Parents usually realize something is wrong when their newborn’s arm lies limp against their body, and no one in the delivery room can give a clear answer about why. In the days that follow, you might hear the term “Erb’s Palsy,” but the explanations feel rushed or incomplete. You are left wondering whether this was a tragic fluke or whether something went wrong in those intense minutes of labor and delivery.
For families in Charleston and across West Virginia, medical records often hold the clearest clues about what truly happened. Those records document what the obstetrician, nurses, anesthesiologist, and pediatric staff did, when they did it, and what they observed. Understanding which records matter, how to get them, and how they are used in a legal case is one of the most effective ways to move from confusion to clarity about your child’s Erb’s Palsy diagnosis.
At Berthold Law Firm, PLLC, we focus on personal injury and medical malpractice cases in Charleston and the surrounding communities, and we spend a great deal of time studying birth records for families in your position. Our legal team works closely with our full-time on-staff nurse, who has extensive clinical experience reviewing complex medical charts, and we offer complimentary consultations so you can explore your options without upfront cost. In this guide, we share how Erb’s Palsy shows up in medical records and how those records are used to build, or rule out, a malpractice claim in West Virginia.
Questions about your child’s medical records after an Erb’s palsy diagnosis? Speak with a Charleston Erb’s palsy attorney to understand what information may be important and how it can relate to a potential legal claim. Call (304) 605-2040
How Erb’s Palsy Happens During Labor & Delivery
Erb’s Palsy is an injury to a group of nerves called the brachial plexus. These nerves run from the neck through the shoulder and control movement and sensation in the shoulder, arm, and hand. When the upper portion of the brachial plexus is stretched or torn, a baby can lose strength or movement in the affected arm, often holding it close to the body with the palm turned inward.
Most Erb’s Palsy injuries occur during difficult vaginal deliveries. One common scenario involves shoulder dystocia, where the baby’s head delivers, but one shoulder becomes stuck behind the mother’s pelvic bone. Obstetric providers are trained to use specific maneuvers to free the shoulder, such as repositioning the mother, applying pressure above the pubic bone, or gently rotating the baby’s shoulders. When these maneuvers are not used correctly, or when a provider pulls too hard on the baby’s head or neck, the brachial plexus nerves can be stretched beyond their limits.
Important risk factors for shoulder dystocia often appear long before delivery. A larger baby, maternal diabetes, a history of prior shoulder dystocia, or a very long second stage of labor can all increase the chances of a difficult birth. Sometimes, even with proper care, an Erb’s Palsy injury happens despite everyone doing their best. In other situations, however, the choice of delivery method, the timing of interventions, and the amount of traction applied can fall below accepted medical standards.
Our role in an Erb’s Palsy case is not to assume that every injury is negligent, but to use records and medical insight to separate unavoidable complications from preventable mistakes. Our team, working with our on-staff nurse, examines the details of the pregnancy and the delivery to understand whether the sequence of decisions and maneuvers was consistent with what reasonably careful providers in West Virginia would have done under the same circumstances.
Why Medical Records Matter So Much In An Erb’s Palsy Case
Medical records are the official written history of a pregnancy, delivery, and newborn course of care. They capture, at least in theory, what the providers did, what they observed, and what they believed was happening in real time. For a family wondering whether their child’s Erb’s Palsy could have been avoided, these documents are critical, because memories fade and stories change, but the chart remains the backbone of any legal analysis.
In an Erb’s Palsy case, records help answer central questions. Did the prenatal records identify a large baby or other risk factors that should have led to a planned cesarean delivery? Did the labor notes describe a sudden shoulder dystocia and, if so, which maneuvers were used and for how long? Was there any mention of difficulty delivering the shoulders or of significant traction applied to the baby’s head? When did staff first document weakness or lack of movement in the baby’s arm, and how did they explain it at the time?
Many parents initially assume that if the hospital chart does not admit a problem, there must not have been one. Others believe they must already have proof of negligence before they talk to a lawyer, so they feel stuck. In reality, it is very common for records to present a polished, minimal-description version of events. Our job is to read behind the surface, compare entries from different staff members, and line up the timing of events with what you remember from the delivery room.
At Berthold Law Firm, PLLC, we use these records to build detailed timelines that show what was happening from the last prenatal visit through the birth and the first weeks of life. Working with our on-staff nurse, we look not just at what was written, but when entries were made, who signed them, and whether later notes attempt to reshape the story. This level of analysis helps us evaluate whether West Virginia standards of obstetric care were likely followed or violated.
Which Erb’s Palsy Medical Records You Need From Charleston Providers
One of the most practical steps you can take is identifying and collecting the right categories of records. Many parents receive only a short discharge summary when they leave a Charleston hospital, and assume that is the full chart. In reality, a complete Erb’s Palsy evaluation often requires several different sets of records from multiple providers.
