to four weeks tend to continue improving and often achieve complete or near-complete recovery. Those who show little or no improvement in the first month face a more challenging road and are more likely to need surgical intervention.

Recovery doesn’t follow a straight line. Some babies improve quickly at first, then plateau. Others show gradual, steady improvement over many months. The pattern and pace of recovery in each child is unique, though the general principles remain consistent.

Long-Term Complications When Brachial Plexus Injuries Don’t Fully Heal

For children who don’t achieve complete spontaneous recovery, several long-term complications may develop:

Internal rotation contractures and shoulder joint abnormalities represent the most common long-term problem, occurring in 50-70% of children with lasting deficits. As the child grows, muscle imbalances cause the shoulder joint to develop abnormally. The shoulder gradually rotates inward and the ball of the joint (humeral head) slides backward out of its normal position in the socket (posterior glenohumeral subluxation). This creates both functional limitations and potential pain.

Muscle atrophy develops when muscles don’t receive normal nerve signals over extended periods. The unused muscles waste away, becoming smaller and weaker than the corresponding muscles in the opposite arm.

Limb length discrepancy occurs because the affected arm may grow more slowly than the unaffected side. The difference is usually subtle but sometimes becomes noticeable as the child grows.

Joint contractures develop at the elbow, with the arm becoming stuck in a bent position if flexion strength recovers but extension doesn’t. The forearm may become fixed in either an inward-rotated (pronated) or outward-rotated (supinated) position.

Hand deformities can develop, including a “claw hand” appearance where the fingers curl abnormally.

Scapular winging occurs when the shoulder blade protrudes away from the back abnormally, indicating weakness in the muscles that normally hold it flat against the rib cage.

In severe cases, even scoliosis (spinal curvature) can develop as the body compensates for one-sided weakness.

These complications don’t just represent cosmetic concerns. They affect the child’s ability to perform daily activities like dressing, eating, bathing, playing, and eventually working and living independently. The functional impact varies from mild inconvenience to significant disability depending on severity.

Physical Therapy for Erb’s Palsy and When to Start Treatment

Physical therapy represents the first line of treatment for all brachial plexus injuries and should begin as early as 2-3 weeks after birth. Even in cases that will eventually require surgery, therapy is essential to maintain range of motion and prevent contractures while awaiting surgical intervention.

The primary goal in the early weeks is preventing the joints from becoming stiff and the soft tissues from tightening. When muscles don’t receive nerve signals and can’t contract actively, the opposing muscle groups gradually pull the joints into abnormal positions, and the tissues shorten and stiffen around these positions. Once contractures develop, they’re difficult to reverse.

Passive range-of-motion exercises form the foundation of early therapy. The therapist or parent gently moves the baby’s arm through its full range of motion at the shoulder, elbow, wrist, and fingers multiple times per day. These movements don’t force the joints beyond their natural limits but ensure they don’t lose mobility.

Parents learn to perform these exercises at home, typically several times daily. The movements should be gentle and never painful. The baby’s arm is moved slowly and smoothly through shoulder rotation, shoulder abduction (lifting away from the body), elbow flexion and extension, forearm rotation, and wrist movements.

As the baby grows and nerve function begins returning, therapy evolves to include active-assisted movements. The therapist or parent provides just enough help to allow the baby to complete movements they’re trying to make but can’t quite accomplish alone. This encourages the developing nerve connections and helps the baby learn to use returning muscle function.

Eventually, active range-of-motion exercises have the baby moving the arm independently without assistance. These exercises strengthen recovering muscles and help develop normal movement patterns.

Gentle stretching becomes increasingly important as the baby grows. Muscles and tendons that aren’t used normally will shorten and tighten. Regular stretching maintains flexibility and prevents permanent contractures that would limit function even if nerve recovery occurs.

As the child grows older and muscle strength returns, strengthening exercises are incorporated to rebuild muscle bulk and power. These might include resistance activities appropriate to the child’s age and ability level.

Splints or braces are sometimes used, particularly at night, to maintain joints in proper alignment and prevent contractures from developing during sleep. The need for bracing depends on which muscles are affected and whether certain muscle groups are overpowering their weakened opposing muscles.

