Dr. Shankar R. Kurpad, Bangalore. 9. Adult Brachial Plexus Injuries – An Appraisal on its Primary Management. Ashwath M . not treated diligentlythey get displaced which can lead to disastrous complication of nonunion and permanent disability. %were females, suggesting males are predisposed to these. Main · Videos; Erbs palsy treatment in bangalore dating. The potatoes are sewing one offset at cases nisi answers, nisi the potatoes are sewing various lawfully. Brachial plexus root avulsion injuries, which are devastating, usually result from high-speed accidents. Nerve transfer provides hope for successful treatment of.
The nursing home was running, since and it was not registered, as per Act, tillnot having all facilities but conducted caesarean deliveries. The OP-3 was not qualified to do private practice, as per the Government norms, thus OP 3 was illegally practicing.
In this context, the counsel also brought our attention towards the Madhya Pradesh Upcharyagriha Taha Rajopchar Sambandi Sthapanaye Ragistrikaran Tatha Anugrapan Adhiniyam, and Notification of Madhya Pradesh, Government, regarding restriction of private practice of the Government doctors.
The OP-Nursing home is a private nursing home and established for a profit making business. It is not a charitable or a government hospital. Banchore was never present at the nursing home. There was dereliction of duty on the part of Dr. Vandana Gupta and Dr. Therefore, the complainant is still suffering and is undergoing treatment in USA. The counsel further contended that, it was a difficult delivery, OP 3, single handedly conducted it.
No opinion or assistance of another Gynecologist was sought to conduct the delivery, no Specialist, such as an Anesthetist and or a Pediatrician, was available, no sufficient number of nurses and infrastructure was available in the hospital. During labour pain, the ward boy gave pressure on the abdomen of patient. The counsel relied upon the judgment of V.
Such a person when consulted by a patient owes him certain duties, viz. A breach of any of those duties gives a right of action for negligence to the patient. The practitioner must bring to his task a reasonable degree of skill and knowledge and must exercise a reasonable degree of care".
The second limb of argument was that the ultrasound USG report dated It was done 5 days prior to delivery. The counsel brought our attention to the post-delivery medical record, the weight of baby on record was around 4 kg, it is accepted by opposite party also.
It was a critical delivery for the mother, having a large baby. OP-3 must have resorted to caesarean section, looking to the heavy weight of the baby. Counsel submitted that patient was admitted with the labour pain and it was a prolonged labour. The baby was delivered after 24 hours of admission. OP-3 failed in her duty of care by not performing LSCS, at proper time, but OP-3 performed forceps delivery with excessive force to the over-weight baby.
OP-3 was the only doctor present in the labour room. It was the duty of opposite party to call for a Pediatrician, after delivery, but she discharged patient, on the same day, itself. The birth certificate produced by OP-Nursing home itself, clearly states that the baby was 4 kg. Thus, it was overweight in the Indian context i. In the instant case, there was forcep delivery, without any due diligence and care by which the baby suffered Erb's palsy of right hand.
As per the medical expert, the infants with Brachial Plexus Injury are more common in macrosomic babies. Such babies are also likely to suffer from shoulder dystocia and if delivered by forceps, these kinds of birth injuries will continue to occur, unless the obstetricians are diligent.
The liberal use of LSCS, instead of forceps and vaginal breech deliveries may help to lower neo-natal morbidity, mortality and major birth injuries. The learned counsel for the complainants denied that the complainants were forced by Dr.
Banchore to OP-Nursing home for delivery. Banchore, a child specialist. There was no professional liaison between Dr. Hence, it was a callous attitude of the OPs. It was necessary to avoid risk of birth trauma. The forceps technique is an outdated and unsafe for delivery. The OP-3 was responsible for lack of degree of skill and care. After delivery, the OP 3 advised the parents to show the child to Orthopedician or Neurophysician.
This itself indicates that she had knowledge of the defect in the right hand of the new born. She had concealed the fact from the parents, prescribed medicines, without calling the specialists to take immediate care of the child.
The OPs neither provided any receipt of payment or discharge slip to the complainant. The OP gave only false assurances that child would be normal, after some time. As per the birth certificate, both mother and child were normal. The OPs have falsely submitted that, the regular pediatrician was not called because Dr. The discharge slip Annexure 2 dated issued by Dr.
Uma Chaturvedi, the Pediatrician of said hospital, clearly depicts about Erb's palsy in the baby's right hand due to forceps delivery and hyper-bilirubinemia with septicemia. Thus, it confirms unhygienic conditions of the nursing home. During the stay in Sector 9 hospital, baby was given phototherapy and antibiotics. The jaundice and septicemia got cured, but the Erb's palsy of the child persisted and needed treatment for a longtime, in USA.
