BIRTH INJURIES

Introduction:
As a result of the birth process ,some injuries occur that may be minor, where as others may be more
serious. Parental reaction to any injury sustained by their newborn infant at birth may be out of proportion to the
harm that has occurred.
Birth injuries:
It is defined as those sustained during Labour and delivery. Birth injuries may be severe enough to cause neonatal
death , still birth or number of morbidities.
Risk factors:
Maternal
• Primiparity
• Short stature
• Maternal pelvic anomalies
• Prolonged or extremely rapid labour
• Oligohydramnios
• Deep transverse arrest of descent of presenting part of the fetus
Foetal
• Abnormal presentation
• Very low birth weight infant or extremely prematurity
• Foetal macrosomia
• Large fetal head
• Foetal anomalies
Interventional/ inorganic
• Use of mid forceps
• Inappropriate vacuum application
• Versions& extractions
Types of birth trauma and management
A. HEAD & NECK INJURIES
1. Associated with foetal monitoring
• Fetal scalp blood sampling for the estimation of PH- heomorrhage and infection
• Foetal scalp electrode for FHR monitoring
2. Cephal hematoma
Definitipon: Subsperiosteal collection of blood secondary to rupture of blood vessels
between the skull and periosteum; its extent is well delineated by the suture line over few
days
Complication:
• Anemia
• Hypotension
• Secondary hyper bilirubinemia
• Infection
• Associated skull fractures
Resolution:
Slow resolution occurs over 1-2 months , occasionally with residual calcification
 Management:
• Observation
• Transfusion and photo therapy(extensive haematomas)
• Rule out bleeding disorders
• Aspiration for smear & culture if infection is suspected
• Skull X -rays and CT scan to diagnose depressed skull fractures
3. Subgaleal haematoma
Definition: Blood that has invaded the potential space between the skull periosteum and scalp galea
aponeurosis , and the area that extend posterior from the orbital ridges to the occipital and
laterally to the ears
Complication:
• Spread of hematoma leading to hemorrhage , shock and death, periorbital and auricular
ecchymosis
• Infection
Resolution: Very slow resorption
Management:
• Observation
• Treatment for blood loss, hyperbilirubinemia and infection
• Rule out bleeding disorders
• and antibiotics if infection occurs
4. Caput Succedaneum
Definition: Serosanguinous , subcutaneous, extraperitoneal fluid collection with poorly defined
margins, it may extend across the midline & over the surface line and is usually associated with
head moulding.
Complications:
• Anemia and hyper bilirubinemia are very rare , Scalp necrosis with permanent scarring
alopecia
• Resolution: Over few days
• Management:
• observation only
5. Vacuum caput:
Definition : Serosanguiness fluid collection well defined by the position of the vacuum extractor on
the scalp
Complications
• Anemia & hyperbilirubinemia are very rare, local infection with scalp abrations and
lacerations
Resolution:With in few hours after birth
Management:
• Observation
• Treatment for blood loss, hyperbilirubinemia and infection
• Rule out bleeding disorders
6. Intracranial haemorrhages:
i. Subependymal haemorrhage- IVH
Clinical features: Due to blood loss- shock, pallor , respiratorty distress , DIC, jaundice,
bulging ant. frontanel, excessive somnolence,, hypotonia, weakness , seizures, temperature
instability, brain stem signs( apnoea, lost extra ocular movements, facial weakness)
Investigation:
• Real time gray scale portable sector USG
• Haemorrhagic CSF
• CT scan/ MRI
• Others- ABC, Haematocrit- low , thrombocytopenia, prolonged PT, PTT& hyper
bilirubinemia
Complications:
• Post – hemorrhagic hydrocephalus
Management:
• The baby should be nursed in quiet environment
• Incubator care- to maintain temperature, oxygen, & humidity
• Avoiding extension of haemorrhage .
