A brachial plexus injury or Erb's palsy diagnosed in a baby after birth can be deeply distressing for parents and families. These injuries affect the nerves that control movement and sensation in the arm and hand, and their consequences can be significant. However, it is important to understand that not every birth injury is the result of medical negligence. Whether a legal claim arises will depend on the specific facts, the medical records and independent expert evidence.
Michael Boylan Litigation is a specialist medical negligence litigation firm with decades of experience in complex birth injury claims in Ireland. We understand the medical and legal issues involved in brachial plexus and Erb's palsy cases, and we work with families to examine what happened and whether the standard of care was met.
What Is a Brachial Plexus Injury?
The role of the brachial plexus in arm and shoulder movement
The brachial plexus is a network of nerves that runs from the neck, through the shoulder and into the arm and hand. These nerves carry signals from the spinal cord to the muscles and skin of the upper limb. They control movement in the shoulder, elbow, wrist and fingers, and they also provide sensation across the arm and hand.
When the brachial plexus is damaged, the nerve signals are disrupted. Depending on which nerves are affected and how severely, the result can range from temporary weakness to permanent loss of function.
How brachial plexus damage can affect a child
A child with a brachial plexus injury may experience a range of difficulties, including:
- Weakness or paralysis in one arm: The affected arm may be noticeably weaker than the other, or it may not move at all.
- Reduced range of movement: The child may have difficulty raising the arm, bending the elbow or turning the wrist.
- Altered sensation: There may be numbness, tingling or reduced feeling in parts of the arm or hand.
- Pain or discomfort: Some children experience ongoing pain, particularly as they grow.
- Abnormal arm positioning: The arm may rest in an unusual posture due to muscle imbalance.
- Developmental effects: Over time, the affected arm may grow differently, with visible differences in size, strength or muscle tone compared to the unaffected side.
Types of brachial plexus nerve injury
Brachial plexus injuries are classified by how severely the nerve is damaged:
- Neuropraxia: The mildest form, where the nerve is stretched but not torn. Recovery is often possible without surgery.
- Neuroma: The nerve is stretched and partially damaged, and scar tissue may form during healing. This scar tissue can press on the healthy nerve and limit recovery.
- Rupture: The nerve is torn but remains attached to the spinal cord. This usually requires surgical intervention.
- Avulsion: The most severe form, where the nerve root is torn away from the spinal cord. This type of injury cannot be repaired by reattaching the nerve directly, and reconstructive surgery may be considered.
What Is Erb's Palsy?
Erb's palsy is a specific type of brachial plexus injury. It typically affects the upper nerves of the brachial plexus, particularly those at the C5 and C6 nerve roots. Because these nerves control the shoulder and upper arm, Erb's palsy most commonly causes weakness or loss of movement in the shoulder, upper arm and elbow.
Common signs of Erb's palsy in a baby or young child
Parents may notice the following signs shortly after birth or in the weeks that follow:
- One arm held limp or motionless: The affected arm may hang by the baby's side with little or no movement.
- Difficulty bending the elbow: The baby may not be able to flex the arm at the elbow.
- Reduced shoulder movement: The baby may struggle to lift or rotate the affected arm at the shoulder.
- "Waiter's tip" positioning: The arm may rest with the wrist turned inward and the fingers slightly curled, resembling a waiter reaching behind for a tip.
- Weaker grip: The baby may have reduced strength or coordination in the affected hand.
- Reduced sensation: The arm or hand may be less responsive to touch.
- Difference in arm size over time: As the child grows, the affected arm may appear thinner or shorter than the other.
How Brachial Plexus and Erb's Palsy Injuries Can Occur During Birth
Shoulder dystocia and difficult delivery
Shoulder dystocia is a recognised obstetric emergency that occurs when, after the baby's head has been delivered, one or both shoulders become impacted behind the mother's pubic bone. This prevents the baby from being delivered without additional intervention. Shoulder dystocia requires prompt and appropriate management by the clinical team to deliver the baby safely. It is a well-recognised complication of labour and does not, on its own, indicate that anything was done wrong.
