BIRTH INJURIES

INTRODUCTION

Birth injury is defined as an impairment of the neonate's body function or structure

due to an adverse event that occurred at birth. The overall incidence of birth injuries
has declined with improvements in obstetrical care and prenatal diagnosis.

DEFINITION

Birth trauma (BT) refers to damage of the tissues and organs of a newly delivered
child, often as a result of physical pressure or trauma during childbirth.

Birth injuries encompass any systemic damages incurred during delivery

(hypoxic, toxic, biochemical, infection factors, etc.)

Birth injury is damage sustained during the birthing process, usually occurring during
transit through the birth canal.

EPIDEMIOLOGY

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 caesarean deliveries, respectively.
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).

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 with
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.

 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 increased risk of delivering a large for gestational age
infant with shoulder dystocia.

 Abnormal fetal presentation – Fetal presentation other than a vertex position,

particularly breech presentation, is associated with an increase in the risk of
birth injury with vaginal delivery. Delivery by cesarean delivery reduces the
morbidity associated with vaginal delivery of breech infants and is discussed
separately.

 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. The instrument is applied to the fetal
head, and then the clinician uses traction to extract the fetus, typically during a
contraction while the mother is pushing. Both forceps and vacuum delivery are
associated with an increase in birth injury when compared with nonoperative
 vaginal delivery. The sequential use of vacuum extraction and forceps
increases the risk of birth injury greater than the use of either instrument alone.

 Cesarean delivery – Cesarean delivery is generally found to have a lower risk

of birth trauma compared with vaginal deliveries. 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 with vaginal delivery
(adjusted OR 0.55, 95% CI 0.53-0.58) . However, when the analysis used the
definition of birth trauma developed by the Agency for Healthcare Research
and Quality Patient Safety Indicator (AHRQPSI), cesarean delivery was
associated with an increased risk of birth trauma (adjusted OR 1.65, 95% CI
1.51-1.81). The AHRQPSI definition did not include clavicle fractures, or
injuries to the brachial plexus and scalp, 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.

Other factors – One study reported an increased incidence of birth trauma to the head
and neck in male infants and in babies born to primiparous mothers . Additionally,
small maternal stature and the presence of maternal pelvic anomalies are associated
with an increased risk of birth injuries.

ETIOLOGIES
The birth process is a blend of compression, contractions, torques, and traction. When
fetal size, presentation, or neurologic immaturity complicates this event, such
intrapartum forces may lead to tissue damage, edema, hemorrhage, or fracture in the
neonate. The use of obstetric instrumentation may further amplify the effects of such
forces or may induce injury alone. Under certain conditions, cesarean delivery can be
an acceptable alternative but does not guarantee an injury-free birth. Factors
predisposing to injury include the following:

 Prima gravida
 Cephalopelvic disproportion, small maternal stature, maternal pelvic
anomalies
 Prolonged or rapid labor
 Deep, transverse arrest of descent of presenting part of the fetus
 Oligohydramnios
 Abnormal presentation (breech)
 Use of midcavity forceps or vacuum extraction
 Versions and extractions
 Very ̶ low-birth-weight infant or extreme prematurity
 Fetal macrosomia
 Large fetal head
 Fetal anomalies

CLASSIFICATION OF BIRTH INJURIES:

Soft tissue
- Abrasions
- Erythema petechia
- Ecchymosis
- Lacerations
- Subcutaneous fat necrosis

Skull
- Caput succedaneum
- Cephalohematoma
- Subgaleal hemorrhage
- Linear fractures
- Intracranial hemorrhages

Face
- Subconjunctival hemorrhage
- Retinal hemorrhage

Peripheral nerve
- Brachial plexus palsy
- Unilateral vocal cord paralysis
- Radial nerve palsy
- Lumbosacral plexus injury

Cranial nerve and spinal cord injuries

- Facial palsy

Musculoskeletal injuries
- Clavicular fractures
- Fractures of long bones
- Sternocleido-mastoid injury

Intra-abdominal injuries
- Liver hematoma
- Splenic hematoma
- Adrenal hemorrhage
- Renal hemorrhage

SOFT TISSUE INJURY:

Soft tissue injury is associated with fetal monitoring, particularly with fetal scalp
blood sampling for pH or fetal scalp electrode for fetal heart monitoring, which has a
low incidence of hemorrhage, infection, or abscess at the site of sampling.

