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at birth. The overall incidence of birth injuries has declined with improvements in obstetrical care and prenatal diagnosis. The reported incidence of birth injuries is about 2 and 1.1 percent in singleton vaginal deliveries of fetuses in a cephalic position and in cesarean delivery deliveries, respectively [1,2]. Injury may occur during labor, delivery, or after delivery, especially in neonates who require resuscitation in the delivery room. There is a wide spectrum of birth injuries ranging from minor and self-limited problems (eg, laceration or bruising) to severe injuries that may result in significant neonatal morbidity or mortality (ie, spinal cord injuries). The risk factors associated with birth trauma and specific birth injuries will be reviewed here. RISK FACTORS The following factors that increase the risk of birth injuries may be due to the fetus (eg, fetal size and presentation), the mother (eg, maternal size and the presence of pelvic anomalies), or the use of obstetrical instrumentation during delivery: Macrosomia – When the fetal weight exceeds 4000 g, the incidence of birth injuries rises as the fetal size increases. In one study, when compared to normosmic neonates, the incidence of birth injury was twofold greater in infants weighing 4000 to 4900 g, three times greater in those with births weights between 4500 to 4999 g, and 4.5 times greater in those with a birth weight greater than 5000 g . In another study, the incidence of fetal injury was 7.7 percent in infants with birth weights greater than 4500 g . The diagnosis of fetal macrosomia and its impact on shoulder dystocia are discussed in greater detail separately. (See "Fetal macrosomia" and "Timing and route of delivery in pregnancies at risk of shoulder dystocia", section on 'Approach to pregnancies where macrosomia is suspected'.) Maternal obesity – Maternal obesity (defined as a body mass index greater than 40 kg/m2) is associated with an increased risk of birth injuries. This may be due to the greater use of instrumentation during delivery and/or these mothers having an increase risk of delivering a
55. The neonatal complications of operative vaginal deliveries are discussed in detail separately. (See "Operative vaginal delivery". section on 'Neonatal complications'. is associated with an increase in the risk of birth injury with vaginal delivery. The sequential use of vacuum extraction and forceps increases the risk of birth injury greater than the use of either instrument alone (table 2). typically during a contraction while the mother is pushing.large for gestational age infants with shoulder dystocia . cesarean delivery was associated with an increased risk of birth trauma .) Cesarean delivery – Cesarean delivery is generally found to have a lower risk of birth trauma compared to vaginal deliveries. 95% CI 0. Delivery by cesarean delivery reduces the morbidity associated with vaginal delivery of breech infants and is discussed separately. The instrument is applied to the fetal head.) Abnormal fetal presentation – Fetal presentation other than a vertex position. particularly breech presentation.) Operative vaginal delivery – Operative vaginal delivery refers to a delivery in which the clinician uses forceps or a vacuum device to assist the mother in delivering the fetus to extrauterine life. (See "The impact of obesity on fertility and pregnancy" and "Cesarean delivery of the obese woman". Both forceps and vacuum delivery are associated with an increase in birth injury when compared to nonoperative vaginal delivery (table 1). when the analysis used the definition of birth trauma developed by the Agency for Healthcare Research and Quality Patient Safety Indicator (AHRQPSI).53-058) . This finding was confirmed by an analysis of the Health Care Cost and Utilization Project Nationwide Inpatient Sample that showed cesarean delivery was associated with a decreased likelihood of all birth trauma compared to vaginal delivery (adjusted OR 0. (See "Overview of breech presentation" and "Delivery of the fetus in breech presentation". However. and then the clinician uses traction to extract the fetus.