The frequency and intensity of therapy varies based on the child’s age, severity of injury, and rate of recovery. Many children need daily home exercises plus formal therapy sessions weekly or monthly. The commitment is substantial, but consistent therapy dramatically improves outcomes.

Occupational Therapy to Help Children with Erb’s Palsy Develop Daily Living Skills

While physical therapy focuses on large movements and maintaining range of motion, occupational therapy addresses fine motor skills and functional activities. Occupational therapy typically begins if recovery hasn’t progressed adequately after 2-4 months of physical therapy.

Occupational therapists work on the specific skills needed for daily living: grasping objects, manipulating small items, feeding, dressing, bathing, and eventually writing and other school-related activities. The focus is functional—helping the child accomplish real-world tasks despite their limitations.

For infants and toddlers, occupational therapy might focus on reaching for toys, transferring objects from hand to hand, and developing pincer grasp. For preschoolers, therapy addresses dressing skills like buttoning, zipping, and pulling shirts over the head. For school-age children, writing, cutting with scissors, and manipulating school supplies become priorities.

Occupational therapists also recommend and provide adaptive equipment that helps compensate for persistent deficits. This might include modified utensils, dressing aids, or specialized tools for specific activities.

Hydrotherapy

Some therapy programs incorporate water-based exercises, taking advantage of the anti-gravity environment that water provides. In water, the affected arm weighs much less than on land, allowing the baby or child to move it more easily and with less stress on joints and muscles.

Hydrotherapy strengthens muscles without the full weight-bearing stress that land-based exercises create. The water provides gentle resistance that builds strength while the buoyancy supports the limb and makes movement possible even when muscles are very weak.

When Does a Child with Erb’s Palsy Need Surgery

Despite intensive physical therapy, some children don’t recover adequate function from conservative treatment alone. Surgery becomes necessary when recovery has plateaued without achieving functional goals.

The timing of surgical intervention is crucial. Most specialists recommend considering surgery if insufficient functional recovery has occurred by 2-6 months of age despite consistent therapy. This timing window exists because nerves respond best to surgical repair during this period. Waiting too long allows muscle atrophy to progress to the point where even successful nerve repair can’t restore function because the muscles have deteriorated beyond recovery.

The decision to pursue surgery involves careful assessment of which movements are recovering, how quickly recovery is occurring, and which specific nerves appear to be functioning. This assessment combines physical examination findings, electrodiagnostic testing results, imaging studies, and careful tracking of recovery milestones.

Nerve Surgery Options for Brachial Plexus Injuries and Success Rates

Primary nerve surgery aims to repair or reconstruct the damaged nerves themselves, restoring the pathway for signals to travel from the spinal cord to the muscles.

Nerve grafting is the most common surgical technique. The surgeon removes the damaged segment of nerve and bridges the gap using nerve tissue harvested from another part of the body. The sural nerve (running along the outside of the lower leg) is most commonly used as donor tissue, though other nerves like the medial cutaneous nerve of the forearm or the saphenous nerve may be used. For extensive injuries requiring long grafts, surgeons sometimes use vascularized ulnar nerve grafts that bring their own blood supply.

The grafted nerve segment acts as a scaffold that guides the regenerating nerve fibers from the healthy nerve above the injury to the muscles below. Over time, nerve fibers grow through the graft, eventually re-establishing the connection. This process takes many months.

Nerve transfer procedures use a different approach. Instead of bridging damaged nerves with grafts, the surgeon takes functioning nerves from expendable sources and connects them to the non-functioning nerves below the injury. Common donor nerves include intercostal nerves (from between the ribs), branches of the thoracodorsal nerve (to muscles in the back), subscapular nerve branches, or branches from the triceps nerve.

The advantage of nerve transfers is that they bring healthy, functioning nerve tissue closer to the target muscles, reducing the distance that regenerating nerve fibers must travel. They work particularly well for specific functional goals like restoring elbow flexion or shoulder external rotation.