Prenatal records are a key starting point. These include notes from your obstetrician or midwife, ultrasound reports, lab results, and any specialist consultations. We look for information about estimated fetal weight, gestational diabetes, maternal pelvis size, blood pressure issues, and any mention of suspected large baby or prior shoulder dystocia. These details matter because they inform whether a vaginal delivery was a reasonable plan or whether a cesarean section should have been strongly considered.
Labor and delivery records are usually the centerpiece of an Erb’s Palsy case. They can include:
- Physician delivery notes, describing the course of labor, any complications, and the method of delivery.
- Nursing notes and flow sheets, which often contain more detailed, moment-by-moment observations about contractions, fetal heart rate, and staff responses.
- Fetal monitoring strips or electronic tracings, showing the baby’s heart rate patterns and how the uterus was contracting, which can indicate stress during labor.
- Operative reports for vaginal deliveries with instruments or for cesarean sections, documenting maneuvers used, the difficulty of the delivery, and any shoulder dystocia.
- Anesthesia records, which can help confirm timing and medications during labor and delivery.
- Newborn assessments, including Apgar scores and initial physical exam findings, especially notes on arm strength and movement.
Postnatal and follow up records also play a crucial role. These can include notes from the nursery or NICU at the Charleston hospital, pediatric visits where arm weakness was documented, imaging or nerve studies ordered to evaluate the brachial plexus, and physical or occupational therapy notes that track progress over time. Together, these records help confirm the timing of the injury and the long-term impact on your child’s function.
Because we routinely handle birth injury and medical malpractice cases in Charleston and throughout West Virginia, we are familiar with how local hospitals and clinics organize their records. That experience helps us know where to look and what to ask for so families are not left with only a partial picture.
How To Request Erb’s Palsy Medical Records In Charleston
Many parents feel uneasy about requesting records from the same hospital and providers who cared for them. You may worry that it will damage relationships or that you are not allowed to see everything. In reality, federal law and West Virginia rules give you the right to obtain copies of your child’s medical records, and hospitals handle record requests every day.
In most cases, you request records by contacting the medical records or health information management department at the Charleston hospital where you delivered and any clinics that saw you during pregnancy or saw your baby after birth. They typically ask you to complete a written authorization form that identifies your child, specifies which records you want, and covers the relevant dates of care. Under HIPAA, providers usually must provide access within a set time frame, and they can charge reasonable copying fees, particularly for paper records or discs that include fetal monitoring strips and imaging.
It often helps to be as specific as possible in your request. For an Erb’s Palsy evaluation, that may mean asking for prenatal records from your OB practice for the entire pregnancy, all labor and delivery records (including fetal monitoring strips and operative reports) from the date of admission through discharge, newborn or NICU records, and pediatric records related to your child’s arm weakness, referrals, imaging, and therapy. Sometimes, different parts of the record, such as fetal monitoring tracings or radiology reports, are stored separately and require separate requests.
Some families prefer to start this process on their own, and that can work as a first step. Others find it less stressful to sign authorizations and allow us to submit targeted, comprehensive record requests on their behalf. At Berthold Law Firm, PLLC, we routinely coordinate this process for Charleston families, track responses, and follow up when important documents are missing. That way, you can focus more on your child’s daily care and therapy while we focus on assembling the full medical picture.
What We Look For In Erb’s Palsy Medical Records
Once records arrive, the real work begins. We do not simply skim a discharge summary and draw conclusions. Our legal team and our on-staff nurse sit down with the full chart and build a detailed timeline, often starting with the last few prenatal visits and moving minute by minute through labor, delivery, and the newborn period. We compare physicians’ notes, nursing notes, fetal monitoring strips, and medication logs to see how the story fits together.
In labor and delivery records, we look closely for documentation of shoulder dystocia. Did the obstetrician explicitly note that the shoulder was stuck, and if so, when? Which maneuvers were described, how many attempts were made, and for how long? We also pay attention to how much detail is included. A vague note that says “shoulder dystocia resolved” without describing the steps taken may raise different questions than a thorough description that matches accepted protocols.
We also watch for red flags. These can include discrepancies between nursing notes and the physician’s summary, signs of prolonged second stage labor without escalation of care, or entries that suggest significant traction was applied to the baby’s head without mention of safer alternatives. The timing of when staff first recorded arm weakness is important too. If a newborn assessment shortly after birth notes decreased movement in one arm, that supports a delivery-related injury rather than something that developed later. On the other hand, if weakness appears only in later notes, we look carefully at what happened in the hours and days after birth.
Our on-staff nurse contributes a clinical perspective that is critical in these reviews. She examines subtle details, such as changes in fetal heart rate patterns on the strips, the sequence of orders and medications, and the consistency of vital signs charting. Together, we ask whether the patterns in the chart are consistent with a reasonable response to a shoulder dystocia or whether they suggest delays, misjudgments, or excessive force.