• Slow administration of osmotically active agents,
• VitK
• Treatment of seizures & hyperbilirubinemia
• Treatment of post – haemorrhagic hydrocephalus
• Prophylatic antibiotics
ii. Posterior fossa haemorrhage
Clinical features:
• Effects of blood loss like IVH
• Bulging frontanel, increasing head circumference, lethargy, irritability
• Abnormal respiration(apnoea)
• Cranial nerve palsies, nystagmus, dysconjugate gaze
• Hypotonia & vomiting
Investigations:
• USG
• CT scan
Management:
• Treatment of blood loss & hyperbilirubinemia open surgical evacuation of the clots
in the patient with neurologic symptoms
iii. Ant. fossa haemorrhage
Clinical features:
• Signs of blood loss
• Neurological manifestations- focal neurological signs, irritability , lethargy, focal
seizures, hemiparesis, gaze preferences, sixth nerve dysfunction, 3rd nerve
compression- dilated and poorly reactive pupil
Investigation:
• CSF
• CT scan
 • USG
Complication:
• Hydrocephalus
Mangement:
• Surgical intervention in case of deterioration
• Treatment of hydrocephalus
iv. Subarachnoid haemorrhage(SAH)
Clinical features:
• features of blood loss
• neurological dysfunction- irritability, seizures, hemiparesis
Investigations:
• CSF examination
• CT scan
Complication: Hydrocephalus rarely
Management:
• Symptomatic treatment-anticonvulsants, blood loss correction
• treatment of hydrocephalus & hyperbilirubinemia
Nursing consideration:
• Vigilant observation of the baby for possible associated complications such as infection or rarely blood loss
and hypovolemia
• Reassurance to the parents
7. Skull fractures
Bones involved- Frontal, parital, occipital
complications:
• Brain contusions
• Disruption of blood vessels
• seizurs
• hypotension & death
• dural laceration
Management:
• X – ray and CT scan for diagnosis
• linear fractures with no neurological manifestations- observation
• depressed fractures- neurological evaluation
• Repeat X- rays at 8-12 weeks to look for growing fractures
8. Facial mandibular fractures
Features:
• Facial asymmetry
• Ecchymosis
• Oedema
• Crepitance
• Respiratory distress
• Poor feeding
• Dislocation of the cartilaginous nasal septum
 Complications:
• unrecognized and untreated facial fractures- craniofacial malformations, ocular, respiratory
& mastication problems
Management:
• protection of airway
• plastic surgeon; ENT reference
• Cranial CT scan
• Treatment of fractures
Nursing considerations:
• Maintain proper body alignment
• Gentle handling
• Careful during dressing
• Immobilization
• Relief of pain
9. Ocular injuries
Types:
a. retinal and subconjunctival haemorrhages- vaginal delivery
b. ocular and periorbital injuries- forceps delivery
c. Disruption of descenets membranes of the Cornea→Scarring→Astigmatism & Amblyopia
d. HYphaema, Vittreous haemorrhage
e. local lacerations
f. palpebral oedema
g. orbital fractures with abnormal extra ocular muscle function
h. lacrimal gland / duct damage
Management:
• Ophthalmic consultations
10. Ear injuries
Types:
• Haematoma of the external pinna- Cauliflower ear
• Lacerations involving the cartilage- refractory perichondritis
• Temporal bone injury- Haemotympanum & ossicular disarticulation
Management:
• Aspiration of pinna haematomas
• Otologic consultation
11. Sternocledomastoid (SCM )muscle injury
Pathology:
Injury to the SCM muscle/ fascia disruption during delivery
↓
haematoma formation
↓
Affection of surrounding musculoskeletal structures←fibrosis
↓
Torticollis
 Management:
• Passive stretching of the muscle
Nursing Management:
• Stretching exercises to the affected SCM . It include,
 Tilting the head away from the affected side so that the ear can be brought into contact with the opposite
shoulder
 Rotating the chin towards the tight SCM muscle. When head is in the stretched position , it should be held
there for about 10 seconds
 The exercise should be done 4-6 times in a day with about 20 repetitions of each exercise at each time.
• The infant is positioned in the crib sothat the head is supported by sandbags in the corrected positions. This
is done to prevent the flattening of the occiput or the development of facial asymmetry
• The head should be rotated so that it tilts away from the involved side and so that the face looks towards
the side of the tight muscle.