Excessive traction during delivery
During a difficult delivery, if excessive force or traction is applied to the baby's head or neck while the shoulder is impacted, this can stretch or damage the brachial plexus nerves. The original content on this page noted that the person delivering the baby must resist the temptation to simply pull hard on the baby's head, as excessive traction will result in damage to the brachial plexus nerves. Whether the level of force used was appropriate is a matter for expert obstetric evidence.
There are a range of standard and approved manoeuvres that should be followed in a shoulder dystocia situation, including suprapubic pressure and the McRoberts position, to help release the impacted shoulder and facilitate safe delivery. A failure to adopt these procedures may be relevant where a child has sustained a brachial plexus injury.
Assisted delivery using forceps or ventouse
Forceps and ventouse (vacuum-assisted) delivery are used in certain circumstances to assist with a difficult birth. While these instruments are widely and safely used, the manner in which they are applied, and the clinical decisions surrounding their use, may be relevant in some cases. It is important not to overstate the risks; the focus in any legal assessment is on whether the instruments were used appropriately in the circumstances.
Risk factors that may need to be considered before birth
Certain factors, if present before or during labour, may increase the likelihood of a difficult delivery. These include:
- Suspected larger baby (macrosomia): Where scans or clinical assessment indicate a larger than average baby.
- Maternal diabetes: Both gestational and pre-existing diabetes are associated with increased birth weight.
- Previous shoulder dystocia: A history of shoulder dystocia in an earlier delivery.
- Prolonged labour: A labour that progresses slowly or stalls.
- Concerns on antenatal scans: Any abnormalities or growth-related findings identified before delivery.
- Previous complicated delivery: A history of difficult births or birth injuries.
Whether these risk factors were identified, documented and acted upon before and during labour may form part of the evidence in a legal claim.
Emergency management during labour
Where shoulder dystocia or fetal distress arises, the obstetric team must respond promptly and follow established clinical protocols. The adequacy of the emergency response, the manoeuvres used, the timing of interventions and the documentation of events are all matters that may be examined when a brachial plexus injury has occurred.
When Can an Erb's Palsy Injury Involve Medical Negligence?
Not every Erb's palsy or brachial plexus injury is caused by negligence. These injuries can occur even when the clinical team acts appropriately.
A medical negligence claim may arise where it can be established, with the support of independent expert evidence, that:
- The care provided fell below the standard reasonably expected of a competent practitioner in the relevant field.
- That failure in care caused or materially contributed to the injury.
This is a factual and legal question, not a matter of assumption. It requires careful review of the medical records, the circumstances of the delivery and the opinions of qualified experts.
What Evidence Is Usually Reviewed in a Brachial Plexus or Erb's Palsy Case?
Antenatal and maternity records
These include booking notes, antenatal clinic records, ultrasound scan reports, risk assessments, records relating to gestational diabetes and any birth planning documentation. These records help establish what was known about the pregnancy before labour began.
Labour and delivery notes
The labour and delivery records are central to most birth injury cases. They include the partogram (a record of the progress of labour), CTG (cardiotocography) traces monitoring the baby's heart rate, notes on any shoulder dystocia, the timeline of delivery, the manoeuvres used, and the staff involved.
Neonatal and paediatric records
After delivery, the baby's condition is assessed and recorded. Relevant records include Apgar scores, immediate clinical observations, referral notes, imaging results (such as MRI or ultrasound of the brachial plexus), neurological assessments and early therapy notes.
Therapy, surgery and long-term care records
As the child grows, additional records become relevant. These may include physiotherapy and occupational therapy records, orthopaedic or nerve surgery consultations, school support assessments, and documentation of the child's ongoing and future care needs.
The Possible Long-Term Effects of Erb's Palsy
Physical effects
The physical consequences of Erb's palsy vary depending on the severity of the nerve injury. They may include reduced strength in the affected arm, restricted range of motion at the shoulder or elbow, chronic pain, muscle imbalance, contractures (tightening of muscles or joints) and visible asymmetry between the two arms.
Developmental and practical effects
Children with Erb's palsy may face difficulties with everyday activities such as dressing, writing, lifting objects, playing sports and participating in school activities. Tasks that require two hands, or significant arm strength, can be particularly challenging. The practical impact often evolves as the child grows and faces new demands.
