1. Diaphragmatic plication for phrenic nerve paralysis following obstructed labour in a neonate: A case report Naqvi Sayyed EH*, Beg Mohammed H, Haseen Azam, Abqari Shaad, Khan Ghazanfer Department of Cardiothoracic Surgery & paediatrics, JN Medical College, AMU, Aligarh Presented by: Dr S. Ehtesham H. Naqvi MS, MCh CTVS, DNB CTVS Assistant professor CTVS, JN Medical College, AMU, Aligarh

2. Phrenic nerve paralysis following obstructed labour: An overview
Etiology: usually excessive lateral hyperextension of the neck during obstructed labour
Incidence: 1: :10,000
Most cases unilateral, more common on the right side.
If excessive stretching of C3-C5 nerve ,simultaneous occurrence of brachial plexus palsy (most common Erbs’ Palsy) : 75% of cases.
Risk factors: Abnormal presentations (Breach, shoulder, face), Cephalo- pelvic disproportions, Forceps interventions

3. Phrenic nerve paralysis following obstructed labour: An overview
Usual presentation
Unilateral involvement: respiratory difficulty, incidental X ray finding
Bilateral involvement :severe respiratory failure presenting as cyanosis in neonatal period.
Examination
reduced respiratory movements, bowel sounds in the chest (eventration), paradoxical respiratory indrawing of abdominal musculature.
Investigations
X ray Chest, Fluoroscopy, USG Chest, CECT Chest

4. Phrenic nerve paralysis following obstructed labour: Management ???
Unilateral Asymptomatic: Conservative
Unilateral with respiratory distress: positive pressure ventilation, conservative/elective diaphragmatic plication at one month
Neonatal diaphragmatic plication Indications: Bilateral paralysis, inability to wean from ventilator, bowel complications, prevention of lung collapse, hypoplasia
Schwartz MZ, Filler RM. Plication of the diaphragm for symptomatic phrenic nerve paralysis. J Pediatr Surg. 1978; 13:259–63
De Vries TS, Koens BL, Vos A. Surgical treatment of diaphragmatic eventration caused by phrenic nerve injury in the newborn. J Pediatr Surg. 1998; 33:602–5

5. CASE REPORT Presentation 25 days male baby weighting 3.2 kg
Full term Breech delivery at some private hospital.
history of the usage of delivery forceps.
difficulty in breathing and laboured breast feeding
Abnormal posture of right arm since birth
Examination
Room air saturation 90-95%. No cyanosis, CVS system WNL
Respiratory movements diminished on right side, Indrawing of right upper abdomen with respiration.
Breath sounds diminished in right lower chest.
Erb's arm palsy on the right side.

6. INVESTIGATIONS Fluoroscopy: paradoxical movements of right diaphragm
INVESTIGATIONS Fluoroscopy: paradoxical movements of right diaphragm. Normal left dome of diaphragm Echocardiography: Structurally normal heart
X ray Chest

7. MANAGEMENT
Risk, benefits of Neonatal diaphragmatic plication measured.
Plan for postoperative ventilatory management.
Discussion with the parents.
Surgical Procedure:
Posterolateral Thoracotomy through right 8th intercoastal space with plication of diaphragm
Peroperative findings:
Lax right hemidiaphragm raised up to mid thoracic levels
Collapsed right lung
Colon occupying supra hepatic space

8. PEROPERATIVE FINDINGS

9. OUTCOMES
Extubated on the next morning of surgery
Discharged on day 7 of surgery
No wound infection
At discharge:
room air saturation %,
no tachypnea,
no difficulty in feeding

10. MESSAGE
Early plication in cases of congenital phrenic nerve palsy may benefit in terms of:
Improvement of ventilation and reduction in respiratory complaints
Growth of lung during the developmental phase
Possible prevention of gastrointestinal complications
However more number of patients need to be reviewed to support the assumption.