When questions remain after our internal review, we may consult outside obstetric or pediatric neurology professionals to obtain formal opinions. This does not mean every Erb’s Palsy case becomes a lawsuit. In some situations, careful record analysis supports the conclusion that providers met the standard of care. In others, the records reveal patterns that warrant moving forward with a malpractice claim on behalf of the child.
Common Problems & Gaps We See In Birth Records
Families are often surprised to learn that medical records, while important, are not always complete or perfectly objective. We frequently see charts from Charleston and other West Virginia hospitals that use templated language to describe deliveries as “routine” or “uncomplicated,” even when other parts of the record hint at a more difficult course. Recognizing these patterns is part of understanding what really happened.
One common issue is under-documentation of shoulder dystocia and maneuvers. A delivery that felt frightening and chaotic to the parents may be reduced in the chart to a single line. Nursing notes or fetal monitoring strips might suggest prolonged pushing, repeated calls for assistance, or changes in fetal heart rate that do not appear anywhere in the physician’s brief summary. Important documents, such as fetal monitoring tracings or certain nursing flow sheets, may not be included in the first batch of records that a family receives.
We also see missing or incomplete newborn assessments. A note might simply say “healthy male infant” without mentioning that the baby was not moving one arm normally. Later pediatric visits may document Erb’s Palsy, but without a detailed explanation of when symptoms first appeared. In some cases, we encounter addenda or late entries added after the fact, which can be legitimate but also raise questions about why the record was changed or supplemented and what was happening around that time.
When we encounter these kinds of gaps, we do not stop at the first set of records. We follow up with additional targeted requests, compare documentation from different providers, and, when warranted, request electronic logs that show when entries were made. Our combination of seasoned legal professionals, advanced research tools, and a medical consultant helps us recognize when the chart leaves out important pieces of the story and how to respond when that happens. This careful approach is especially important when we are challenging the documentation of large institutions such as hospitals and insurance companies.
How Medical Records Support Your Erb’s Palsy Claim In West Virginia
If the evidence points toward preventable error, medical records form the foundation of a potential malpractice claim. In West Virginia, as in other states, an Erb’s Palsy case typically requires showing three things with the help of qualified medical opinions. First, that the providers did not meet the standard of care that reasonably careful obstetric or pediatric professionals would have followed. Second, that this failure more likely than not caused the brachial plexus injury. Third, that the child has suffered real harm as a result, including functional limitations and future needs.
Labor and delivery records are central to the first two elements. They are used by medical professionals who review the case to answer questions such as whether a cesarean delivery should have been offered, whether the response to shoulder dystocia was timely and appropriate, and whether the technique used to free the baby’s shoulders was within accepted practice. Newborn and early pediatric records help confirm that arm weakness was noted soon after birth, supporting the link between delivery events and the injury.
Pediatric neurology records, imaging, nerve studies, and therapy notes demonstrate the third element, harm. They show how much movement your child has recovered, what limitations remain, and what interventions such as surgery, bracing, or ongoing therapy may be needed in the future. These records help build a picture of your child’s day-to-day challenges and long-term outlook, which is essential for valuing a claim and planning for their needs.
Because we have handled complex personal injury and medical malpractice matters in both West Virginia state and federal courts, we understand how judges, juries, and insurers evaluate this kind of evidence. Our AV rating from Martindale-Hubbell reflects our commitment to high legal ability and ethical conduct, which is especially important when presenting sensitive medical records and expert opinions on behalf of an injured child.
Next Steps If You Are Worried About Your Child’s Erb’s Palsy
Learning that your child has Erb’s Palsy is overwhelming, and trying to sort out what happened from a stack of medical records can feel impossible. You do not have to have every record or a perfect understanding of the medicine before you talk with a lawyer. Simple steps like gathering any records you already have, writing down what you remember from the day of delivery, and noting your child’s current diagnoses and therapies can be enough to start a meaningful conversation.
At Berthold Law Firm, PLLC, we see it as our responsibility to take on the hard work of record collection and analysis so you can focus on your child. Our team, including our on-staff nurse, reviews prenatal, delivery, and pediatric records to help answer the questions that have been left hanging. During a complimentary consultation, we can talk through what you have, explain what additional records might be needed from Charleston and surrounding West Virginia providers, and discuss the options that may be available for your family.
If you are concerned about whether your child’s Erb’s Palsy could have been prevented, we invite you to reach out and have your situation reviewed in detail. You should not have to navigate complex medical and legal questions alone.
Building a legal case involving Erb’s palsy often starts with a careful review of medical records and birth details. Call (304) 605-2040 or contact online our Charleston Erb’s palsy lawyers to discuss your situation and receive guidance on the next steps for your family.