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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 9  |  Issue : 3  |  Page : 57-60

Obstetric brachial palsy: Challenges of management in a developing country


1 Orthopaedic Unit, Department of Surgery, John F Keneddy Memorial Hospital, Monrovia, Liberia
2 Orthopaedic Unit, Department of Surgery, John F Keneddy Memorial Hospital, Monrovia, Liberia; Aminukano Teaching Hospital, Bayero University, Kano, Nigeria
3 Physiotherapy and Monrovia Rehabilitation Centre, John F Keneddy Memorial Hospital, Monrovia, Liberia

Date of Submission08-Jan-2020
Date of Acceptance25-Apr-2020
Date of Web Publication23-Sep-2020

Correspondence Address:
Dr. Mohammed Kabir Abubakar
Consultant Orthopaedic Surgeon, Orthopaedic Unit, Department of Surgery, John F Kennedy Memorial Hospital, Monrovia, Liberia and Aminukano Teaching Hospital, Bayero University, Kano, Nigeria

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_1_20

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  Abstract 


Background: Obstetric brachial palsy is not common in the presence of satisfactory Obstetric practice. The objective of this study was to highlight the challenges in the management of Obstetric brachial palsy (OBP) in Liberia.
Patients and Method: The study was carried out at John F Kennedy (JFK) Memorial Hospital Monrovia Liberia, the largest tertiary institution in Liberia, between October 2018 and June 2019. Records of all patients with OBP that presented to the orthopedic outpatient clinic were used for the study. All the patients were less than 3 months old. The follow-up status at 8–12 weeks and as at June 2019 were recorded. Phone numbers provided on the charts were used to trace the parents of the patients or care givers.
Results: Records of 10 patients were analyzed. There were seven males and three females. Birth weight ranged 2.6–4.5 kg, the gestational ages at birth was 36–40 weeks. Parity of the mothers were 1–3. Five patients had Erbs Palsy, three patients had Klumpkes paralysis, and two patients had global deformity. All 10 patients had right upper limb involvement. All the patients were referred for physiotherapy. At 8–12 weeks of presentation, three patients came for follow-up, seven were lost to follow-up. A follow-up phone call in June 2019 revealed improvement in four patients, some improvement in one patient, whereas five patients could not be reached. Conclusion: OBP is not uncommon in our setting and usually occurs on the right upper limb. Majority of the patients that present soon after birth would have significant improvement on physiotherapy.

Keywords: Developing country, Erbs Palsy, Obstetric brachial palsy


How to cite this article:
Gbozee L, Abubakar MK, Hennings SS. Obstetric brachial palsy: Challenges of management in a developing country. Arch Int Surg 2019;9:57-60

How to cite this URL:
Gbozee L, Abubakar MK, Hennings SS. Obstetric brachial palsy: Challenges of management in a developing country. Arch Int Surg [serial online] 2019 [cited 2020 Nov 26];9:57-60. Available from: https://www.archintsurg.org/text.asp?2019/9/3/57/295918




  Introduction Top


Obstetric brachial palsy (OBP) also known as perinatal brachial injury is injury to the brachial plexus that occurs at birth. The incidence varies from 0.15 to 3 per 1000 live birth.[1] It was first described in 1779 by Smellie.[2] OBP presents with a myriad of symptoms and signs depending on the severity and the part of the Brachial plexus that is involved. Classically three types of presentation are seen: upper trunk involving C5–C6 with or without C7 involvement (Erbs Palsy), C5–C8 and occasionally T1 involvement (Global), and Lower trunk involvement C8–T1 (Klumpke's palsy).[3]

There is no agreement on the exact cause of Obstetric palsy. Traditionally, shoulder dystocia has been implicated as the main cause of OBP. However, several theories have been put forward that suggests the contrary. These include, intrauterine maladaptation of the fetus,[4] intrauterine electrophysiological abnormalities[5] and posterior shoulder getting stuck on the sacral promontory during the early phase of labor.[6] The aim of this study was to highlight the challenges involved in the management of obstetrics palsy in Liberia.