Success rates for nerve transfers vary depending on which nerves are transferred and which functions are being restored. Overall success rates average around 60%, but this varies significantly by injury pattern. For upper brachial plexus injuries affecting primarily C5-C6, success rates reach approximately 75%. For complete injuries affecting all nerve roots, success drops to about 29%.

For the specific goal of restoring elbow flexion (the ability to bend the elbow, which is crucial for hand-to-mouth activities), nerve transfers achieve muscle function of grade M3 or better in about 84% of cases. Grade M3 represents the ability to move against gravity, which is functionally useful even if not normal strength.

Neurolysis involves surgically removing scar tissue that has formed around nerves and is compressing them. Sometimes the nerve itself is intact but encased in scar tissue that prevents signals from passing through. Carefully removing this scar tissue can restore function without needing grafts or transfers.

Primary nerve surgery is most effective when performed between 2-6 months after birth. Surgery during this window gives the best chance of meaningful functional recovery while preventing irreversible muscle deterioration.

Additional Surgeries That May Be Needed as Children with Erb’s Palsy Grow

Even with successful nerve surgery, some children develop complications that require additional surgical procedures as they grow. These secondary surgeries address the consequences of prolonged muscle imbalance and abnormal joint development.

Tendon releases cut tight tendons that are pulling joints into abnormal positions and limiting movement. Tendon transfers disconnect functioning but less critical tendons and reattach them in new positions where they can power more important movements. For example, a functioning muscle that normally rotates the shoulder inward might be transferred to assist with outward rotation if those muscles never recovered.

Muscle transfers, including free functional muscle transplantation, involve taking an entire muscle with its blood supply and nerve from elsewhere in the body and transplanting it to the affected arm to replace a non-functioning muscle. These are complex microsurgical procedures typically reserved for severe cases.

Joint reconstruction procedures address deformities like posterior shoulder subluxation, where the ball of the shoulder joint has slipped backward out of its normal position. Various surgical techniques can reposition the joint and rebalance the soft tissues to maintain better alignment.

These secondary procedures are typically performed when the child is older, after primary nerve recovery has plateaued and the functional deficit has declared itself. They focus on improving specific functional limitations that interfere with daily activities.

Can Brachial Plexus Injuries Be Prevented During Pregnancy and Delivery

The question of whether these injuries are preventable is complex. While risk factors can be identified and managed, shoulder dystocia—the primary cause of most brachial plexus injuries—is largely unpredictable and unpreventable in many cases.

Prenatal care plays an important role in risk reduction. Screening for gestational diabetes and maintaining tight blood sugar control when diabetes is present reduces the risk of macrosomia (large baby), which in turn reduces injury risk. Following Institute of Medicine guidelines for weight gain during pregnancy (typically 25-35 pounds for women starting at normal weight) also helps prevent excessive fetal size.

Regular prenatal visits allow early detection and management of risk factors. Ultrasound monitoring can assess fetal size, though it’s important to understand that ultrasound estimates of fetal weight have a margin of error of about plus or minus 10%.

Delivery management decisions sometimes include cesarean delivery when risk factors are particularly high. The American College of Obstetricians and Gynecologists (ACOG) recommends considering cesarean delivery for non-diabetic mothers when estimated fetal weight exceeds 5,000 grams (11 pounds) and for diabetic mothers when estimated fetal weight exceeds 4,500 grams (9 pounds, 15 ounces). Cesarean section has been shown to have a protective effect against brachial plexus injury.

However, routine cesarean delivery for all suspected large babies is not recommended because fetal weight estimates are imprecise and most large babies deliver without complications. Similarly, inducing labor early because of suspected macrosomia has not been shown to conclusively reduce brachial plexus injury risk and may actually increase cesarean rates without improving outcomes.

Labor induction before 39 weeks specifically for suspected macrosomia is not routinely recommended based on current evidence. The risks and benefits must be carefully weighed in each individual situation.

How Medical Teams Should Handle Shoulder Dystocia to Prevent Nerve Damage

Since shoulder dystocia cannot always be predicted or prevented, proper management when it does occur is critical for minimizing injury risk.

