When a baby's shoulder becomes stuck during delivery — a condition called shoulder dystocia — the next few minutes are critical. How the medical team responds in those moments can mean the difference between a healthy delivery and a lifelong injury. Erb's palsy, caused by damage to the brachial plexus nerves, is one of the most common and most preventable consequences of shoulder dystocia mismanagement.
What Is Shoulder Dystocia?
Shoulder dystocia occurs when the baby's head delivers but the anterior (front) shoulder becomes impacted behind the mother's pubic bone. This obstetric emergency occurs in approximately 0.6-1.4% of vaginal deliveries and requires immediate, skilled intervention. Risk factors include: high birth weight (macrosomia — babies over 8 lbs 13 oz), maternal gestational diabetes, maternal obesity, post-term pregnancy (past 40 weeks), previous shoulder dystocia, and prolonged second stage of labor.
What Is Erb's Palsy?
Erb's palsy (also called Erb-Duchenne palsy) results from damage to the upper brachial plexus — the network of nerves running from the neck through the shoulder that controls movement and sensation in the arm and hand. There are four types of brachial plexus injuries in order of severity:
Neuropraxia (stretch): The nerve is stretched but not torn. Most common type. Usually resolves within 3 months with physical therapy. Neuroma: The nerve is stretched and some fibers are damaged, creating scar tissue. May require therapy; some cases resolve, others result in permanent weakness. Rupture: The nerve is torn but not at the spinal cord. Requires surgical repair (nerve graft). Avulsion: The nerve root is torn from the spinal cord. Most severe form. Surgery (nerve transfer) may provide partial improvement, but significant permanent disability is typical.
How Does Delivery Negligence Cause Erb's Palsy?
The primary cause of brachial plexus injury during delivery is excessive lateral traction — pulling the baby's head downward and to the side while the shoulder is still impacted. This stretches or tears the brachial plexus nerves. Specific forms of negligence include:
Applying excessive force: Instead of using gentle, controlled maneuvers, the provider pulls too hard on the baby's head/neck. Failing to recognize risk factors: When a baby is estimated to be large (macrosomic), providers should plan for potential shoulder dystocia and consider elective C-section. Improper maneuver sequence: Evidence-based protocols (HELPERR mnemonic) dictate a specific sequence: call for Help, Episiotomy evaluation, Legs (McRoberts maneuver), suprapubic Pressure, Enter maneuvers (internal rotation), Remove posterior arm, and Roll the patient. Deviating from this sequence increases injury risk. Delayed response: Every second counts during shoulder dystocia. Excessive time between delivery of the head and delivery of the body increases the risk of nerve injury and oxygen deprivation. Failure to plan for C-section: When risk factors for shoulder dystocia are present and the baby is estimated to be large, failure to discuss or offer cesarean delivery may constitute negligence.
Signs Your Baby May Have Erb's Palsy
Parents should watch for these signs in newborns and infants: the affected arm hangs limp at the side, the arm is internally rotated with the wrist flexed (the 'waiter's tip' position), decreased or absent grip strength on the affected side, lack of Moro reflex (startle reflex) on the affected side, and limited or no movement of the shoulder, elbow, or wrist.
Treatment and Prognosis
Treatment depends on severity: mild cases may resolve with physical and occupational therapy over 3-6 months. Moderate cases may require Botox injections, constraint-induced movement therapy, or electrical stimulation. Severe cases (ruptures and avulsions) typically require microsurgery — nerve grafts or nerve transfers — ideally performed before 6 months of age. Even with treatment, many children with moderate to severe Erb's palsy experience permanent limitations in arm function, range of motion, and strength.
Erb's Palsy Settlements and Verdicts
Erb's palsy cases have produced significant verdicts and settlements: mild cases that resolve with therapy typically settle for $100,000-$500,000. Moderate cases requiring surgery settle for $500,000-$2 million. Severe permanent cases with lasting disability have produced verdicts of $5 million to $25 million+. These amounts reflect the cost of surgery, ongoing therapy, adaptive equipment, and the impact on the child's future earning capacity and quality of life.
What Parents Should Do
If your child was diagnosed with Erb's palsy or brachial plexus injury after a difficult delivery, take these steps: follow all recommended medical treatment plans, request complete medical records from the delivery including nursing notes and fetal monitoring strips, photograph your child's arm position and any visible symptoms, keep a detailed journal of your child's progress and limitations, and consult a birth injury attorney who can have the records reviewed by independent medical experts.
Bond Legal represents families affected by Erb's palsy and shoulder dystocia injuries nationwide. Free consultations. pay no attorney fees unless we recover compensation for you. Call (866) 423-7724.
