What Is Erb’s Palsy?

Erb’s palsy (Erb-Duchenne palsy) is a birth injury affecting the upper brachial plexus nerves (C5-C6, sometimes C7), causing weakness or paralysis of the shoulder, upper arm, and sometimes forearm — typically resulting from excessive lateral traction applied to the baby’s head and neck during a difficult vaginal delivery. When Erb’s palsy results from preventable delivery room errors, a Charlotte brachial plexus injury attorney can help families pursue compensation for the child’s medical treatment and any permanent limitations.

Erb’s palsy is the most common brachial plexus birth injury, accounting for approximately 45–50% of all neonatal brachial plexus palsy cases. The incidence is approximately 0.9 to 2.6 per 1,000 live births, with the rate significantly higher in deliveries complicated by shoulder dystocia. The characteristic presentation is the “waiter’s tip” posture — the affected arm hangs limp at the side, internally rotated at the shoulder, extended at the elbow, and pronated at the forearm, with the wrist flexed and fingers curled.

The critical legal question is whether the nerve injury was caused by excessive traction applied by the delivering provider during delivery — particularly during management of shoulder dystocia — or whether it resulted from the natural forces of labor. When medical records, delivery technique, and expert analysis establish that the traction exceeded what a reasonably prudent practitioner would apply under the circumstances, the injury constitutes medical malpractice under N.C.G.S. § 90-21.12.

What Are the Types of Brachial Plexus Injury?

Brachial plexus birth injuries are classified by severity into four types: neurapraxia (nerve stretch without tearing — best prognosis), axonotmesis (nerve fiber damage with intact sheath — variable recovery), neurotmesis (complete nerve rupture — requires surgery), and avulsion (nerve root torn from spinal cord — most severe, requires nerve transfer surgery). The severity classification determines both the treatment plan and the damages calculation in a malpractice claim.

Erb’s Palsy vs. Total Plexus Palsy

Erb’s palsy (upper plexus: C5-C6) affects the shoulder and upper arm. Extended Erb’s palsy (C5-C7) additionally involves forearm and wrist. Total plexus palsy (C5-T1) affects the entire arm including the hand — often involving Horner syndrome when T1 is involved. See our page on Klumpke’s palsy (lower plexus: C8-T1).

How Does Medical Negligence Cause Erb’s Palsy?

Medical negligence causes Erb’s palsy when delivering providers apply excessive lateral traction to the baby’s head during shoulder dystocia, fail to perform proper shoulder dystocia relief maneuvers (McRoberts, suprapubic pressure, Woods screw), fail to anticipate shoulder dystocia in high-risk deliveries, or persist with vaginal delivery when cesarean section is indicated. Under N.C.G.S. § 90-21.12, providers must use the care a reasonably prudent practitioner would exercise.

Excessive Lateral Traction During Shoulder Dystocia

When the anterior shoulder becomes lodged behind the pubic symphysis, some providers pull harder on the baby’s head — applying excessive lateral traction that stretches the brachial plexus nerves beyond their tolerance. The standard of care requires providers to immediately proceed to recognized shoulder dystocia relief maneuvers.

Failure to Perform Proper Relief Maneuvers

The ACOG-recommended sequence includes:

1. McRoberts maneuver — hyperflexing the mother’s thighs to widen the pelvic outlet
2. Suprapubic pressure — applying pressure above the pubic bone to dislodge the anterior shoulder
3. Delivery of the posterior arm
4. Woods corkscrew / Rubin maneuver — rotating the baby’s shoulders
5. Gaskin maneuver — repositioning the mother onto hands and knees
6. Zavanelli maneuver — last resort: pushing head back for emergency C-section

Failure to Anticipate Shoulder Dystocia

Risk factors requiring proactive management include:

• Estimated fetal weight >4,000g (macrosomia)
• Maternal gestational diabetes or obesity
• History of prior shoulder dystocia
• Prolonged second stage of labor
• Operative vaginal delivery (vacuum or forceps)
• Post-dates pregnancy (>42 weeks)

What Are the Signs and Symptoms of Erb’s Palsy?

Signs of Erb’s palsy are typically visible immediately after birth: the characteristic “waiter’s tip” posture (arm limp at the side, internally rotated, elbow extended, forearm pronated, wrist flexed), inability to move the affected shoulder or arm, absent Moro reflex on the affected side, and decreased grip strength.

Classic “Waiter’s Tip” Presentation

• Arm hangs limp at the baby’s side
• Shoulder adducted and internally rotated
• Elbow extended (cannot flex)
• Forearm pronated (palm facing backward)
• Wrist flexed with fingers curled
• Unable to lift arm, reach above head, or bring hand to mouth

Diagnostic Evaluation

The workup includes physical examination, electromyography (EMG) and nerve conduction studies (at 3–4 weeks and repeated at 3 months), and MRI myelography to evaluate for nerve root avulsion. EMG findings are critical evidence in malpractice cases.

How Do You Prove Erb’s Palsy Was Caused by Medical Malpractice?

Proving Erb’s palsy malpractice requires establishing that the delivering provider applied excessive lateral traction exceeding the standard of care, or failed to properly manage shoulder dystocia, or failed to offer cesarean section when risk factors were present — using delivery records, nursing notes, and expert testimony from board-certified obstetricians.

Key Evidence

• Delivery records — documenting shoulder dystocia, maneuvers attempted, head-to-body delivery interval
• Nursing notes — recording sequence of events and time stamps
• Estimated fetal weight — whether macrosomia was identified
• EMG/nerve conduction studies — documenting nerve roots affected and severity
• Surgical records — if nerve grafting was required, confirming severity
• Hospital shoulder dystocia protocols — comparing actual practice to protocol

The Defense: “Propulsive Forces”

Defense attorneys argue that the brachial plexus injury was caused by the natural propulsive forces of labor rather than physician traction. However, medical literature demonstrates that brachial plexus injuries result from lateral traction applied by the provider, not the linear forces of maternal pushing. Our experts are prepared to rebut this defense.

