What I find difficult in BPBP

Management of obstetrical palsies is a challenge for a variety of reasons.

Explaining and counseling the parents: There is no doubt that the injury has occurred
because of excessive force in delivering the baby. However, this has to be conveyed
without blaming either the midwife or the obstetrician. The deficit is usually obvious
to the clinician but the parents find it difficult to accept. The concept of nerves
and the fact that different nerves are responsible for different functions is fundamental.
Very often, ordinary household examples are necessary to make them understand the
severity of the injury without, at the same time, frightening them about the future
consequences. An honest and detailed discussion is necessary at the outset.

Offering surgery: Extensive palsies are evident and most parents accept surgical treatment
readily. The real difficulty is explaining the uncertain and, often, limited possibility
of restoration of function.

The majority of patients have suffered lesions of the C5 and C6 roots. There is no
doubt that surgery should be offered early if spontaneous recovery is not seen. The
rate of progressive improvement is the crux and repeated observations are necessary.
The pectoralis major function enables trick movements that can fool the clinician.
Incorrect interpretation of the function at the early stages can push us to defer
surgery. The consequences of such a conservative attitude are only evident over two-three
years when the shoulder function remains poor with development of deformities. Only
experience can help arrive at a better evaluation.

Evaluation of nerve stumps and trimming: The primary operation in obstetrical palsies
is always systematic exploration of the brachial plexus. The upper trunk is identified
with the help of the suprascapular nerve and it is traced proximally. The phrenic
nerve is isolated and the nerves are examined at the intervertebral foramina. The
branches to the serratus anterior should be looked for and stimulated (under the microscope).
The appearance of the sectioned stump needs careful evaluation. The quality of shoulder
function restored depends on the number of growing axons directed to the posterior
division of the upper trunk. Dissection within the foramina is often difficult. One
must reach proximal to the zone of injury to ensure use of a good stump.

Post-operative immobilization: Movements of the head and neck must be prevented. This
is particularly true when nerve grafting is done. Older children are, obviously, more
active and immobilizing them is a daunting task. The parents are instructed to maintain
strict attention throughout the waking hours for a month.

Post-operative therapy: Most children are operated upon at 4-5 months of age. Nerve
transfers such as ulnar-biceps or intercostals to musculocutaneous produce contractions
within 3-4 months. However, it is difficult to communicate the mechanism of activating
the muscle to an 8 months old baby. The parents are instructed to encourage the child
to grasp objects in a manner designed to produce biceps action. The child will use
the biceps only when it perceives strong contraction of the muscle. This task is even
more difficult for intercostals. Often, we can see the biceps contracting when the
child cries but active elbow flexion can take two years to appear. Automatically,
the use of the hand function is delayed.

Incorporation of the restored function in daily activity: Delay in nerve reconstruction
prolongs the period of weak shoulder and elbow functions. As a result, the child cannot
reach out for an object and take it to the mouth at the suitable time. This pushes
me to offer surgery at an early stage if the shoulder abduction and biceps do not
appear by three months.