Erb's Palsy and Brachial Plexus Birth Injury Lawsuits

The Anatomy of a Brachial Plexus Birth Injury

The brachial plexus is the network of nerves carrying motor and sensory signals from the spinal cord (roots C5 through T1) to the shoulder, arm, and hand. The plexus runs through the supraclavicular region. When excessive lateral traction is applied to the fetal head during shoulder dystocia, the nerves stretch, partially tear (neurapraxia or axonotmesis), or fully rupture or avulse from the spinal cord (neurotmesis, root avulsion).

• Erb's palsy (C5-C6, sometimes C7): The classic upper plexus injury. Produces the "waiter's tip" posture: shoulder adducted and internally rotated, elbow extended, forearm pronated, wrist flexed. Shoulder abduction and external rotation, elbow flexion, and forearm supination are weak or absent. The most common pattern. Many mild cases resolve in weeks to months. Permanent deficit in shoulder external rotation is a frequent residual.
• Klumpke's palsy (C8-T1): Lower plexus injury. Produces a "claw hand" with weakness or paralysis of intrinsic hand muscles and wrist flexors. May include Horner's syndrome (ptosis, miosis, anhidrosis) if T1 sympathetic fibers are involved. Less common but more disabling because hand function is so central to daily life.
• Total brachial plexus injury (C5-T1): The full plexus is involved. Produces a flail arm with no active motor function and often dense sensory loss. The most severe form. Frequently associated with root avulsion injuries that cannot be repaired with simple grafting.

The level of injury within the nerve (neurapraxia, axonotmesis, neurotmesis, avulsion) determines whether spontaneous recovery is possible. Neurapraxia recovers; complete root avulsion does not. Diagnostic studies in the first months (clinical exam, EMG, nerve conduction studies, sometimes MRI of the plexus or CT myelography) help establish injury level and inform the surgical decision.

The Negligence Pattern: Lateral Traction vs the Maneuver Sequence

The American College of Obstetricians and Gynecologists and decades of obstetric literature describe a specific maneuver sequence for shoulder dystocia. The maneuvers are designed to disimpact the anterior shoulder without applying force to the fetal neck.^[1] The anticipation framework, the full maneuver sequence, and the institutional readiness expectations are covered in depth on our shoulder dystocia malpractice page.

The standard maneuver sequence:

• McRoberts maneuver: Sharp flexion of the mother's hips toward the abdomen. Rotates the pubic symphysis cephalad and flattens the lumbar lordosis. Resolves a substantial fraction of dystocias on its own.
• Suprapubic pressure: Steady or rocking pressure just above the pubic symphysis, directed downward and laterally, to dislodge the impacted anterior shoulder. Should never be confused with fundal pressure, which is contraindicated.
• Rotational maneuvers (Wood's corkscrew, Rubin): Rotating the posterior or anterior shoulder to convert it to an oblique diameter and free the impaction.
• Delivery of the posterior arm (Jacquemier maneuver): Sweeping the posterior arm across the chest and out, reducing the bisacromial diameter and allowing the anterior shoulder to deliver.
• Last-resort maneuvers: All-fours position (Gaskin), deliberate clavicular fracture, symphysiotomy, and Zavanelli (cephalic replacement and cesarean). These are deployed only when the prior maneuvers fail.

None of these maneuvers requires force on the fetal head. The negligence pattern in OBPP litigation is the substitution of lateral traction on the fetal head for the maneuver sequence. When a provider feels resistance after delivery of the head and pulls laterally rather than calling for help, repositioning the mother, applying suprapubic pressure, and working the rotational and posterior arm maneuvers, the brachial plexus pays the price.

The defense will commonly argue:

• That the injury was caused by maternal forces (the natural propulsive force of labor) rather than provider traction, citing the "maternal propulsive forces" literature.
• That the injury occurred in utero from positional compression before delivery.
• That the brachial plexus injury followed a posterior shoulder dystocia rather than an anterior one, removing the typical traction-causation pathway.

Each defense argument has counter-literature and counter-evidence. Strong cases beat the defense by reconstructing the delivery from contemporaneous records: the timing of the head-to-body delivery interval, who was at the bedside, which maneuvers were attempted and documented, the sequence and duration of each, and whether the documentation patterns match a maneuver-sequence response or a traction response. Delivery room nursing notes are often the most useful corroborating evidence.

Risk Factors That Should Have Triggered a Different Delivery Plan

Shoulder dystocia is unpredictable. It is not unforeseeable. Specific risk factors are well documented and well within an OB-GYN's knowledge base. When the risk factors are present and the provider proceeds with vaginal delivery without an informed consent discussion of cesarean, the breach analysis sharpens substantially.