Abrasions and lacerations

Abrasions and lacerations sometimes may occur as scalpel cuts during cesarean
delivery or during instrumental delivery (ie, vacuum, forceps). Infection remains a
risk, but most of these lesions uneventfully heal.

Management consists of careful cleaning, application of antibiotic ointment, and

observation. Bring edges together using Steri-Strips. Lacerations occasionally require
suturing.

SUBCUANEOUS FAT NECROSIS

Subcutaneous fat necrosis is not usually detected at birth. Irregular, hard, nonpitting,
subcutaneous plaques 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.

HEAD INJURIES

EXTRA CRANIAL BLEEDING

CEPHAL HEMATOMA

Cephalhematoma is a subperiosteal collection of blood secondary to rupture of blood

vessels between the skull and the periosteum; suture lines delineate its extent. Most
commonly parietal, cephalhematoma may occasionally be observed over the occipital
bone.

The extent of hemorrhage may be severe enough to cause anemia and hypotension,
although this is uncommon. The resolving hematoma predisposes to
hyperbilirubinemia. Rarely, cephalhematoma may be a focus of infection that leads to
meningitis or osteomyelitis. Linear skull fractures may underlie a cephalhematoma (5-
20% of cephalhematomas). Resolution occurs over weeks, occasionally with residual
calcification.

No laboratory studies are usually necessary. Skull radiography or computed

tomography (CT) scanning is performed if neurologic symptoms are present. Usually,
management solely consists of observation. Transfusion for anemia, hypovolemia, or
both is necessary if blood accumulation is significant. Aspiration is not required for
resolution and is likely to increase the risk of infection.

Hyperbilirubinemia occurs following the breakdown of the red blood cells (RBCs)
within the hematoma. This type of hyperbilirubinemia occurs later than classic
physiologic hyperbilirubinemia. The presence of a bleeding disorder should be
considered. Skull radiography or CT scanning is also performed if a concomitant
depressed skull fracture is a possibility.

SUBGALEAL HEMATOMA
Subgaleal hematoma is bleeding in the potential space between the skull periosteum
and the scalp galea aponeurosis. Ninety percent of cases result from a vacuum applied
to the head at delivery. Subgaleal hematoma has a high frequency of occurrence of
associated head trauma (40%), such as intracranial hemorrhage or skull fracture. The
occurrence of these features does not significantly correlate with the severity of
subgaleal hemorrhage.

The diagnosis is generally a clinical one, with a fluctuant, boggy mass developing
over the scalp (especially over the occiput). The swelling develops gradually 12-72
hours after delivery, although it may be noted immediately after delivery in severe
cases. The hematoma spreads across the whole calvaria; its growth is insidious, and
subgaleal hematoma may not be recognized for hours.

Patients with subgaleal hematoma may present with hemorrhagic shock. The swelling
may obscure the fontanelle and cross suture lines (distinguishing it from
cephalhematoma). Watch for significant hyperbilirubinemia. In the absence of shock
or intracranial injury, the long-term prognosis is generally good.

Laboratory studies consist of a hematocrit evaluation. Management consists of

vigilant observation over days to detect progression and provide therapy for such
problems as shock and anemia. Transfusion and phototherapy may be necessary.
Investigation for coagulopathy may be indicated.

CAPUT SUCCEDANEUM

Caput succedaneum is a serosanguineous, subcutaneous, extraperiosteal fluid

collection with poorly defined margins; it is caused by the pressure of the presenting
part against the dilating cervix. Caput succedaneum extends across the midline and
over suture lines and is associated with head molding. Caput succedaneum does not
usually cause complications and usually resolves over the first few days. Management
consists of observation only.