Healthcare providers train in systematic protocols for shoulder dystocia resolution. The most widely taught is the HELPERR mnemonic:

H stands for Help—immediately calling for additional personnel including extra nurses, attending physicians, anesthesia, and pediatrics.

E represents Evaluate for episiotomy if additional room is needed, though this isn’t routinely performed.

L indicates Legs—specifically the McRoberts maneuver, which is the first-line intervention. Assistants help the mother flex her thighs sharply up against her abdomen, which rotates the pelvis and often dislodges the impacted shoulder.

P means suprapubic Pressure—an assistant applies firm downward pressure just above the mother’s pubic bone, attempting to push the baby’s anterior shoulder down and under the pubic bone. This is not the same as fundal pressure (pushing on top of the uterus), which is contraindicated because it can worsen the impaction and increase injury risk.

E stands for Enter—performing internal maneuvers where the provider reaches into the vagina and manually attempts to rotate the baby’s shoulders or change their position. Specific techniques include the Rubin maneuver, Woods screw maneuver, and reverse Woods screw maneuver.

R represents Remove the posterior arm—the provider reaches in, finds the baby’s posterior arm (the one toward the mother’s back), and sweeps it across the baby’s chest and out, which reduces the shoulder-to-shoulder diameter and often allows delivery.

The second R stands for Roll—rolling the mother onto her hands and knees (the Gaskin or all-fours position), which changes the pelvic dimensions and sometimes allows the shoulders to disengage.

Critical elements of proper management include avoiding excessive traction on the baby’s head and neck, avoiding fundal pressure which can worsen the situation, and avoiding having the mother push while maneuvers are being performed.

Documentation of shoulder dystocia is essential. An immediate operative report should document the exact time the head delivered, the time complete delivery was achieved, which maneuvers were used and in what order, which personnel were present, and any complications that occurred. This documentation serves both medical and legal purposes.

Training and simulation have proven effective in improving shoulder dystocia outcomes. Hospitals that implement regular simulation training and systematic protocols see reduced injury rates, shorter resolution times, and improved team communication during these emergency situations.

Medical Malpractice and Legal Options for Brachial Plexus Birth Injuries

Brachial plexus injuries frequently become the subject of medical malpractice litigation. The visible, permanent nature of many injuries combined with questions about whether different management might have prevented the injury creates an environment where legal claims are common.

Reported settlements and verdicts in these cases vary enormously but can be substantial. The average settlement for brachial plexus birth injuries ranges from $750,000 to $2.5 million, though severe cases with permanent disability have resulted in verdicts exceeding $10 million. Recent cases include a $15.8 million verdict in Louisiana in 2022, a $4.5 million settlement in Illinois in 2025, and multiple New York settlements in the $2.5-3 million range.

Proving medical malpractice requires demonstrating four elements: 

• that a doctor-patient relationship existed creating a duty of care, 
• that the healthcare provider breached the standard of care,
• that this breach directly caused the injury, 
• and that quantifiable damages resulted.

Common allegations in brachial plexus injury cases include failure to recognize risk factors that should have prompted cesarean delivery, failure to recommend or perform cesarean when indicated based on fetal size or maternal diabetes, application of excessive traction during delivery, improper use of forceps or vacuum, inadequate management of shoulder dystocia, and failure to implement appropriate maneuvers in correct sequence.

It’s important to understand that not all brachial plexus injuries represent medical malpractice. Shoulder dystocia can occur unpredictably in low-risk deliveries, and injury can occur even when all appropriate maneuvers are performed correctly. The legal question centers on whether the care provided met accepted standards, not simply whether an injury occurred.

Statutes of limitations for filing medical malpractice claims vary by state but typically range from 2-3 years. Some states have special provisions for injuries to minors that may extend this timeframe. Families concerned about potential malpractice should consult with an attorney familiar with medical malpractice law in their state relatively quickly, as waiting too long can forfeit legal rights.

Medical Costs and Financial Impact of Brachial Plexus Injuries

Beyond any legal settlements, the economic impact of brachial plexus injuries can be substantial. Initial hospitalization for affected newborns is approximately 20% longer and 40% more expensive compared to uncomplicated deliveries.