  Patients and Method Top


Study area

The study was carried out at John F Kennedy (JFK) Memorial Hospital Monrovia Liberia, between October 2018 and June 2019. JFK Memorial Hospital is the largest tertiary institution in Liberia. It is the major referral hospital and serves a population of approximately 5 million people. JFK Memorial hospital is a 300-bedded hospital that has three major branches all located within the same premises: (A) Memorial hospital which has the outpatient department, emergency and trauma unit, Departments of Medicine, Surgery, Pediatrics, ophthalmology and dental surgery; (B) The Maternity hospital that has the Obstetric and gynecology department; and (C) the Monrovia rehabilitation center that has the Physiotherapy unit, the prosthetics and orthotics unit, and the occupational therapy unit. The hospital is equally supported by a laboratory, and morgue.

Inclusion criteria

The inclusion criteria of the study included all babies less than 3 months old OBP that presented to the orthopedic outpatient clinic of JFK memorial hospital Monrovia Liberia between October 2018 and March 2019 and presented for follow-up within 8–12 weeks of first presentation. Also the phone number of the patients care giver must be available on the patients chart.

Information was extracted from patient's record. These include date of presentation, age at presentation, age of pregnancy at delivery, duration of labor, parity of mother, maternal age, diagnosis at presentation, side affected, treatment instituted, and follow-up after 8–12 weeks. Assessment with phone call as at June 2019 was also done. Three questions were asked. If the parents or care givers think there has been (A) improvement, (B) deterioration and (C) no change, following physiotherapy. Improvement here means the patient is able to carry out physiological movements that hitherto were unable to do, whereas deterioration means patient has lost some physiological movement that he or she was able to do before the commencement of physiotherapy.


  Result Top


Overall, 10 patients met the inclusion criteria [Table 1]. Of these, seven were males and three were females. Birth weight of the patients ranges from 2.6 to 4.5 kg. The gestational ages at birth were between 36 and 40 weeks. The parity of the mothers was between 1 and 3. Five patients had Erbs Palsy, three Klumpkes paralysis, and two had global deformity including one clavicular fracture. All the 10 patients had right upper limp involvement. All the patients were referred to the physiotherapy unit for commencement of treatment. The physiotherapy prescribed included electrical stimulation, massage, and stretching exercise at the physiotherapy unit. Between 8 and 12 weeks of presentation, three patients came back for follow-up, whereas seven did not come back for follow-up. A phone call assessment of the responses given by the parents or care givers in June 2019 indicated improvement in four patients, some improvement in one patient, whereas five patients could not be reached for phone assessment.
Table 1: Results

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  Discussion Top


We had records of 10 patients of which seven were males and three were females. We cannot conclude that there is a sex predilection for the occurrence of obstetric palsy because our study population is too small.[7],[8],[9],[10] The mean age of presentation is 4 weeks and the age range of presentation is 1–8 weeks. This age of presentation is much higher than the age of presentation in the developed countries and some developing countries.[8],[11],[12],[13] This may be due to lack of awareness on how to identify obstetric palsy at birth by birth attendants and early care givers. The average birth weight of our patients was 3.31 kg. We however noticed that the patient with the highest birth weight of 4.5 kg had the most severe injury including clavicular fracture. It is well documented that birth weight correlates with severity of injury in obstetric palsy.[10], 12, [14],[15],[16]

All our patients were delivered at term. Thus, we cannot attribute their palsy to either preterm or post term complications.[10],[12],[14] Though assessing prolonged labor is highly subjective, we used 12 h as our cut-off for normal labor and above 12 h as prolonged.[17] We had five patients delivered following prolonged labor and incidentally all the patients with severe symptoms were those that were delivered following prolonged labor. This conforms with most studies that associate prolonged labor with severity of Obstetric palsy.[3],[8],[14],[18], [19,[20] Erbs palsy was the commonest in our study despite the small number. This is followed by Klumpkes paralysis and then global palsy. This trend has been previously documented.[18],[21] However, some studies have documented a higher prevalence of global paralysis than Klumpkes paralysis.[10],[22] All our patients had the right upper limb affected. Though our sample size is small, it still conforms to most reported cases where right sided pathology is more common.[3],[8],[9] This has been attributed to the left occiput anterior fetal position, which is the commonest presentation during delivery.[23]