INTRA CRANIAL BLEEDING

EPIDURAL HAEMORRHAGE

 Rare
  Usually associated with fractures

 Irritability, lethargy, and seizures progress to signs of increased ICP and

ultimately uncal herniation

 Diagnosed by CT

SUBDURAL HAEMORRHAGE

 Diagnosed by CT
 May be due to rupture of the straight sinus, vein of Galen, transverse sinus,
inferior sagittal sinus, or superficial bridging vessels

 Symptoms within 24 hours of birth : apneas, seizure activity, altered state,

irritability, focal neurologic signs, loss of consciousness

 With midline shift : consider neurosurgical Treatment

 Can cause secondary cerebral infarction due to arterial compression

 Infants may develop normally or have persistent focal neurologic findings,

including hydrocephalus

SUBARACHNOID HAEMORRHAGE

 often asymptomatic
 apnea

 irritability and seizures

 CSF bloody

 CT diagnosis

INTRA CEREBELLAR

 Can present with signs of brainstem compression

INTRAVENTRICULAR
  Mostly premature infants
 Less likely caused by intrapartum factors

 Risk of post-hemorrhagic hydrocephalus

FRACTURES OF HEAD ( SKULL)

 Mostly linear, often with cephalhematoma

 Usually after prolonged labor or forceps delivery

 Fetal skull pressed against symphysis, sacral promontory or ischial spine

 Risk of leptomeningeal cyst

 Follow up Xrays ~ 2 months after injury.

LEPTOMENINGEAL CYST:

Skull fracture with dural tear leads to herniation of pia and arachnoid layers
(leptomeninges) through the dural tear. CSF pulsations lead to progressive erosion
of skull around the fracture site. Margins of fracture still apparent months after
injury. Greater diastasis of the fracture as time goes on

DEPRESSED SKULL FRACTURE

 Indications for surgery include:

 Radiographic evidence of bone fragment in cerebrum

 Presence of neurological deficits.

 Signs of intra cranial pressure increase

 Signs of CSF beneath the galea

 Failure to respond to closed manipulation.

 Indication for non surgical management

  Depression less than 2 cm width and depression over a major venous
sinus.

 Without neurological symptoms.

FACE INJURIES

NASAL DEFORMITIES:

 < 1% of nasal deformities are due to actual dislocations of the triangular

cartilage of the nasal septum
 Differentiate from positional deformities by manually moving the septum to
midline and observe the resultant shape of the nares

– True dislocation = marked asymmetry of the nares persists; consult

ENT

– Failure to recognize a true dislocation can lead to permanent deformity

SUBCONJUNCTIVAL HAEMORRHAGE:

Subconjunctival hemorrhage is the 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.

OCCULAR INJURIES

•Minor ocular trauma, such as retinal and subconjunctival hemorrhages, and lid
edema, are common and resolve spontaneously without affecting the infant.
•Resolution of a retinal hemorrhage occurs within one to five days and a
subconjunctival hemorrhage within one to two weeks.

Significant ocular injuries include:

– Hyphema (blood in the anterior chamber)
– Vitreous hemorrhage
– Orbital fracture
– Lacrimal duct or gland injury
– Disruption of Descemet's membrane of the cornea (which can
result in astigmatism and amblyopia).
• Prompt ophthalmologic consultation should be obtained for patients with, or
suspected to have ocular injuries.

TORTICOLIS:

 Lateral tilt of the neck and head typically due to a tight sternocleidomastoid
muscle
– Head and neck tilt toward the involved side and chin is turned away
from the involved side
 Most common causes:
– Congenital Muscular Torticollis: fibrosis of the sternomastoid muscle
from uterine packing problem
– Vertebral Anomalies: Klippel-Feil syndrome (congenital anomalies of
the cervical spine).
 Diagnosis
– Usually made clinically, may palpate mass in the muscle early in
postnatal period
– Examine infant for other congenital anomalies
– Radiographs of the cervical spine should be done to rule out any
vertebral anomalies if there is no response to stretching exercises of the
sternomastoid muscle
 Treatment
– Stretching exercises are successful in 90% of the cases
– Surgical correction may be considered in resistant cases after 1 year of
age

NERVE INJURY
BRACHIAL PLAEXUS INJURY

Peripheral nerve damage in the form of brachial plexus injury occurs most commonly
in large babies, frequently with shoulder dystocia or breech delivery. Incidence
 for brachial plexus injury is 0.5-2 per 1000 live births. Most cases are Erb palsy;
entire brachial plexus involvement occurs in 10% of cases.