Risk factors associated with shoulder dystocia and OBPP:

• Fetal macrosomia. Estimated fetal weight over 4,500 grams (about 9 pounds 15 ounces) in a non-diabetic mother, or over 4,000 grams in a diabetic mother, substantially increases shoulder dystocia risk.
• Maternal diabetes (gestational or pregestational). Truncal and shoulder adiposity in infants of diabetic mothers is disproportionate to overall fetal weight, raising bisacromial diameter and dystocia risk.
• Prior shoulder dystocia. A documented prior dystocia is among the strongest predictors of recurrence. ACOG recommends an informed consent discussion regarding the option of cesarean.
• Prolonged second stage of labor. Particularly when combined with arrest of descent.
• Operative vaginal delivery. Vacuum extraction and forceps-assisted delivery elevate shoulder dystocia risk, particularly in the setting of macrosomia.
• Excessive maternal weight gain and obesity. Associated with both macrosomia and dystocia.
• Post-term pregnancy. Particularly in conjunction with macrosomia.

After enough OBPP cases, you learn to read the delivery note for what is not in it. A maneuver-sequence response is documentable. A traction response is documentable too, by what the chart leaves out.

The risk factors are noted in the prenatal records, the labor records, and the ultrasound history. The question on a brachial plexus malpractice case is often whether the OB-GYN sat down with the mother, documented the risk factors, and presented cesarean as a reasonable alternative when the third-trimester ultrasound showed estimated fetal weight in the macrosomic range. If the provider did not, that conversation is the missing piece that strong cases use to reframe the dystocia not as an unforeseeable emergency but as a foreseeable risk the family was never given a chance to weigh.

Treatment, Surgery, and Permanence Prognosis

Most mild Erb's palsy injuries resolve within the first months of life. Persistent deficit at 3 months, particularly absent biceps function at 3 months, predicts a poorer spontaneous recovery and is the trigger for surgical referral in many programs.^[2]

Treatment progression:

• Observation and therapy: Passive and active range of motion, occupational and physical therapy, splinting as needed. Pediatric brachial plexus programs typically follow infants closely in the first 6 months.
• Primary nerve surgery: Nerve graft, neurolysis, or nerve transfer in infants whose deficits persist past 3 to 6 months and meet program-specific surgical criteria. Sural nerve grafts are common. Procedures are performed in the first year of life in most programs.
• Secondary reconstructive surgery: In older children with residual deficits, tendon transfers (latissimus dorsi, teres major), shoulder humeral osteotomy, contracture release, and joint reconstruction. Often performed in the toddler-through-school-age years and revisited as the child grows.
• Lifelong therapy and functional adaptation: Permanent residual deficits commonly include weakness of shoulder external rotation, elbow flexion, and forearm supination; limb-length discrepancy; and impaired fine motor control. Adapting to one-handed function and lifelong therapy needs add real cost.

For severe cases (total plexus injury, multiple root avulsions, persistent flail arm), functional outcomes remain limited even with optimal surgical and therapeutic management. Damages reflect that limitation.

The Lawyer Lawyers Call

Lead trial attorney Don Worley brings 20+ years of birth injury and complex medical malpractice experience and is known in the legal community as "the Lawyer Lawyers Call When Cases Get Complicated."

Damages and Settlement Value in Brachial Plexus Birth Injury Cases

Brachial plexus birth injury cases recover meaningful damages where the deficit is permanent, but they do not reach the catastrophic ranges of severe HIE or quadriplegic cerebral palsy. The damages framework focuses on functional limitation in the affected arm, the surgical and therapeutic course, and the lifetime impact on the child's earning capacity and quality of life.

Damages available in an OBPP malpractice case:

• Past medical expenses (primary nerve surgery, reconstructive surgeries, therapy)
• Future medical expenses (additional reconstructive surgery, lifelong therapy, equipment, splints, adaptive aids)
• Future medical care for sequelae (limb-length discrepancy management, contracture release, glenohumeral joint reconstruction)
• Lost future earning capacity (calculated as the gap between an unimpaired earnings trajectory and the child's projected earning capacity given the permanent limitation, particularly relevant for dominant-arm injuries)
• Pain and suffering (subject to state non-economic damage caps in many jurisdictions)
• Loss of consortium for parents where state law allows
• Out-of-pocket family expenses related to surgical and therapeutic care

State damage caps on non-economic damages affect the ceiling on brachial plexus cases more than they do on catastrophic-brain-injury cases, because non-economic damages represent a larger proportion of the total in cases without lifetime attendant care needs. The cap regime in your state shapes the demand. For state-by-state filing windows including minority tolling, see our birth injury statute of limitations page. The full four-element framework that brachial plexus claims share with other birth injury malpractice claims (duty, breach, causation, damages) is covered on our anchor page.

Brachial plexus birth injury cases are accepted on contingency. Families pay nothing out of pocket. You Win or It's Free.