may occur when the birth canal is too small or the fetus is too large (as sometimes occurs when the mother has diabetes).. and injuries to the brachial plexus and scalp. A difficult delivery. . section on 'Shoulder-pelvis disproportion'.51-1. Most injuries resolve without treatment. nerves are damaged or bones are broken.com/contents/neonatal-birth-injuries#H4 Birth Injury Share This Birth injury is damage sustained during the birthing process. usually occurring during transit through the birth canal. Did You Know. with the risk of injury to the fetus.65. 95% CI 1. Overall. the rate of birth injuries is much lower now than in previous decades because of improved prenatal assessment with ultrasonography and because cesarean delivery may be done in certain circumstances. which were more frequently seen in vaginal deliveries. These findings suggest that risk varies between cesarean and vaginal delivery depending upon the type of birth injury. The AHRQPSI definition did not include clavicle fractures.(adjusted OR 1.uptodate. Infrequently. Other maternal factors – Small maternal stature and the presence of maternal pelvic anomalies are associated with an increased risk of birth injuries.. (See "Timing and route of delivery in pregnancies at risk of shoulder dystocia". Many newborns have minor injuries during birth.81). Injury is also more likely when the fetus is lying in an abnormal position in the uterus before birth. Serious birth injuries are now quite rare as compared with a few decades ago.) http://www.
Bleeding in the brain (intracranial hemorrhage) is caused by the rupture of a blood vessel within the skull. A subdural hemorrhage can put increased pressure on the surface of the brain. Intraventricular hemorrhages occur into the normal fluid-filled spaces (ventricles) in the brain. are now much less common because of improved childbirth techniques. Subdural hemorrhages. poor feeding. such as . Cephalohematomas feel soft and can increase in size initially after birth. Intraventricular and intraparenchymal hemorrhages usually occur in very premature newborns and occur more typically as a result of an underdeveloped brain (see Problems in Newborns: Underdeveloped Brain) rather than a birth injury. Newborns with subarachnoid hemorrhages may occasionally have seizures during the first few days of life but ultimately do well. This blood accumulation is called a cephalohematoma.Head and Brain Injury: In most births. Skull fractures are very rare. Bleeding in the brain is much more common among very premature infants. Unless the fracture forms an indentation (depressed fracture). It results from inadequate blood flow to the brain (ischemia) or a diminished amount of oxygen in the blood (hypoxia). Bleeding in the spaces around the brain results from deformity of the skull bones during delivery or from a lack of oxygen. All newborns who have a hemorrhage receive supportive measures. Bleeding can occur in several places within the skull. Intraparenchymal hemorrhages occur into the brain tissue itself. Subarachnoid hemorrhages occur below the innermost of the two membranes that cover the brain. They are the most common type of intracranial hemorrhage. such as seizures or high levels of bilirubin in the blood. Most infants with bleeding do not have symptoms. Swelling of the scalp and bruising are common but not serious and resolve within a few days. the head is the first part to enter the birth canal and experiences much of the pressure during the delivery. which occur between the outer and the inner layers of brain covering. or seizures. usually occurring in full-term newborns. But bleeding may cause sluggishness (lethargy). it heals rapidly without treatment. Cephalohematomas do not need treatment and disappear over weeks to months. Newborns with subdural hemorrhages may develop problems. Fracture of one of the bones of the skull may occur. Blood may accumulate below the thick fibrous covering (periosteum) of one of the skull bones.
Some common causes include the following: Abnormal development of the fetus (for example. During a difficult delivery of a large infant. There are many causes. These injuries can result in paralysis below where the injury occurred. Injury of the nerves to the newborn's arm and diaphragm usually resolves completely within a few weeks. Nerve Injury: Rarely. Weakness or paralysis of the newborn's arm or hand results. and the weakness usually resolves by 2 to 3 months of age. fluids given by vein (intravenously). the newborn may have difficulty breathing. It results when too little blood flows to the fetus's or newborn's tissues or when there is too little oxygen in the blood. In this case. and sometimes the exact cause cannot be identified. when there is a genetic abnormality) Infection in the fetus Exposure to certain drugs before birth Pressure on the umbilical cord or a clot in one of the blood vessels in the umbilical cord . This injury is evident when the newborn cries and the face appears asymmetric. the arm remains weak after several weeks. Damage to the spinal cord is often permanent. Occasionally. In this case. surgery may be needed to reattach torn nerves. until they recover. some of the larger nerves to one of the newborn's arms can be stretched and injured.warmth. Perinatal Asphyxia: Perinatal asphyxia means that there has been some injury to the fetus or the newborn around the time of birth. resulting in paralysis of the diaphragm on the same side. Injuries to the spinal cord due to overstretching during delivery are extremely rare. Very rarely. the nerve going to the diaphragm (the muscular sheath that separates the organs of the chest from those of the abdomen) is damaged. Extreme movements at the shoulder should be avoided to allow the nerves to heal. No treatment is needed. Subdural hemorrhages should be treated by a surgeon. and other treatments to maintain body functions. nerve injuries may occur. Pressure on the facial nerve caused by forceps used to assist delivery or by the fetus's head lying against the mother's pelvis can result in weakness of the muscles on one side of the face.