Traumatic lesions associated with brachial plexus injury include the following:

 Fractured clavicle (10%)

 Fractured humerus (10%)
 Subluxation of cervical spine (5%)
 Cervical cord injury (5-10%)
 Facial palsy (10-20%)

ERBS PALSY
Erb palsy (C5-C6) is most common and is associated with lack of shoulder motion.
The involved extremity lies adducted, prone, and internally rotated. Moro, biceps, and
radial reflexes are absent on the affected side. The grasp reflex is usually present. Five
percent of patients have an accompanying (ipsilateral) phrenic nerve paresis.

KLUMPKE PARALLYSIS

Klumpke paralysis (C7-8, T1) is rare and results in weakness of the intrinsic muscles
of the hand; the grasp reflex is absent. If cervical sympathetic fibers of the first
thoracic spinal nerve are involved, Horner syndrome is present.

A study by Iffy et al indicated that an approximately four-fold rise in the incidence of

shoulder dystocia has occurred in the United States since the mid-20th century, with a
review of 11 other countries revealing no comparable increase in most other nations.
The investigators considered the rise in dystocia to be primarily related to a trend in
the United States, starting in the 1980s, toward active management of the birthing
process, in place of a more conservative approach.[6]

Prognosis

No uniformly accepted guidelines for determining prognosis are available. Narakas

developed a classification system (types I-V) based on the severity and extent of the
lesion, providing clues to the prognosis in the first 2 months of life.

According to the collaborative perinatal study (59 infants), 88% of cases resolved in
the first 4 months, 92% resolved by 12 months, and 93% resolved by 48 months. In
another study, which examined 28 patients with upper plexus involvement and 38
with total plexus palsy, 92% spontaneously recovered.

Residual long-term deficits may include progressive bony deformities, muscle

atrophy, joint contractures, possible impaired growth of the limb, weakness of the
shoulder girdle, and/or Erb engram flexion of the elbow accompanied by adduction of
shoulder.

Workup

Workup consists of radiographic studies of the shoulder and upper arm to rule out
bony injury. The chest should be examined to rule out associated phrenic nerve injury.
Electromyography (EMG) and nerve conduction studies are occasionally useful.

Fast spin-echo magnetic resonance imaging (MRI) can be used to evaluate plexus
injuries noninvasively in a relatively short time, minimizing the need for general
anesthesia. MRI can define meningoceles and may distinguish between intact nerve
roots and pseudomeningoceles (indicative of complete avulsion).

Carefully performed, intrathecally enhanced CT myelography may show

preganglionic disruption, pseudomeningoceles, and partial nerve root avulsion. CT
myelography is more invasive and offers few advantages over MRI.

Immobilization, physical therapy, and surgery

Management consists of prevention of contractures. Immobilize the limb gently

across the abdomen for the first week and then start passive range-of-motion exercises
at all joints of the limb. Use supportive wrist splints.

The best results from surgical repair appear to be obtained in the first year of
life. Several investigators have recommended surgical exploration and grafting if no
function is present in the upper roots at age 3 months, although the recommendation
for early explorations is far from universal.

Complications of brachial plexus exploration include infection, poor outcome, and

burns from the operating microscope. Patients with root avulsion do not do well.

Palliative procedures involving tendon transfers have been of some use. Results from
a study by Ruchelsman et al of 21 children who suffered brachial plexus birth injury
indicated that patients who have no active wrist extension following the trauma can be
successfully treated with a tendon transfer but that surgical outcomes tend to be worse
in patients with global palsy.[12]

Latissimus dorsi and teres major transfers to the rotator cuff have been advocated for
improved shoulder function in Erb palsy. One permanent and 3 transitory axillary
nerve palsies have been reported from the procedure.

