Birth
Injuries
Hailemariam Mekonnen
[Link].,Ass't professor
Pediatrics Nursing
Bahir Dar University
Birth Injuries
BIRTH INJURIES
• An impairment of the infants
body function or structure due to Aruna. A P
I Year MSc Nursing
adverse influences that occur at
birth
• Injuries to the infant may result
from mechanical forces (i.e.,
compression, traction) during the
birth process
Birth Injuries
• 0.7% (Seven of every 1,000) births
BIRTH INJURIES
result in birth injuries. though most
women give birth in modern
hospitals surrounded by medical Aruna. A P
professionals I Year MSc Nursing
• Birth injuries account for fewer than
2% of neonatal deaths
• Infant mortality resulting from birth
trauma fell from 64.2 to 7.5 deaths
per 100,000 live births from 1970-
1985
Factors predisposing to injury
include the following
• Primiparity
• Small maternal stature
• Maternal pelvic anomalies
• Prolonged or unusually rapid labor
• Oligohydramnios
• Malpresentation of the fetus (breech)
• Cephalopelvic disproportion
• Deep transverse arrest of presenting part of the
fetus
Factors predisposing to injury
include the following
• Use of mid forceps or vaccum
extraction
• Versions and extractions
• Very low birth weight or extreme
prematurity
• Fetal macrosomia birth weight over
about 4,000 grams
• Fetal macrocephali (Large head)
• Fetus anomalies
CLASSIFICATION OF BIRTH
INJURIES
• Soft tissue injuries
• Head and neck injuries
• Facial injuries
• Cranial nerve injuries
• Spinal cord injuries
• Peripheral Nerve injury
• Fractures - Torticollis
• Intra-abdominal injury
CLASSIFICATION OF BIRTH
INJURIES
Soft tissue Peripheral nerve
- Abrasions - Brachial plexus palsy
- Erythema petechia - Unilateral vocal cord paralysis
- Ecchymosis - Radial nerve palsy
- Lacerations -Lumbosacral plexus injury
-Subcutaneous fat necrosis
Skull Musculoskeletal injuries
- Caput succedaneum - Clavicular fractures
- Cephalohematoma - Fractures of long bones
- Subgaleal hemorrhage -Sternocleido-mastoid injury
- Linear fractures
-Intracranial hemorrhages Intra-abdominal injuries
Face - Liver hematoma
- Subconjunctival hemorrhage
-Retinal hemorrhage - Splenic hematoma
Cranial nerve & spinal cord - Adrenal hemorrhage
injuries - Renal hemorrhage
- Facial palsy
SOFT TISSUE INJURIES
- Abrasions
- Erythema petechia
- Ecchymosis
- Lacerations
- Subcutaneous fat necrosis
Abrasions and lacerations
May occur as scalpel cuts during Cesarean
delivery or during instrumental delivery (i.e,
vacuum, forceps)
Infection remains a risk, but most uneventfully
heal
Management
Careful cleaning, application of antibiotic
ointment, and observation
Lacerations occasionally require suturing
Subcutaneous fat necrosis
Irregular, hard, nonpitting,
subcutaneous induration with
overlying dusky red-purple
discoloration on the extremities,
face, trunk, or buttocks
May be caused by pressure during
delivery.
No treatment is necessary
Subcutaneous fat necrosis
sometimes calcifies
SKULL INJURIES
- Caput succedaneum
- Cephalohematoma
- Subgaleal hemorrhage
- Skull fractures (Linear-Depressed)
- Intracranial hemorrhages
Caput succedaneum
• Oedema of the presenting part
caused by pressure during a
vaginal delivery
• This is a serosanguineous,
subcutaneous, extraperiosteal
fluid collection with poorly
defined margins, non fluctuating
Cephalhematoma
• Subperiosteal collection of
blood between the skull and
the periosteum.
• It may be unilateral or
bilateral, and appears within
hours of delivery as a soft,
fluctuant swelling on the side
of the head.
• A cephalhaematoma never
extends beyond the edges of
the bone or crosses suture
lines
Cranial X-ray of the girl with Cephalohematoma
Subgaleal hematoma
Bleeding in the potential space between
skull periosteum & scalp galea aponeurosis
Crosses suture lines
(і) Shock and pallor: tachycardia, a low blood pressure, within 30
minutes of the haemorrhage the haemoglobin and packed cell
volume start to fall rapidly.