However. ranging from mild learning disorders to delayed development to cerebral palsy. or even coma. Many survivors will be completely normal. A fractured bone in a newborn is kept from moving as much as possible by use of a sling or cast. Specific causes of perinatal asphyxia should be identified if possible and treated as appropriate. A fracture of the collarbone (clavicle) is most common. and blood transfusions are given when too much blood has been lost. There may also be problems with the lungs and breathing. and newborns may experience lethargy. They are immediately given fluids into a vein and then a blood transfusion. Newborns receive breathing and circulation support as needed. but others will have permanent signs of neurologic damage. Recently. Kidney function and the output of urine can be affected by the lack of oxygen but do recover. Regardless of the cause. seizures. bones may be broken (fractured) during a difficult delivery. Injury to the Skin and Soft Tissues: The newborn's skin may show some evidence of minor injury after delivery. Brain function may be affected. Newborns are kept warm. arm or leg fractures are very unusual. If asphyxia results from rapid blood loss. The upper arm bone (humerus) or upper leg bone (femur) may break during a difficult delivery. antibiotics are given to treat blood infections. For example. Sudden loss of blood Asphyxia can also occur if the function of the placenta is inadequate and the placenta cannot provide enough oxygen to the fetus during labor. Bone Injury: Rarely. Asphyxiated newborns may show signs of injury to one or more organ systems. it has been shown that cooling the full-term newborn's head for several hours beginning soon after birth offers some protection to the brain from injury and thus diminishes the neurologic damage. and have a very slow heart rate. breathe weakly or not at all. Fractures in newborns almost always heal completely and rapidly. affected newborns appear pale and lifeless. Swelling and bruising may occur around the orbits of the eyes and . newborns will be in shock. especially those areas that receive pressure during contractions or emerge from the birth canal first during delivery. Some severely asphyxiated infants will not survive. and blood sugar levels are monitored.
At first glance. no treatment is needed. Bruises typically resolve within just a few days. Mongolian spots are bluish gray. or at the back of the neck (where they are called stork bites). Bruises typically resolve Common Birthmarks and Minor Skin Markings in Newborns There are several skin markings that are considered normal in newborns. Bruises or marks caused by forceps may occur on the newborn's face and scalp. White cysts are sometimes found on the gums or in the center of the roof of the mouth (Epstein's pearls). Milia are tiny. This type of birthmark fades as the infant grows but sometimes remains as a faint mark that becomes brighter when the infant becomes excited or upset. They are of no consequence. Bruising of the feet may occur after a breech delivery. flat areas that usually occur over the lower back or buttocks. Common Birthmarks and Minor Skin Markings in Newborns There are several skin markings that are considered normal in newborns. Milia become smaller or disappear over a period of weeks. they appear to be bruises but are not and should not be . They are caused by plugged sweat gland ducts. Usually. Pink marks that are caused by dilated capillaries under the skin may occur on the forehead just above the nose.on the face during face-first deliveries and of the scrotum or labia after breech deliveries. in the upper eyelids. pearly white cysts that are normally found over the nose and cheeks. Bruising of the feet may occur after a breech delivery. Bruises or marks caused by forceps may occur on the newborn's face and scalp.
. and are of no consequence. tend to appear less noticeable with age. It starts as a flat. red or purplish area anywhere on the skin. so that by the time the child reaches school age. Over a period of weeks. For this reason. They usually occur in black or Asian newborns.mistaken for signs of abuse. After several years. surgery and other treatments are typically not needed. strawberry hemangiomas shrink and become fainter. A strawberry hemangioma is a common birthmark. appearing much like a strawberry. it becomes darker red and also becomes raised over the surface of the skin. most are no longer visible.
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