CRANIAL NERVE INJURY

Cranial nerve and spinal cord injuries result from hyperextension, traction, and
overstretching with simultaneous rotation; they may range from localized neurapraxia
to complete nerve or cord transection.

Unilateral branches of the facial nerve and vagus nerve, in the form of recurrent
laryngeal nerve, are most commonly involved in cranial nerve injuries and result in
temporary or permanent paralysis.

Compression by the forceps blade has been implicated in some facial nerve injury, but
most facial nerve palsy is unrelated to trauma from obstetric instrumentation (eg,
forceps). The compression appears to occur as the head passes by the sacrum.

Physical findings for central nerve injuries are asymmetrical facies with crying. The
mouth is drawn towards the normal side, wrinkles are deeper on the normal side, and
movement of the forehead and eyelid is unaffected. The paralyzed side is smooth with
a swollen appearance, the nasolabial fold is absent, and the corner of the mouth
droops. No evidence of trauma is present on the face.

Physical findings for peripheral nerve injuries are asymmetrical facies with crying.
Sometimes evidence of forceps marks is present. With peripheral nerve branch injury,
the paralysis is limited to the forehead, eye, or mouth.

– The differential diagnosis includes Central paresis - affecting opposite

side, does not affect orbicularis orbi and forehead muscles, caused by
damage in posterior fossa
– Nuclear agenesis (Mobius syndrome) - frequently bilateral, face
motionless, other cranial nerves affected as well

– Congenital absence or hypoplasia of depressor muscle of the angle of

the mouth
Management and recovery

Most infants begin to recover in the first week, but full resolution may take several
months. Palsy that is due to trauma usually resolves or improves, whereas palsy that
persists is often due to absence of the nerve.

Management consists of protecting the open eye with patches and synthetic tears
(methylcellulose drops) every 4 hours. Consultation with a neurologist and a surgeon
should be sought if no improvement is observed in 7-10 days.

DIAPHRAGMATIC PARALYSIS

Diaphragmatic paralysis secondary to traumatic injury to the cervical nerve roots that
supply the phrenic nerve can occur as an isolated finding or in association with
brachial plexus injury. The clinical syndrome is variable. The course is biphasic;
initially the infant experiences respiratory distress with tachypnea and blood gases
suggestive of hypoventilation (ie, hypoxemia, hypercapnia, acidosis). Over the next
several days, the infant may improve with oxygen and varying degrees of ventilatory
support. Elevated hemidiaphragm may not be observed in the early stages.
Approximately 80% of lesions involve the right side and about 10% are bilateral.

The diagnosis is established by ultrasonography or fluoroscopy of the chest, which

reveals the elevated hemidiaphragm with paradoxic movement of the affected side
with breathing.

Prognosis

The mortality rate for unilateral lesions is approximately 10-15%. Most patients
recover in the first 6-12 months. An outcome for bilateral lesions is poorer. The
mortality rate approaches 50%, and prolonged ventilatory support may be necessary.

Management consists of careful surveillance of respiratory status, and intervention,

when appropriate, is critical.

LARYNGEAL NERVE INJURY

Disturbance of laryngeal nerve function may affect swallowing and breathing.
Laryngeal nerve injury appears to result from an intrauterine posture in which the
head is rotated and flexed laterally. During delivery, similar head movement (when
marked) may injure the laryngeal nerve, accounting for approximately 10% of cases
of vocal cord paralysis attributed to birth trauma.

The infant presents with a hoarse cry or respiratory stridor, caused most often by
unilateral laryngeal nerve paralysis. Swallowing may be affected if the superior
branch is involved. Bilateral paralysis may be caused by trauma to both laryngeal
nerves or, more commonly, by a central nervous system (CNS) injury, such as hypoxia
or hemorrhage, that involves the brain stem. Patients with bilateral paralysis often
present with severe respiratory distress or asphyxia.