• Crib toys should be placed so that the neck is stretched when the infant reaches for them
• Proper demonstration of the exercise to the parents
B. CRANIAL NERVE , SPINAL CORD & PERIPHARAL NERVE INJURIES:
Commonly associated with breech delivery
Cause- Hyper extension , traction,& over stretching with simultaneous rotation
Types- Localized neurapraxia to complete nerve and cord transaction
1. Cranial nerve injuries
i. Facial nerve injury
Cause:Compression by the forceps blades
Clinical features:
• Central nerve injury- Assymmetrical crying facies, mouth drawn to normal side, wrinkles
are more on the normal side, forehead and eyelid unaffected, nasolabial fold is absent on the
affected side , corner of the mouth droops on the affected side
• Peripheral nerve injury:- Asymmetrical crying facies
• Peripharal nerve branch injury- asymmetrical crying facies, paralysis limited to forehead, ,
eye or mouth
Mangement:
• Protection of open eye- patches and synthetic tears 4th hourly
• Neurological and surgical consultation
Nursing management:
• Feeding is first given by NG tube in order to prevent aspiration
• When possible the infant should be feed orally using a soft nipple having a large hole
• Eye shield to prevent drying of the conjunctiva and cornea
• Gentle restraining of the hands
ii. Recurrent laryngeal nerve injury
Clinical Feature;
• Unilateral abductor paralysis(hoarse cry, respiratory stridor)
• Bilateral vocal cord damage- Severe respiratory distress, asphyxia
Management:
• Unilateral paralysis-small frequent feed to minimize risk of aspiration
• Bilateral paralasis- intubation may be required
 • Tracheostomy if recovery doesnot occur by 6 wks
2. Spinal cord injuries
Cause:
• Hyperextented head
• Vaginal breech delivery
Clinical feature:
• Alert yet flaccid
• Low APGAR score
• Motor function absent distal to the level of injury with loss of deep tenden reflexes
• Temperature instability
• Constipation and urinary retension
• Sensory level if cord is transected
Management:
• Resuscitation and prevention of further injuries
• Head to be immobilized
• Neurological examinations and cervical spinal Xrays
• CT scan, myelogram, MRI if required
• Attention to bowel/ bladder function
3. Cranial nerve root injuries
i. phrenic nerve palsy(C3, 4, & 5)
Unilateral and associated with brachial plexus injuries
Clinical features:
• Respiratory distress ipsilaterally diminished breath sounds
Management:
• USG/Fluroscopic studies- Paradoxical movements of the diaphragm
• Pulmonary toilet
• Refractory cases- diagphramatic placation, phrenic nerve pacing
Nursing management:
• The neonate is placed on the affected side , and oxygen is given as necessary
• The neonate is treated like any infant having respiratory difficulty
• The infant should be feed intravenously , by gavage , and then orally as the condition
improves
• Observe for the symptoms of pulmonary infection, which may complicate the infant’s
condition
ii. Injuries to Brachial plexus
Clinical features:
Duchenne – Erb paralysis(C5-6):
• Affected arm in adducted and internally rotated with elbow extended (Waiter’s tip position)
• Forearm is prone and wrist is flexed
• The limb falls limply to the side of the body when passively adducted
• Moro’s, biceps, radial reflexes absent on affected side
• Grasp reflex intact
Klumpke’s paralysis (C7& T1)
• intrinsic muscles of the hand are affected & grasp is absent( claw Hand)
 • Biceps and radial reflex are present
• Horner’s syndrome, if cervical sympathetic fibres of T1 are involved
• injury to the entire brachial plexus – the entire arm is flaccid , all reflexes are absent
Complications
• Contractures
Management:
• X –ray studies to rule out bony injury, chest examination to rule out diagphragmatic
involvement
• Passive movements started after 7-10 days( After resolution of the nerve edema)
• Splints to prevent wrist and digit contractures
Recovery:
• improvement in 1-2 wks – normal function
• no improvement is 6 months – permanent deficit
Nursing Management:
• The goal of the care is to prevent the contractures of the paralysed muscle
• The arm should be partially immobilisd in a position of maximum relaxation so that the
nonparalysed muscles cannot exert pull on the affected muscles
• By the use of splint or brace when the upper arm is paralysed, the arm is abducted 90
degrees and rotate internally at the shoulder with the elbow flexed so that the palm of the
hand is turned towards the head
• When the lower arms and hand areparalysed , the lower arm and the wrist are kept in a
neutral position and the hand is placed over a small pad
• The infant is immobilized for 6months during part of the day and night
• A longer period of immobilization may be necessary for some infants.