What Is Rule 9(j) and How Does It Affect Erb’s Palsy Lawsuits?

North Carolina Rule 9(j) requires expert certification that the standard of care was breached before an Erb’s palsy lawsuit can be filed — the certifying expert must be a board-certified obstetrician qualified under Rule 702 to testify about delivery technique and shoulder dystocia management.

Under Rule 9(j), the expert must review delivery records and certify that the provider’s actions fell below the standard of care. Under Rule 702, the expert must be qualified by training and experience in obstetric delivery technique.

Our firm works with board-certified obstetricians, maternal-fetal medicine specialists, and pediatric neurologists who regularly testify in brachial plexus cases and can effectively counter the “propulsive forces” defense.

Who Can Be Held Liable in an Erb’s Palsy Case?

Potentially liable parties include the delivering obstetrician or midwife (for excessive traction or failure to perform proper maneuvers), the prenatal care provider (for failing to identify macrosomia), labor and delivery nurses (for failing to assist or document properly), and the hospital (for inadequate shoulder dystocia training or protocols).

Delivering Obstetrician or Midwife

The primary liability typically falls on the provider who applied the traction causing the nerve injury and who was responsible for the decision to attempt vaginal delivery versus cesarean section.

Prenatal Care Provider

If the prenatal provider failed to diagnose gestational diabetes, failed to estimate fetal weight, or failed to counsel about risks of vaginal delivery with a macrosomic fetus, they may bear separate liability.

Hospital

Hospitals may be liable for failure to require shoulder dystocia simulation training, inadequate staffing, or failure to have emergency protocols in place.

What Is the Statute of Limitations for Erb’s Palsy Claims in NC?

The statute of limitations for a minor’s Erb’s palsy claim extends until the child’s 10th birthday under N.C.G.S. § 1-17(c)(1), while parents’ claims follow the standard 3-year deadline under N.C.G.S. § 1-15(c).

What Damages Can Be Recovered in an Erb’s Palsy Lawsuit?

Recoverable damages include uncapped economic damages (nerve surgery, physical and occupational therapy, future surgeries, adaptive equipment, and lost earning capacity), non-economic damages capped at $712,847 (pain, suffering, disfigurement), and potentially punitive damages for gross negligence.

Economic Damages (No Cap)

• Nerve surgery — grafting ($50K–$100K+), nerve transfer, secondary reconstructive procedures
• Physical and occupational therapy — intensive therapy from infancy; ongoing for permanent cases
• Botox injections — to manage contractures and improve range of motion
• Adaptive equipment — modified clothing, adaptive tools, ergonomic devices
• Lost earning capacity — for permanent cases affecting occupational function

Non-economic damages are capped at $712,847 under N.C.G.S. § 90-21.19. Punitive damages may be available under Chapter 1D.

What Is the NC Non-Economic Damages Cap in Erb’s Palsy Cases?

North Carolina caps non-economic damages at $712,847 effective January 1, 2026, but economic damages — including nerve surgery, therapy, adaptive equipment, and lost earning capacity — have no cap and vary significantly based on whether the Erb’s palsy is permanent.

In resolving cases, damages are primarily medical costs and pain/suffering. In permanent cases requiring nerve surgery with lifelong arm limitations, total damages can reach $1 million to $5+ million.

How Does Contributory Negligence Affect Erb’s Palsy Cases?

North Carolina’s pure contributory negligence rule under N.C.G.S. § 1-139 is inapplicable to the child’s claim because a newborn cannot contribute to delivery room negligence — and the mother’s pushing does not constitute contributory negligence because she follows provider instructions.

Under N.C.G.S. § 1-139, the delivering provider controls the technique and force applied during delivery. Brachial plexus injuries result from lateral traction on the head — a force only applied by the provider.

What Is the Difference Between Erb’s Palsy and Klumpke’s Palsy?

Erb’s palsy affects the upper brachial plexus (C5-C6) causing shoulder and upper arm weakness with the “waiter’s tip” posture, while Klumpke’s palsy affects the lower plexus (C8-T1) causing hand and wrist weakness with a “claw hand” deformity — both caused by excessive traction during delivery but affecting different nerve roots.

What Is the Lifetime Cost of Treating Erb’s Palsy?

Lifetime costs range from $50,000–$200,000 for resolving cases to $500,000–$5+ million for permanent cases requiring nerve surgery, secondary reconstructive procedures, ongoing therapy, and lost earning capacity compensation.

What Is the Erb’s Palsy Claims Process in North Carolina?

The claims process follows the standard NC medical malpractice sequence: free case evaluation, record collection (including delivery records and EMG studies), Rule 9(j) expert review, life care planning, filing in Superior Court, discovery, mediation, and trial if necessary.

A unique aspect of Erb’s palsy cases is that timing matters strategically. If the child’s condition is still improving (within 3–6 months), we may monitor recovery before filing — because permanent damage directly affects damages. However, we begin preserving evidence and conducting expert review immediately under Rule 9(j).

What Should You Do If Your Child Was Born with Erb’s Palsy?

If your child was born with arm weakness or paralysis after a difficult delivery — especially one involving shoulder dystocia, vacuum extraction, or forceps — you should: (1) follow through with all recommended physical therapy, (2) request complete delivery records, (3) document the delivery events, (4) avoid hospital risk management discussions, and (5) contact an Erb’s palsy attorney promptly.

Frequently Asked Questions About Erb’s Palsy Claims in North Carolina

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