Despite all the known modalities of treatment of obstetric palsy,[3],[9],[15],[20],[21],[22],[23],[24] our patients received electrical stimulation, massage, and stretching exercise from the physiotherapy unit of the hospital as these are the only available and viable treatment modalities in our hospital and Liberia as at the time of this study. As at 8–12 weeks of first visit and commencement of therapy, only three patients were regular at follow-up. All the three patients reported improvement.

The compliance of the two patients with global deformity may not be unconnected to the severity of their condition, which may be an impetus for the parents to adhere with the treatment regimen. As at June 2019 when data were being extracted from the records of the patients, all the patients have spent over 3 months from their first visit. Most of the parents alluded to the fact that there is some functional improvement despite little or no treatment. This conforms to the natural history of OBP as has been reported in other studies.[9], 18, [21],[22],[23],[24],[25]

Challenges of managing our patients with OBP in JFK Memorial Hospital Monrovia, Liberia, include late presentation of patients, poor communication with referring facility and medical record keeping and lack of adequate investigative facilities to make a more accurate diagnosis. In addition to poor understanding of the cause, risk factors, and natural history of the disease, there are also inadequate treatment modalities apart from physical therapy and unwillingness of parents to come for additional treatment and follow-up.


  Recommendations Top


We recommend improvement in record keeping and communication between referring facilities. There should be training and retraining of birth attendants, nurses, doctors, and other stake holders on the risk factors and early recognition of OBP and safe obstetric practices. Adequate diagnostic and treatment facilities should be made available, whereas management of the patients should have a multidisciplinary approach. Finally, there is need for our clinical follow-up to include provision for home visits in the course of treatment of OBP.


  Conclusion Top


OBP is quite a common condition and its severity depends on several factors. However, early recognition of risk factors and subsequent intervention will greatly improve functional outcome. In developing countries such as Liberia, training of health care providers in identification and prevention of risk factors will go a long way in reducing the menace of OBP. In addition building the capacity of clinician's to make diagnosis and treatment will enhance the overall care and quality of life of the patients.

Acknowledgement

No external funding was provided.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest. The authors alone are responsible for the content and writing of the paper.



 
  References Top

1.
Duchenne GB. De l'Electrisation Localisee et de son Application a la Pathologie et a la Therapeutique. 3rd ed. Paris: Bailliere; 1872.  Back to cited text no. 1
    
2.
Smellie W. A Collection of Cases and Observation in Midwifery to Illustrate His Former Treatise or First Volume on That Subject. London: W Strahan, T Cadell, G Nicol; 1779. p. 446.  Back to cited text no. 2
    
3.
Thatte MR, Mehta R. Obstetric brachial plexus injury. Indian J Plastic Surg 2011;44:380-9.  Back to cited text no. 3
    
4.
Jennett RJ, Tarby TJ, Kreinick CJ. Brachial plexus palsy: An old problem revisited. Am J Obstet Gynecol 1992;166:1673-6.  Back to cited text no. 4
    
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Koenigsberger MR. Brachial plexus palsy at birth: Intrauterine or due to delivery trauma? Ann Neurol 1980;8:228.  Back to cited text no. 5
    
6.
Deaver JE, Cohen WR. An approach to the prediction of neonatal Erb palsy. J Perinat Med 2009;37:150-5.  Back to cited text no. 6
    
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DeFrancesco, Shah DK, Rogers BH, Shah AS. The epidemiology of brachial plexus birth palsy in the United States: Declining incidence and evolving risk factors. J Pediatr Orthop 2019;39:e134-e140. doi: 10.1097/BPO.0000000000001089.  Back to cited text no. 7
    
