OBSTETRIC BRACHIAL PLEXUS PALSY - OBPP (ERB S PALSY) PATHWAY FOR THE NEWBORN. NNNI Obstetric Brachial Plexus Palsy (OBPP) Pathway Working Group

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1 OBSTETRIC BRACHIAL PLEXUS PALSY - OBPP (ERB S PALSY) PATHWAY FOR THE NEWBORN Author: NNNI Obstetric Brachial Plexus Palsy (OBPP) Pathway Working Group For use in: Acute hospital settings including post-natal wards, neonatal units and midwifery led units. Population: Guidance is specific to the care of newborn babies. For use by: Neonatal and paediatric medical and nursing staff, hospital midwives, physiotherapists, occupational therapists, and paediatric orthopedic staff. Key Words: Obstetric Brachial Plexus Palsy (OBPP), Erb s Palsy Date of Ratification: June 2018 Review due: June 2020 SHSCT Clinical Guidelines ID: CG0573 Approved by: Neonatal Network Northern Ireland Clinical Lead, Neonatal Network NI Dr Sanjeev Bali Date: June 2018 Signed: Ratified by Neonatal Network NI Board Chair, Neonatal Network NI Board Mrs Eileen McEneaney Date: June 2018 Signed:

2 Document Reader Information Title Document purpose Author Newborn Obstetric Brachial Plexus Palsy (OBPP) Pathway 1. Standardise practice 2. Consistent pathway for parents/families NNNI task and finish group Publication date April 2018 Target audience Circulation list Description Superseded documents Action required Contact details HSC Trusts specifically targeting: Managers and clinical leads responsible for the provision of neonatal and maternity services Medical, nursing and midwifery staff working in acute neonatal and paediatric settings Hospital midwives Physiotherapists and occupational therapists who provide paediatric services As above This document outlines an agreed regional pathway for the assessment and referral to specialist services of the newborn where obstetric brachial plexus palsy (OBPP) is suspected. Not applicable. For dissemination and implementation across HSC Trusts. Dr Sanjeev Bali Clinical Lead Neonatal Network NI c/o Antrim Hospital

3 NEWBORN OBSTETRIC BRACHIAL PLEXUS PALSY (OBPP) PATHWAY INTRODUCTION Currently in Northern Ireland, there is no unified practice across Trusts for the assessment and management of newborns who are suspected of having an obstetric brachial plexus palsy (OBPP). In order to provide clarity and consistency for these newborns and their parents, this pathway has been developed through the NNNI by a multidisciplinary working group drawn from relevant clinical specialties. This pathway aims to standardise practice to ensure that all newborn babies presenting with symptoms of OBPP have an appropriate paediatric orthopaedic assessment in Northern Ireland with onward referral for treatment outside Northern Ireland if required. The pathway also encompasses referral to local physiotherapy and occupational therapy services. The pathway should be adhered to in all acute health care settings where newborn babies are cared for including post-natal wards, neonatal units and midwifery led units. BACKGROUND - OBSTETRIC BRACHIAL PLEXUS PALSY (OBPP) Obstetric Brachial Plexus Palsy (OBPP), also known as Erb's Palsy, is a paralysis which affects the nerves in the upper arm, shoulder and hand. It is often caused by an injury during birth to the upper part of the brachial plexus when it is put under traction. This may resolve quickly, but for some babies treatment may be necessary. A diagnosis of OBPP should be considered if a newborn is noticed to have weakness/flaccidity of an arm in conjunction with an asymmetrical Moro reflex at birth. AIM To support clinical decision making around the assessment and management of newborns who are suspected of having OBPP. To standardise assessment and referral pathways to ensure appropriate, timely and consistent practice. To provide guidance on initial assessment and relevant management to clinical teams and families.

4 SCOPE OF THE GUIDELINE This guideline covers the assessment and referral of a newborn with suspected OBPP. It provides guidance to the staff looking after the newborn in the hospital setting and in the midwifery led setting. The guidance outlines the referral pathway to: 1. the Paediatric Orthopaedic Team based in RBHSC Belfast; 2. the Paediatric Physiotherapy Team in local Trusts; and, 3. the Paediatric Occupational Therapy team in RBHSC Belfast and local Trusts. ROLES/RESPONSIBILITIES It is the responsibility of all relevant staff (including, neonatal and paediatric medical staff, neonatal nurses, hospital midwives, physiotherapists and occupational therapists providing services to newborn babies and paediatric orthopaedic specialists) to be aware of this pathway and to follow the recommendations. There will undoubtedly be times when circumstances may differ from those described. In line with best practice, the rationale for deviation from the agreed pathway should be documented in the medical notes following discussions with the lead consultant neonatologist / paediatrician responsible for that patient s care. DIAGNOSTIC ASSESSMENT The diagnostic assessment of OBPP should take place as part of the newborn clinical examination which is completed prior to discharge of the baby from the hospital setting. This examination is outlined in the parent held child record (Red Book). If, during the examination, there is weakness or reduced movements of either upper limb noted or an asymmetric Moro reflex, then a more detailed neurological assessment should be carried out by paediatric medical staff. The assessment by the paediatric medical staff should take into account the baby s perinatal history including delivery details along with any family history such as musculoskeletal issues. The detailed examination is required to look for signs of focal or global neurologic deficits. Obstetric brachial plexus palsy usually presents with a certain posture for example, "waiter's tip posture of the affected arm, and an asymmetric Moro reflex. Other neurological patterns noted may raise the suspicion of a more global nervous system condition. This guidance relates specifically to an OBPP pattern. Early referral to the paediatric service based in Belfast is important in all such cases for specialist assessment and further management which could include referral to a supra-specialist centre based in Royal Hospital for Sick Children, Glasgow.