(ii) Diffuse swelling of the head. Sutures usually are not palpable.
The amount of blood under the scalp is far more than is
estimated. Within 48 hours the blood tracks between the fibres of
the occipital and frontal muscles causing bruising behind the ears,
along the posterior hair line and around the eyes.
Cephalhematoma
If infection is suspected, aspiration of the mass
If sepsis, antibiotics
hyperbilirubinemia – photo therapy
Subgaleal hematoma
Transfusions may be required if blood loss is
significant.
In severe cases, surgery may be required to cauterize
the bleeding vessels.
Skull fractures
Linear skull fractures
Usually the parietal bones.
Compression forceps, or skull against symphysis or ischeal
spines.
Rarely, dural tear, with leptomeningeal cyst.
Depressed skull fractures
Indications for surgery include
radiographic evidence of bone
fragments in the cerebrum
presence of neurologic deficits
signs of increased intracranial pressure
signs of cerebrospinal fluid beneath the galea
failure to respond to closed manipulation.
Indications for nonsurgical management include
Depressions less than 2 cm in width and depressions over a
major venous sinus
Without neurologic symptoms
Intracranial hemorrhages
• Bleeding can occur
– External to the brain into the epidural, subdural or subarachnoid space
– In to the parenchyma of the cerebrum or cerebellum
– Into the ventricles from the subependymal germinal matrix or choroid
plexus
• Intracranial haemorrhage
• Epidural hemorrhage
• Subdural hemorrhage
• Subarachnoid hemorrhage
• Intraparenchymal haemorrhage
• Germinal matrix hemorrhage / intraventricular haemorrhage
Intracranial hemorrhages
Intracranial hemorrhages
• Extradural (epidural)
• Subdural
(i) Shock and/or anaemia due to blood loss
(ii) Neurological signs due to brain compression, e.g.
convulsions, apnoea, a dilated pupil or a depressed
level of consciousness
(iii) A full fontanelle and splayed sutures due to
raised intracranial pressure
Intracranial hemorrhages
Subarachnoid hemorrhages (SAH)
(i) Attacks of secondary asphyxia and apnoe, irregular
breathing, bradycardia.
(ii) Hyperestesia, tremor, seizures, bulging of fontanella.
“Sunset” and Grefe symptoms are positive.
(iii) Changes of spinal fluid in lumbar puncture: it becomes
xanthochromic or/and contains blood
Intraventricular (IVH) hemorrhages
Periventricular hemorrhage, intraventricular hemorrhage.
Periventricular hemorrhagic infarction (PVHI) on MRI.
Periventricular hemorrhage, intraventricular hemorrhage.
Severe or grade III hemorrhage (subependymal with
significant ventricular enlargement) in ultrasonography.
FACIAL INJURIES
- Subconjunctival hemorrhage
-Retinal hemorrhage
-Other ocular injuries
-Nasal septal dislocation
Subconjunctival hemorrhage
Breakage of small blood vessels in the
eyes of a baby. One or both of the eyes
may have a bright red band around the
iris
This is very common and does not
cause damage to the eyes. The redness
is usually absorbed in a week to ten
days
Other Ocular injuries
• Rupture of Descemet’s membrane
of the cornea
• lid lacerations
• hyphema (blood in anterior
chamber)
• vitreous hemorrhage
• Purtscher’s retinopathy
• corneal edema,
• corneal abrasion
Nasal Septal dislocation
Involves dislocation of the triangular cartilaginous
portion of the septum from the vomerine groove
Clinical features Management
airway obstruction. Definitive diagnosis can be
deviation of the nose to one side made by rhinoscopy
The nares are asymmetric, with
flattening of the side of the manual reduction
dislocation (Metzenbaum sign). performed by an
Application of pressure on the tip otolaryngologist using a
of the nose (Jeppesen and nasal elevator.
Windfeld test) causes collapse of Reduction should be
the nostrils, and the deviated performed by 3 days of age
septum becomes more apparent.
