BIRTH BRACHIAL PLEXUS PALSY EVALUATION FORM

1. BIODATA
Age: ______________________ D.O. B: _________________________
Sex: _______________________
Birth weight: _________________ Current weight: __________________

2. CHIEF COMPLAINT
Limp upper limb post-delivery: Yes No
Limb affected: Right Left

3. MATERNAL HISTORY
Age at first pregnancy: ________ Parity: __________________
BMI: __________________
Antenatal history:
YES NO DETAILS
Gestational Diabetes Mellitus
Illness during pregnancy
Cephalopelvic disproportion
Uterine malformation e.g.
bicornate uterus
Abnormal placental position
Fibroids

4. LABOUR HISTORY
Fetal presentation: Vertex Breech Face Shoulder dystocia
Other: _________________________
History of prolonged labour? Yes No
Place of delivery? Home Clinical setting
Delivery conducted by trained personnel? Yes No
History of fetal distress? Yes No
Induction of labour? Yes No
Epidural anaesthesia administered? Yes No
Mode of delivery:
Vaginal: Caesarean section:
If Vaginal delivery, history of assisted delivery? Yes: No:
Give details (Forceps or Vacuum assisted): ____________________________
If caesarean section, any adverse events during operation? Yes No
Give details: ____________________________________________________

5. POST NATAL HISTORY

 Birth asphyxia: Yes No
History of perinatal injury? Yes No
Give details: ____________________________________________________
Initial movement after birth:

YES NO
Shoulder
Elbow
Forearm
Hand and fingers
Flail upper limb
Horner’s syndrome

Any physiotherapy administered? Yes No

If yes:
Type: __________________________________________________________
Duration: _______________________________________________________
Intensity (Number of times per day): _________________________________
If no: When was the first change in movement noted:

Movement Time since birth (months)

Abduction
Shoulder Adduction
Flexion
Elbow Extension
Pronation
Forearm Supination
Extension
Wrist Flexion
Extension
Finger Flexion

Any progression/improvement in movement? Yes No

6. SURGICAL HISTORY
Any nerve surgery done? Yes No
Age at time of surgery: __________________________________________________
Type of nerve surgery done: ______________________________________________
_____________________________________________________________________

7. PHYSICAL EXAM
Head
Caput: ______________________________________________________________
Horner’s syndrome: Ptosis Miosis Enopthalmos
Neck
Any swelling or bulging? Yes No
Trunk
Any bruising noted? Yes No
If yes, state the site: _____________________________________________
Clavicle: Any deformities? Yes No
Upper limb
Right: Left:
Humerus: Any deformities? Yes No
Posturing? Tip hand: Flail:
Motor grading

Grade
Abduction
Shoulder Adduction
External rotation
Internal rotation
Extension
Elbow Flexion
Pronation
Forearm Supination
Extension
Wrist Flexion
Extension
Fingers Flexion

*Modified MRC grading for Brachial plexus birth palsy (Gilbert and Tassin)
Grade Findings
MO No contraction
M1 Flicker or contraction without movement
M2 Movement with gravity eliminated
M3 Normal range of motion against gravity