Obstetric paralysis is flaccid paralysis of the upper limb in a child resulting from birth trauma of the brachial plexus, often with concomitant hypoxic damage. They are manifested by a decrease in tone and mobility in the affected arm, a violation of sensitivity and local thermoregulation. With untimely therapy, they lead to the development of muscle contractures. Diagnosis of obstetric paralysis is carried out on the basis of clinical data, results of electromyography and radiography. Treatment is aimed at normalizing the position of the limb, improving innervation and preventing the development of contractures.
P14.9 Birth injury of peripheral nerves, unspecified
Obstetric paralysis got its name due to the fact that it is etiologically associated with incorrect obstetric tactics of childbirth. Pathology was first observed, studied and described by the French neurologist Duchene and the German doctor Erb in the second half of the XIX century. Currently, it is known that damage to the nerve plexuses is possible in normal childbirth. Despite the great success of medicine in the field of obstetrics, the frequency of occurrence has not decreased in recent years and is about 0.2-0.4% for all forms of obstetric paralysis. For this reason, such injuries received in childbirth remain relevant in modern pediatrics. Even successful therapy does not allow to fully restore the function of the damaged limb, which further reduces the quality of life of patients.
Obstetric paralysis develops as a result of damage to the nerves of the brachial plexus during the passage of the baby through the birth canal. The cause may be mechanical compression at birth of the head and shoulders, as well as the use of obstetric forceps. Hypoxia during prolonged labor increases the risk of obstetric paralysis, since ischemia also leads to nerve damage. Birth trauma of a newborn can be obtained if the birth canal does not match the size of the fetus.
Thus, a large fetus weighing over 4 kg is much more at risk of developing this pathology. With breech presentation, there is a high risk of injury or rupture of the sternocleidomastoid muscle, which also plays a role in the pathogenesis of paralysis.
Division is carried out on the basis of localization of trauma in the nerve plexus. There are upper, lower and total paralysis.
- Upper obstetric Duchene-Erb paralysis) develops with damage to the upper primary bundle of the brachial plexus or the upper roots of the spinal cord corresponding to the first six cervical vertebrae.
- Dejerin-Klumpke paralysis (lower) affects the lower bundle of the brachial plexus or the roots of the spinal cord from the last cervical vertebra and below.
- Total obstetric paralysis affects the entire bundle and is the most severe form of paresis. In addition, there are combined beam lesions of varying degrees and atypical paresis, in which both sides are involved.
As a rule, such paralysis is noticeable from birth, except in cases of mild course, which are detected as the level of conscious activity of the child increases, that is, by 3-6 months. But more often, a pediatrician and a pediatric neurologist diagnose reduced muscle tone and a change in sensitivity at the first examination. The arm is hanging, there are no Moreau and Robinson reflexes, as well as the palm-mouth reflex. Depending on the localization of obstetric paralysis, muscle tone and sensitivity are more reduced either in the proximal part of the arm (shoulder joint, shoulder) or distally (forearm and hand). At the same time, motor activity can be observed in the innervation zone of intact nerves, although to a lesser extent than from the healthy side.
There are some features of the clinic of upper and lower obstetric paralysis. Since the proximal part of the limb is affected in Duchene-Erb paralysis, the shoulder is brought and rotated inward, resulting in a pronounced furrow between the shoulder and the trunk (a symptom of a “doll’s hand”). The head may be tilted to the sick side, especially if the sternocleidomastoid muscle was touched during the birth injury. The scapula in this case lags noticeably behind the spine. With Dejerin-Klumpke paralysis, the arm is also rotated inward, but more at the level of the forearm and hand. The hand may hang passively or, conversely, be in tension (a symptom of a “clawed paw”), depending on which nerve of the forearm is damaged.
Sensitivity in the damaged limb is reduced, however, it is possible to determine hypesthesia in newborns only if it is sufficiently pronounced. The child either does not experience pain when tapping with a hammer, or hyperesthesia is noted at the slightest physical contact with the area of paralysis. The limb remains cold to the touch.
In obstetric paralysis, there may be general cerebral symptoms in the form of excitement, tremor, suppression of unconditioned reflexes. These are signs of hypoxia. Usually they are present for a short time and pass on their own. One of the main complications of obstetric paralysis is muscle contractures and bone deformities developing after them as a result of the pathological position of the limb.
In most cases, the diagnosis is not difficult. Obstetric paralysis can be suspected based on the course of labor, the fact of hypoxia and the results of the examination. The level of paralysis is confirmed during the electromyography of the child. Firstly, the study makes it possible to differentiate primary muscle pathologies from injuries associated with the nervous system. Secondly, a violation of the speed of the pulse passing through specific nerves diagnoses their involvement in the process and makes it possible to distinguish between upper or lower paralysis. It is mandatory to conduct radiography to exclude a fracture of the collarbone.
Therapy begins in the maternity hospital and continues in the neurology department, where the child is transferred for the next few months. The first stage of treatment of obstetric paralysis consists in fixing the limb in an unbent state, in the position of abduction and supination. For this purpose, special abduction tires are used. First, the hand is removed from the body to the maximum distance that the child can bear calmly. The ultimate goal is to achieve the removal of the limb at a right angle. The splint is indicated for permanent wear, except during hygienic procedures and physiotherapy.
The complex of therapeutic measures for obstetric paralysis includes massage and physiotherapy. Massage is carried out for a long time, necessarily by a certified specialist. There is a positive effect of thermal methods of physiotherapy (paraffin, hot wrapping). Electrophoresis with anticholinesterase drugs and antispasmodics, tropic to the vessels of the brain and spinal cord, is also used. Systemic drug therapy uses cholinesterase inhibitors and vitamins of group B. The external use of absorbable enzyme preparations is shown.
Prognosis and prevention
The prognosis depends on the degree of damage and the time of initiation of therapeutic measures. Total obstetric paralysis is amenable to only minor correction and requires long-term therapy for many years. Muscle tone, sensitivity and strength are not fully restored. If the treatment was started late, it is possible to form muscle contractures that significantly worsen the prognosis for a cure. In addition, muscle contractures subsequently lead to bone deformities. As a result, underdevelopment, atrophy is noticeable on the affected side, osteoporosis is radiologically confirmed. Prevention of obstetric paralysis is possible only with proper management of childbirth.