Treatment and rehabilitation needs
Management of Erb's palsy may involve ongoing physiotherapy, occupational therapy, regular monitoring of nerve recovery, and in some cases, surgical review or intervention. Some children may benefit from assistive supports or equipment. Long-term care planning is often necessary to address the child's changing needs.
Emotional impact on families
A birth injury diagnosis can be difficult for the entire family. Parents may experience worry, frustration and uncertainty about their child's future. Siblings and the wider family may also be affected. These emotional consequences, while harder to measure, are real and are recognised in the legal process.
Brachial Plexus and Erb's Palsy Claims for Children in Ireland
Who brings a claim on behalf of a child?
In Ireland, a child cannot bring a legal claim in their own name. A parent or legal guardian may act as a "next friend" and bring proceedings on the child's behalf. Any settlement reached for a child must be approved by the court, and the funds are typically held by the Accountant's Office of the High Court until the child reaches 18 years of age.
Time limits for children's medical negligence claims
The limitation rules for minors differ from those applying to adults. The standard two-year limitation period does not begin to run until the child reaches the age of 18. This means a child has until their 20th birthday to initiate a claim. However, specific legal advice should always be taken based on the individual facts, as the rules can be affected by the circumstances of the case.
Why early advice can still be important
Even though the limitation period for a child's claim extends beyond their 18th birthday, there can be significant benefits to seeking legal advice early. Medical records may be easier to obtain closer to the time of the events, witnesses' recollections are fresher, and expert review can be arranged while the relevant circumstances are still clear. Early advice helps families understand what happened and whether there are grounds to investigate further. It is not about pressuring anyone to bring a claim.
Questions Families Often Have About Erb's Palsy and Brachial Plexus Injuries
Is Erb's palsy always caused by medical negligence?
No. Erb's palsy can occur in different circumstances, and not every case involves substandard care. A legal claim depends on whether there is evidence that the care provided fell below the appropriate standard and that this failure caused or materially contributed to the injury.
What is the link between shoulder dystocia and Erb's palsy?
Shoulder dystocia is a recognised complication of childbirth. When the baby's shoulder becomes impacted during delivery, the risk of brachial plexus injury increases. Whether an Erb's palsy injury was avoidable depends on the specific circumstances, including how the shoulder dystocia was managed and what manoeuvres were used.
What records are important in an Erb's palsy case?
The most relevant records typically include maternity and antenatal notes, labour and delivery records, neonatal assessments, therapy and rehabilitation records, and any expert medical reports obtained during the legal process.
Can an Erb's palsy injury improve over time?
Some brachial plexus injuries, particularly neuropraxia, can improve significantly with time and appropriate treatment. Others, particularly rupture or avulsion injuries, may result in permanent restriction. The medical prognosis depends on the type and severity of the nerve damage and the treatment received.
How is medical negligence assessed in Ireland?
In Ireland, a medical negligence claim requires proof of three things: that the healthcare provider owed a duty of care to the patient; that the care provided fell below the standard reasonably expected of a competent practitioner (a breach of duty); and that this breach caused or materially contributed to the injury (causation). Each element must be supported by independent expert evidence.
Should parents wait until the child is older before seeking legal advice?
While the limitation period for a minor does not expire until two years after the child's 18th birthday, there are practical reasons for seeking advice earlier. Early investigation helps preserve medical records, allows for timely expert review and gives families a clearer understanding of what happened. Whether or not to bring a claim is always a decision for the family, based on informed legal advice.
Recent Cases of Note
- €340,000 in damages on behalf of a 10-year-old boy who suffered Erb's palsy as a result of admitted mismanagement of labour and delivery.
- €425,000 on behalf of a 5-year-old girl who suffered Erb's palsy as a result of complications at birth.
Speak With Michael Boylan Litigation About a Possible Brachial Plexus or Erb's Palsy Injury
If your child has been diagnosed with Erb's palsy or a brachial plexus injury following birth, Michael Boylan Litigation can review the circumstances and explain the legal issues that may arise under Irish medical negligence law. We approach every case with care and with a focus on the facts.
To discuss your child's case, contact us to arrange an initial discussion.
*In contentious business, a solicitor may not calculate fees or other charges as a percentage or proportion of any award or settlement. This statement is made in compliance with Regulation 8 of the Solicitors Advertising Regulations 2019 (SI No. 518 of 2019).