Direct laryngoscopic examination is necessary to make the diagnosis and to

distinguish vocal cord paralysis from other causes of respiratory distress and stridor in
the newborn. Differentiate from other rare etiologies such as cardiovascular or CNS
malformations or a mediastinal tumor.

Paralysis often resolves in 4-6 weeks, although recovery may take as long as 6-12
months in severe cases. Treatment is symptomatic. Once the neonate is stable,
providing small, frequent feeds minimizes the risk of aspiration. Infants with bilateral
involvement may require gavage feeding and tracheotomy.

SPINALCORD INJURY
Spinal cord injury incurred during delivery results from excessive traction or rotation.
Traction is more important in breech deliveries (the minority of cases), and torsion is
more significant in vertex deliveries. The true incidence of spinal cord injuries is
difficult to determine. The lower cervical and upper thoracic region for breech
delivery and the upper and midcervical region for vertex delivery are the major sites
of injury.

Major neuropathologic changes consist of acute lesions, which are hemorrhages,

especially epidural lesions, intraspinal lesions, and edema. Hemorrhagic lesions are
associated with varying degrees of stretching, laceration, and disruption or total
transaction. Occasionally, the dura may be torn, and rarely, vertebral fractures or
dislocations may be observed.

The clinical presentation is stillbirth or rapid neonatal death with failure to establish
adequate respiratory function, especially in cases involving the upper cervical cord or
lower brainstem. Severe respiratory failure may be obscured by mechanical
ventilation and may cause ethical issues later. The infant may survive with weakness
and hypotonia, and the true etiology may not be recognized. A neuromuscular disorder
or transient hypoxic ischemic encephalopathy may be considered. Most infants later
develop spasticity that may be mistaken for cerebral palsy.

The diagnosis is made using MRI or CT myelography. Little evidence indicates that
laminectomy or decompression has anything to offer. A potential role for
methylprednisolone is recognized. Supportive therapy is important.

Prevention is the most important aspect of medical care. Obstetric management of

breech deliveries, instrumental deliveries, and pharmacologic augmentation of labor
must be appropriate. Occasionally, injury may be sustained in utero.

BONE INJURY
Fractures are most often observed following breech delivery, shoulder dystopia, or
both in infants with excessive birth weights.

CLAVICULAR FRACTURE

The clavicle is the most frequently fractured bone in the neonate during birth; this is
most often an unpredictable, unavoidable complication of normal birth.[13] Some
correlation with birth weight, midforceps delivery, and shoulder dystocia is
recognized.[14] The infant may present with pseudoparalysis. Examination may reveal
crepitus, palpable bony irregularity, and sternocleidomastoid muscle spasm.
Radiographic studies confirm the fracture.

Healing usually occurs in 7-10 days. In order to decrease pain, arm motion may be
limited by pinning the infant's sleeve to the shirt. Assess other associated injury to the
spine, brachial plexus, or humerus.

LONG BONE FRACTURE

Loss of spontaneous arm or leg movement is an early sign of long bone fracture,
followed by swelling and pain on passive movement. The obstetrician may feel or
hear a snap at the time of delivery. Radiographic studies of the limb confirm the
diagnosis and distinguish this condition from septic arthritis.

Femoral and humeral shaft fractures are treated with splinting. Closed reduction and
casting is necessary only when displaced. Watch for evidence of radial nerve injury
with humeral fracture. Callus formation occurs, and complete recovery is expected in
2-4 weeks. In 8-10 days, the callus formation is sufficient to discontinue
immobilization. Orthopedic consultation is recommended.

EPIPHYSEAL DISPLACEMENT

Separation of the humeral or femoral epiphysis occurs through the hypertrophied

layer of cartilage cells in the epiphysis. The diagnosis is clinically based on swelling
around the shoulder, crepitus, and pain when the shoulder is moved. Motion is
painful, and the arm lies limp by the side. Because the proximal humeral epiphysis is
not ossified at birth, it is not visible on radiography. Callus appears in 8-10 days and is
visible on radiography.