Brachial plexus injuries: outcome following neurotization with intercostal nerve
It is reproduced as under: The learned counsel for OPs Mr. Vandana Gupta OP-3is a senior consultant and worked as a Specialist in District Hospital, conducted complicated vaginal and operative surgeries, referred from all over the interior places of surrounding districts. The nursing home is fully equipped with modern equipments with sufficient staff to deal with the emergency LSCS. Sawant Child Specialist and Dr. Vaidya Anesthetist are associated with their nursing home.
Counsel brought our attention towards, the statement RR4 showing number of deliveries conducted, its mode and the other major operations, conducted by OP during to Further submitted that, the Chief Medical and Health Officer of Durg, inspected their nursing home for the infrastructure, staff and other medical facilities.
Accordingly, the recognition order was given on The counsel further submitted that Dr. Banchore, a Pediatrician, is relative of the patient. Therefore, OPs have not taken any charges for the treatment of patient. The patient was brought at 2. The OP-3 examined her in consultation chamber at her residence. Accordingly, the due date of delivery was Left Occipital Anterior and vertex was engaged.
Therefore, patient was admitted in the nursing home. The operative graphic representation i. It is submitted that, there was no concealment of baby's health, after delivery. There is no relation between neonatal jaundice and use of outlet forceps. After delivery, the Child Specialist Dr. The birth certificate was issued for the registration of birth purpose under local Municipal Corporation. It is not to be considered as a medical or evidence certificate.
The affidavit of Dr. Banchore is false and misleading because, he used to sit and practice in the chamber of OP's Polyclinic along with other doctors.
His name is clearly mentioned in the pamphlet of polyclinic. Banchore used to sit in Gupta Polyclinic. Therefore, those affidavits fully confirm the presence of Dr. Banchore, at the time of delivery. The counsel further submitted that, Dr. Banchore, is a highly greedy, dishonest and corrupt doctor and has no morals or medical ethics.
He demanded a bribe of Rs. Since she showed her inability to pay the amount due to poverty, Dr. Banchore refused to issue the certificate. Banchore was caught red-handed, accepting the bribe in the raid. Copy of complaint is Annexure RR Banchore is still under suspension after remaining in District Jail, Durg for two days. The charge sheet against Dr. Banchore is pending trial, in the court of Special Judge at Durg.
The counsel for OPs denied about the ultrasound features of macrosomia. The weight falling within 10th - 90th percentile, is taken as appropriate, for gestational age". Counsel further relied upon various textbooks like "Perinatology and Contraception" by D.
Dutta, in the matter of elective forceps delivery. Counsel further relied upon the report given by Dr. Child was treated by several Specialist Doctors in Neurology, Rehabilitation. Vatsal and expressed that the brachial plexus injury was probably caused by traction on head and neck away from the impacted shoulder.
We have gone through the standard medical text books on Obstetrics and Gynecology, Birth Injuries etc. The medical board constituted under Chairmanship of Professor Dr. On evaluation of the available records of labour and delivery the following observations were made: The antenatal period seemed to be normal.
There is no record showing, whether or not, the mother was a diabetic. According to the partogram, the onset of labour was at 2: She started active phase at 9: The duration of first stage of labour was 9.
It was a forceps delivery, the indication being maternal exhaustion. There was no antenatal indication for not conducting a normal vaginal delivery. The indication of forceps has been mentioned as maternal exhaustion and not a prolonged 2nd stage which is an indication of the fact that there was no cephalopelvic disproportion.
The occurrence of brachial plexus injuries is 0. This is also called obstetrical palsy. This is more likely to occur, after instrumental delivery. But,may also occu,r after a normal delivery, especially in big babies.
The generally accepted mechanism in case of shoulder dystocia is traction to the neck caused by pull of the obstetricians hand or instruments like forceps or vacuum. However, birth brachial plexus injuries have occurred, following caesarean sections and also that shoulder dystocia does not always lead to such injuries.
There is some electrophysiological evidence to show that birth injuries could have occurred in the intrauterine period, since denervation potentials are seen on day 1, after delivery, which is not possible, in case it occurred at the moment of delivery.
Thus, there is no agreement among the brachial plexus surgeons about the mechanism or active prevention of these injuries and the grievance filed by the complainant may not be supported by evidence available so far in the literature. Reference to Medical Literature: The anterior fetal shoulder can become wedged behind the symphysis pubis and fail to deliver, using normally exerted downward traction and maternal pushing.
Because the umbilical cord is compressed within the birth canal, such dystocia is an emergency.
Master Vatsal Aniket Verma & Ors. vs Gupta Nursing Home & Ors. on 25 January,
Several maneuvers, in addition to downward traction on the fetal head, may be performed to free the shoulder. This required a team approach, in which effective communication and leadership are critical.