• After 7-10 days , complete ROM exercises may be given gently several times each day
inorder to maintain muscle tone and prevent contraction deformity
• Before or splint or brace is obtained , the nurse can pin the infants long shirt sleeve to the
mattress covering
• When any form of immobilization is used , the fingers and hands must be observed for any
coldness or discolouration and the skin for signs of irritation
• When a splint is used the parents must be taught how to apply it properly and how to
provide the skin care
• They should be taught the proper dressing technique- affected hand first and on removing
the unaffected hand first
• More physical contact and affection than normal child

C. BONE INJURIES
Common in breech delivery & shoulder dystocia in macrosomic infants
Cause: limb traction and rotation
1. Clavicular fracture
Most common injury
Clinical features:
• Pseudoparalysis on the affected side
• Crepitus
 • Palpable bony irregularity & sternocledomastoid muscle spasm
• Greenstick fracture can be asymptomatic
Management:
• X- ray studies of the chest, shoulders and cervical spine
• Orthopaedic consultation
2. Long bone injuries
Bones : Hemurus, femur
Clinical features:Swelling, crepitus and pain
Complication :injury to nerve in vicinity
Management :Splinting ; closed reduction & casting if required
3. Epiphyseal displacement
Cause :Rotation with strong traction
Clinical features:swelling, crepitus, pain
Management :X- ray not very useful as epiphyses are not ossified at birth
Limb immobilization for 10-14 days allows callus formation
D. INTRAABDOMINAL INJURIES
Types : Rupture/ Subscapular haemorrhage into liver spleen or adrenal gland
Clinical features:Abdominal distension, pallor, poor feeding, tachycardia, tachypnoea, shock etc
Management :Clinical examination and serial determinations of the haematocrit levels
-Abdominal USG
- Paracentesis in case of intraperitoneal bleeding
E. SOFT TISSUE INJURIES:
1) Patechiae and echymosis
• Spontaneous resolution in 1 week.
• Complications- Anemia; hyperbilirubinemia
2) Abrations And laceration
3) Subcutaneous fat necrosis
Clinical features :Appear in first two weeks of life
Irregularly shaped , hard , non pitting, subcutaneous plaque
with overlying dusky, red purple discolouration
Sites :Cheeks, arms, back , buttocks, thighs
PREVENTION OF BIRTH INJURIES IN NEWBORN
A comprehensive antenatal and postnatal care is key to the success in the reduction of birth trauma.
Antenatal Period:
• To screen out the at risk babies
• To employ liberal use of LSCS
Intranatal period:
Normal delivery:
• Continuous foetal monitoring
• Attention during episiotomy
• The neck should not be unduely stretched
Preterm delivery:
• To prevent anoxia
• To avoid strong sedative
• Liberal episiotomy and use of forceps to minimize intracranial compression
 • To administer inj. Vit K to minimize or prevent haemorrhage from the traumatized area
Forceps delivery:
• Difficult cases- LSCS
• Proper application of pressure
Ventouse delivery:
• Avoid in preterm
Vaginal breech delivery:
• Proper selection of cases
Conclusion:
Since many of the birth injuries do not require treatment , the nurse can help to clear up the
misconceptions and alleviate anxieties by simple explanations.Assisting the parents to cope with the more serious
injuries requires more through explanations and constant support by members of the health team.
Bibliography:
1. Wong D.L etal . Essentials Of Paediatric Nursing. 6th edition. Missouri: Mosby;2001
2. Marlow D.R. Redding B. Textbook of Paediatric nursing. 1st edition.Singapore: Harwourt Brace &
company; 1998
3. Judith S.A. Straight A’s in Pediatric Nursing. 2nd edition.Lippincott Williams and Wilkins:Philadelphia;
2008
4. Parthasarathy IAP textbook of Paediatrics. 2nd edition. jaypee: NewDelhi; 2002
5. Hatfield N.T. Broadribb’s introductory Paediatric nursing. 7th edition. Wolters Kluwer: New Delhi; 2009
6. D.C Dutta. Textbook Of Obstetrics including Perinatology & Contraception. 6th edition. Central
Publication; Culcutta: 2004
7. Meharban Singh . Care of Newborn . 6th edition. Published by Narinder K. Sagar; NewDelhi: 2004
 BIRTH
INJURIES
SUBMITTED TO SUBMITTED BY
Ms . G. Laviga Ms. Shesly P. Jose
Lecturer II Year MSc (N)
NUINS NUINS