Long-term costs accumulate from physical therapy, occupational therapy, surgical procedures, additional hospitalizations, imaging studies, electrodiagnostic testing, adaptive equipment, and potentially lost earning capacity in adulthood if permanent disability affects the ability to work.

These direct healthcare costs are accompanied by indirect costs including time away from work for parents attending therapy appointments and procedures, home modifications if needed, specialized clothing or equipment, and the general life impact of caring for a child with special needs.

Understanding the potential financial impact helps families plan for their child’s care and underscores why legal consultation may be appropriate if negligence is suspected. Compensation from settlements or verdicts can fund necessary medical care and support the child requires.

Latest Research and Advances in Treating Brachial Plexus Injuries

Medical understanding and treatment of brachial plexus injuries continues to evolve. Recent advances include improved microsurgical techniques that allow more precise nerve reconstruction, enhanced imaging methods that better visualize nerve damage and recovery, and development of validated outcome measures that allow better comparison of different treatment approaches.

Research continues into optimal timing for surgical intervention and which specific techniques work best for different injury patterns. The field is moving toward earlier referral to specialized multidisciplinary brachial plexus clinics where teams of neurologists, neurosurgeons, orthopedic surgeons, therapists, and other specialists collaborate on comprehensive treatment plans.

Intraoperative decision-making algorithms help surgeons assess nerve viability during surgery and choose the best reconstruction approach for each specific situation. Research into bioabsorbable scaffolding materials may eventually improve nerve regeneration outcomes.

Despite these advances, significant gaps remain in medical knowledge. The exact mechanisms of injury during delivery are not completely understood. Better tools are needed to predict which babies will recover spontaneously versus which need early surgery. Standardized outcome measures would allow more meaningful comparison of results across different studies and treatment approaches.

Researchers continue working to develop improved prenatal risk stratification methods that might allow better prediction of which deliveries carry highest risk, potentially allowing more targeted prevention strategies.

What Life Looks Like for Children Growing Up with Erb’s Palsy

For families dealing with brachial plexus injuries, the day-to-day reality involves much more than medical terminology and treatment protocols. It means learning to perform range-of-motion exercises on a tiny newborn, attending multiple therapy appointments weekly, making decisions about surgery with incomplete information about outcomes, advocating for appropriate services as the child grows, and watching your child struggle with tasks that come easily to other children.

It means celebrating victories that might seem small to others—the first time the affected arm moves at all, the return of biceps function, the ability to bring the hand to the mouth for the first time. It means managing your own emotions while staying positive and encouraging for your child.

Children with Erb’s palsy often adapt remarkably well, finding creative ways to accomplish tasks despite their limitations. They may develop exceptional strength and skill in their unaffected arm, or learn modified techniques for two-handed activities. Many participate fully in school, sports, and social activities, refusing to let their injury define them.

The visible nature of the injury means children often face questions from peers and sometimes stares or comments from strangers. Helping children develop confidence and effective ways to explain their condition becomes part of parenting a child with Erb’s palsy.

The outcome for any individual child remains uncertain at birth. Some will achieve complete recovery and live entirely normal lives. Others will have mild limitations that barely affect daily function. Some will have moderate deficits requiring ongoing therapy and possibly additional surgery but will remain independent and capable. A smaller percentage will have severe, permanent limitations affecting their ability to perform daily activities and work.

What remains consistent is that early intervention, appropriate therapy, timely surgical intervention when needed, and ongoing support give each child the best possible chance at maximizing their potential. Medical knowledge continues advancing, surgical techniques keep improving, and therapy approaches become more sophisticated.

For families beginning this journey, connecting with others who have traveled the same path can provide invaluable support, practical advice, and hope. Many hospitals with brachial plexus clinics facilitate family connections, and national organizations provide resources and community for affected families.

The path forward from a brachial plexus injury diagnosis is not one any family would choose, but it is a path that thousands of families have navigated before, and with appropriate medical care, dedication to therapy, and resilience, many children achieve outcomes that far exceed initial fears in those first frightening days after diagnosis.