Consensus regarding a specific definition of shoulder dystocia is lacking. Some investigators focus on, whether, maneuvers to free the shoulder are needed, whereas, others use the head-to-body delivery time interval as defining Beall, Spong and coworkers reported that the mean head-to-body delivery time in normal births was 24 seconds compared with 79 seconds in those with shoulder dystocia.
Currently, however, the diagnosis continues to rely on the clinical perception that the normal downward traction needed for fetal shoulder delivery is ineffective.
Because of these differing definitions, the incidence of shoulder dystocia varies. Current reports cite an incidence between 0. There is evidence that the incidence has increased in recent decades, likely due to increasing fetal birthweight Mackenzie, Alternatively, this increase may be due to more attention given to appropriate documentation of dystocia Nocon, Because shoulder dystocia cannot be accurately predicted, clinicians should be well versed in its management principles.
Because of ongoing cord compression with this dystocia, one goal is to reduce the head-to-body delivery time. This is balanced against the second goal, which is avoidance of fetal and maternal injury from aggressive manipulations. Accordingly, an initial gentle attempt at traction, assisted by maternal expulsive efforts, is recommended. Adequate analgesia is certainly ideal. Some clinicians advocate performing a large episiotomy to provide room for manipulations.
Of note, paris and Gurewitsch and their colleagues reported no change in the brachial plexus injury rate for groups in which episiotomy was not performed during shoulder dystocia management. After gentle traction, various techniques can be used to free the anterior shoulder from its impacted position behind the symphysis pubis.
Of these, moderate suprapubic pressure can be applied by an assistant, while downward traction is applied to the fetal head. Pressure is applied with the heel of the hand to the anterior shoulder wedged above and behind the symphysis. The anterior shoulder is thus either depressed or rotated, or both, so the shoulders occupy the oblique plane of the pelvis and the anterior shoulder can be freed.
They are identified in 1 to 3 per term births Baskett, ; Joyner, ; Lindqvist, In the study of more than 8 million singleton births reported by Moczygemba and colleaguesthe incidence of brachial nerve injury was 1. Breech delivery and shoulder dystocia are risks for this trauma. However, severe plexopathy may also occur without risk factors or shoulder dystocia Torki, The injury with plexopathy is actually to the nerve roots that supply the brachial plexus - C and T1.
With haemorrhage and edema, axonal function may be temporarily impaired, but the recovery chances are good. However, with avulsion, the prognosis is poor. Injuries with breech delivery are normally of this type, whereas the more extensive lesions follow difficult cephalic deliveries Ubachs, The C roots join to form the upper trunk of the plexus, and injury leads to paralysis of the deltoid, infraspinatus, and flexor muscles of the forearm.
Erb's Palsy Treatment | Birth Injury Guide
The affected arm is held straight and internally rotated, the elbow is extended, and the wrist and fingers flexed. Finger function usually is retained. Because lateral head traction is frequently employed to effect delivery of the shoulders in normal vertex presentations, most cases of Erb paralysis follow deliveries that do not appear difficult. Damage to the C8-T1 roots supplying the lower plexus results in Klumpke paralysis, in which the hand is flaccid.
Total involvement of all brachial plexus nerve roots results in flaccidity of the arm and hand, and with severe damage, there may also be Horner syndrome.
Unfortunately, as discussed in Chapter 27 p. In most cases, axonal death does not occur and the prognosis is good. Lindqvist and associates reported complete recovery in 86 percent of children with C trauma, which was the most common injury, and in 38 percent of those with C damage. Examples of physical therapy exercises may include: Gentle stretching exercises Range of motion exercises Strength exercises In addition to exercises performed during physical therapy, parents are encouraged to continue these exercises at home.
Furthermore, physical therapists will usually show parents the correct to hold their infant while in order to eliminate any additional problems to the affected area. Nerve Graft Repairs Nerve grafts repair is a procedure in which nerves from parts of a sensory nerve is taken from another part of the body to be used grafting material in order to repair the damaged nerve.
Through the graft, once set in place, regenerating nerve fibers can then grow through the graft and connect with the muscles.
As a result, patients have a chance in recovering their muscle functions in the affected arm once the nerve injuries repair. Studies suggests that patients who undergo nerve graft repairs have the best chances of success. Nerve Decompression Nerve decompression surgery is considered a minimally invasive procedure in which a small incision is made into the skin, followed by the insertion of a specialized surgical instrument that decompresses the affected nerves.
Once the affected nerves are decompressed, pressures from other parts of the body are eliminated, allowing the damaged nerves to repair. For example, your child may experience long-term arm weakness as well as long-term shoulder rotation difficulties.