PERIPHERAL NERVE
INJURIES
- Brachial plexus palsy
- Phrenic nerve injury
- Laryngeal nerve injury
(unilateral vocal cord paralysis)
- Radial nerve palsy
-Lumbosacral plexus injury
PERIPHERAL NERVE INJURIES
Brachial plexus injury
Risk factors
Macrosomia
Shoulder dystocia
Instrumented deliveries
Malpresentation
Brachial plexus injury
• Erb-Duchenne palsy (C5-C6)
• The most common
• Lack of shoulder motion.
• The involved extremity lies adducted, prone,
and internally rotated.
• Moro, biceps, and radial reflexes are absent
on the affected side.
• Grasp reflex is usually present.
• Erb’s palsy may be associated with injury to
the phrenic nerve, innervated with
fibers from C3–C5
Brachial plexus injury
Diagnosis & Management
• Physical examination.
• Radiographs of the shoulder and upper arm
• Initial treatment is conservative.
• The arm is immobilized across the upper abdomen vs elevated
in abduction external rotation of shoulder during the first
week
• Physical therapy with passive range-of-motion exercises at the
shoulder, elbow and wrist should begin after the first week.
• Infants without recovery by 3 to 6 months of age may be
considered for surgical exploration
Phrenic nerve injury
• The phrenic nerve arises from the third through fifth cervical
nerve roots.
• Injury to the phrenic nerve leads to paralysis of the ipsilateral
diaphragm.
• respiratory distress, with diminished breath sounds on the
affected side.
• Chest radiographs show elevation of the affected diaphragm,
with mediastinal shift to the contralateral side.
• Ultrasonography or fluoroscopy can confirm the diagnosis by
showing paradoxical diaphragmatic movement during
inspiration
Phrenic nerve injury
Treatment
• Initial treatment is supportive
• Oxygen
• Respiratory failure may be treated with
continuous positive airway pressure or
mechanical ventilation.
• Gavage feedings.
• Plication of the diaphragm
Laryngeal nerve injury
Symptoms Treatment
Stridor Small frequent feedings may be
respiratory distress required to decrease the risk of
hoarse cry aspiration.
dysphagia, Intubation
Aspiration Tracheostomy
Bilateral paralysis tends to
produce more severe distress, and
Diagnosis therefore requires intubation and
By direct laryngoscopy tracheostomy placement more
frequently
CRANIAL NERVE
& SPINAL CORD INJURIES
-Facial palsy
-Spinal cord
injuries
-
Facial paralysis
• can be caused by pressure on the facial
nerves during birth or by the use of forceps
during birth. The affected side of the face
droops and the infant is unable to close the
eye tightly on that side. When crying the
mouth is pulled across to the normal side.
• protection of the involved eye by
application of artificial tears and taping to
prevent corneal injury.
• neurosurgical repair of the nerve should be
considered only after lack of resolution
during 1 year of observation
Spinal cord injury
Excessive traction or rotation
failure to establish adequate respiratory
function
the baby usually is posing as frog
“oscillation” test is positive
(prick leg of the newborn with needle leg will flex
and extend in all joints several times)
Spinal cord injury
Spinal cord injury
Management
• If cord injury is suspected
in the delivery room,
• The head, neck, and spine
should be immobilized.
• Therapy is supportive.
MUSCULOSKELETAL
INJURIES
- Clavicular fractures
- Fractures of long bones
-Sternocleido-mastoid injury
The clavicle & long bone
fracture
Clavicle is the most frequently bone
injure in the neonate during birth and
most often is an unpredictable
unavoidable complication of normal birth.
The infant may present with
pseudoparalysis.
Examination may reveal crepitus, palpable
bony irregularity, and sternocleidomastoid
muscle spasm.
Desault's bandage should be used for 7-
10 days.
INTRA-ABDOMINAL
INJURIES
-Liver hematoma
- Splenic hematoma
- Adrenal hemorrhage
- Renal hemorrhage
CONCLUSIONS
1- Recognition of trauma
2- Careful physical and neurologic evaluation
3- Establish whether additional injuries exist
4- Injury may result from resuscitation
5- Assess Symmetry of structure & function
6- Specific examination such as cranial
nerve, joint range of motion, scalp/skull
integrity.
THANK YOU