5 Figure 1, sets out the Neonatal OBPP Pathway in the newborn. Referral forms and contact details are provided in appendix 1. AUDIT The neonatal network and stakeholders for this work will audit the OBPP pathway in The audit will reflect standards outlined in this pathway with a focus on: Timely identification of OBPP prior to discharge from hospital; Appropriate referral to the regional paediatric orthopaedic service; Timely local neonatal outpatient review (4 weeks post discharge); Timely triage (within 1 week of referral); For those cases which require supra regional services, referral within 8 weeks; Proportion of babies with suspicion of OBPP managed in line with guidance.

6 Figure 1: Newborn Obstetric Brachial Nerve Plexus Palsy (OBPP) Pathway

7 REFERENCES Association of Paediatric Chartered Physiotherapists, (2012) Obstetric Brachial Plexus Palsy: A Guide for Management 3. Association of Paediatric Chartered Physiotherapists, (2012) Obstetric Brachial Plexus Palsy: A Guide for Parents 4. National Obstetric Brachial Plexus Injury Service, (2017) Guidelines on Initial Management and Referral of Obstetric Brachial Plexus Palsy, Glasgow: Yorkhill Hospital, available at: WORKING GROUP MEMBERSHIP 1. Dr Sanjeev Bali, NHSCT, NNNI Clinical Lead (Chair) 2. Dr Alison Verner Neonatal Consultant Lead, BHSCT 3. Mr Jim Ballard- Paediatric Orthopaedic Surgeon, BHSCT 4. Emma Cameron Senior Paediatric Physiotherapist, NHSCT 5. Claire McGinley Neonatal Network Project Manager 6. Gail Hanna Physiotherapist, BHSCT 7. Catherine Glover Occupational Therapist, BHSCT 8. Sabrina Sorrie NI Erb s Palsy Group Rep

8 Appendix 1 Obstetric Brachial Plexus Palsy (OBPP) Referral Form to Paediatric Orthopaedics RBHSC, Belfast Patient Details Referrer Details Name Name: DOB Designation: H+C Hospital: Address Phone/ Phone GP Consultant: GP address Phone/ GP phone Clinical Details Birth Weight Side affected (L/R) Fracture at birth? (clavicle/humerus/other /none) Type of Delivery Cephalic Breech Caesarean Forceps Ventouse Comments (e.g. rapid 2 nd stage, Apgar score, etc) Examination Findings (e.g. Horners Syndrome, other abnormalities or neurological conditions)

9 Notes / comments Please send this referral form to all the following: 1 Orthopaedics Send to the Paediatric Orthopaedic Service RBHSC sharon.quinn@belfasttrust.hscni.net / Kerry.mcgreevy@belfasttrust.hscni.net AND post referral to : Consultant Orthopaedic Surgeons (Tr&Orth) Royal Belfast Hospital for Sick Children 180 Falls Road Belfast BT12 6BE 2 Physiotherapy as an URGENT referral to local trust BHSCT NSCHT WHSCT SEHSCT SHSCT Physiotherapy Dept, RBHSC, Belfast, BT12 6BE physiocentralbooking@northerntrust.hscni.net WHSCT Paediatric Physiotherapy Referral Proces, refer appendix 2 cbo.physiotherapy@setrust.hscni.net ahp.cbu@southerntrust.hscni.net 3 Occupational Therapy To the Paediatric Occupational Therapist RBHSC catherinec.glover@belfasttrust.hscni.net 4 Named Consultant Neonatologist / Paediatrician Send a copy of the referral to the baby s consultant paediatrician / neonatologist secretary to arrange 4 week follow up.

10 Appendix 2 WHSCT Paediatric Physiotherapy Referral Process Please ensure that all babies are referred to inpatient staff via the PAS system to ensure inpatient pick-up and send referral for out-patient follow-up to the following centres dependent on area of residence. Paediatric Physiotherapy Department contact Details 1 Home address within postal areas BT47, BT48, BT49 Post referral to : Paediatric Physiotherapy Bridgeview House Gransha Park Clooney Road Londonderry BT47 6TG 2 Home address within postal areas BT78, BT79, BT81, BT82 Post referral to : Paediatric Physiotherapy Department Children s Centre Omagh Hospital and Primary Care Complex 7 Donaghanie Road Omagh BT79 0JJ 3 Home address within postal areas BT74, BT92, BT93, BT94 Post referral to : Paediatric Physiotherapy Department Children s Centre Southwest Acute Hospital 124 Irvinestown Road Enniskillen BT74 6DN