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Yarfi C, Elekusi C, Banson AN, Angmorterh SK, Kortei NK, Ofori EK. Prevalence and predisposing factors of brachial plexus birth palsy in a regional hospital in Ghana: A five year retrospective study. Pan Afr Med J 2019;32:211.  Back to cited text no. 8
    
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Lagerkvist AL, Johansson U, Johansson A, Bager B, Uvebrant P. Obstetric brachial plexus palsy: A prospective, population-based study of incidence, recovery, and residual impairment at 18 months of age. Dev Med Child Neurol 2010;52:529-5.  Back to cited text no. 9
    
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Ashrafzadeh F, Boskabadi H, Rad MF, Hosseinee PS. A study on the risk factors for obstetrical brachial plexus palsy. Iran J Child Neurol 2010;4:13-8.  Back to cited text no. 10
    
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Chauhan SP, Blackwell SB, Ananth CV. Neonatal brachial plexus palsy: Incidence, prevalence, and temporal trends. Semin Perinatol 2014;38:210-8.  Back to cited text no. 11
    
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Malessy MJA, Pondaag W, Yang LJ-S, Hofstede-Buitenhuis SM, le Cessie S, et al. Severe obstetric brachial plexus palsies can be identified at one month of age. PLoS ONE 2011;6:e26193.  Back to cited text no. 13
    
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Nath RK, Kumar N, Avila MB, Nath DK, Melcher SE, Eichhorn MG, et al. Risk factors at birth for permanent obstetric brachial plexus injury and associated osseous deformities. ISRN Pediatr 2012;2012:7. Article ID 307039.  Back to cited text no. 14
    
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O'Berry P, Brown M, Phillips L, Evans SH. Obstetrical brachial plexus palsy. Curr Probl Pediatr Adolesc HealthCare 2017;47:151-5.  Back to cited text no. 15
    
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Alfonso DT. Causes of neonatal brachial plexus palsy. Bull NYU Hosp Jt Dis 2011;69:11-6.  Back to cited text no. 16
    
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World Health Organization. Managing Prolonged and Obstructed Labour. Geneva: Department of Making Pregnancy Safer, Family and Community Health, WHO; 2006.  Back to cited text no. 17
    
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El-Sayed AA. Obstetric brachial plexus palsy following routine versus difficult deliverie. J Child Neurol 2014;29:920-3.  Back to cited text no. 18
    
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Weizsaecker K, Deaver J, Cohen W. Labour characteristics and neonatal Erb's palsy. BJOG 2007;114:1003-9.  Back to cited text no. 19
    
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Kay SEJ. Obstetrical brachial palsy. Br J Plast Surg 1998;3:43-50.  Back to cited text no. 20
    
21.
Andersen J, Watt J, Olson J, Van Aerde J. Perinatal brachial plexus palsy. Paediatr Child Health 2006;11:93-100.  Back to cited text no. 21
    
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Ruchelsman DE, Pettrone S, Price AE, Grossman JAI. Brachial plexus birth palsy: An overview of early treatment considerations. Bull NYU Hosp Jt Dis 2009;67:83-9.  Back to cited text no. 22
    
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Abzug JM, Kozin SH. Evaluation and management of brachial plexus birth palsy. Orthop Clin N Am 2014;45:225-32.  Back to cited text no. 23
    
24.
Al-Qattan MM, El-Sayed AAF. Obstetric brachial plexus palsy: The mallet grading system for shoulder function—revisited. BioMed Res Int 2014;2014:1-3. Article ID 398121. doi: 10.1155/2014/398121.  Back to cited text no. 24
    
25.
Pondaag W, Malessy MJA, van Dijk JG, Thomeer RTWM. Natural history of obstetric brachial plexus palsy: A systematic review. Dev Med Child Neurol 2004;46:138-44.  Back to cited text no. 25
    



 
 
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Introduction
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