Management consists of immobilizing the arm for 8-10 days. Fracture of the distal
epiphysis is more likely to have a significant residual deformity than is fracture of the
proximal humeral epiphysis.

INTRA ABDOMIANL INJURY

Intra-abdominal injury is relatively uncommon and can sometimes be overlooked as a
cause of death in the newborn. Hemorrhage is the most serious acute complication,
and the liver is the most commonly damaged internal organ.

Signs and symptoms of intraperitoneal bleed

Bleeding may be fulminant or insidious, but patients ultimately present with

circulatory collapse. Intra-abdominal bleeding should be considered for every infant
who presents with shock, pallor, unexplained anemia, and abdominal distension.
Overlying abdominal skin may have a bluish discoloration. Radiographic findings are
not diagnostic but may suggest free peritoneal fluid. Paracentesis is the procedure of
choice.

HEPATIC RUPTURE

The most common lesion is subcapsular hematoma, which increases to 4-5 cm before
rupturing. Symptoms of shock may be delayed. Lacerations are less common; they are
often caused by an abnormal pull on the peritoneal support ligaments or by the effect
of excessive pressure by the costal margin. Infants with hepatomegaly may be at
higher risk. Other predisposing factors include prematurity, postmaturity, coagulation
disorders, and asphyxia. In cases associated with asphyxia, a vigorous resuscitative
effort (often by unusual methods) is the culprit.
Splenic rupture is at least a fifth as common as liver laceration. Predisposing factors
and mechanisms of injury are similar.

Rapid identification and stabilization of the infant are the keys to management, along
with assessment of coagulation defect. Blood transfusion is the most urgent initial
step. Persistent coagulopathy may be treated with fresh frozen plasma, the transfusion
of platelets, and other measures.

Patients with hepatic rupture usually present immediately following birth, or the
rupture becomes obvious within the first few hours or days after delivery.

PERINATAL ASPHYXIA

Perinatal asphyxia means that there has been some injury to the fetus or the newborn
around the time of birth. 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. There are many
causes, and sometimes the exact cause cannot be identified. Some common causes
include the following:

 Abnormal development of the fetus (for example, 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

 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.

Regardless of the cause, affected newborns appear pale and lifeless, breathe weakly or
not at all, and have a very slow heart rate. If asphyxia results from rapid blood loss,
newborns will be in shock. They are immediately given fluids into a vein and then a
blood transfusion. Newborns receive breathing and circulation support as needed.
Newborns are kept warm, and blood sugar levels are monitored.

Asphyxiated newborns may show signs of injury to one or more organ systems. Brain
function may be affected, and newborns may experience lethargy, seizures, or even
coma. Kidney function and the output of urine can be affected by the lack of oxygen
but do recover. There may also be problems with the lungs and breathing.

Many survivors will be completely normal, but others will have permanent signs of
neurologic damage, ranging from mild learning disorders to delayed development to
cerebral palsy. Some severely asphyxiated infants will not survive. Specific causes of
perinatal asphyxia should be identified if possible and treated as appropriate. For
example, antibiotics are given to treat blood infections, and blood transfusions are
given when too much blood has been lost. Recently, 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.

MANAGEMENT MODALITIES

Since every birth injury is unique, it’s difficult to determine the exact treatment that
will work for each baby without a proper diagnosis. In addition, some parents may opt
to have their babies go through more traditional treatments while others may prefer
holistic, natural methods of healing. Regardless of which options you choose, it’s
important to speak with your healthcare provider beforehand to weigh out the pros
and cons of each type of treatment.

Surgery

Not all birth injuries will require surgery. However, in some instances, severe injuries
may require surgery in order for the infant to have the best chances of survival. In
other instances, surgery can determine if an infant will be able to have full use of any
injured limbs.

The most common types of birth injuries that generally require surgery include:

 Severe cases of brachial plexus injuries, when other forms of treatment, such
as physical therapy, didn’t work
 Brain hemorrhaging
 A fractured skull

Medications
A wide variety of medications are used to treat birth injuries. As with surgery, not all
birth injuries require medications. In many cases, however, medication is prescribed
for pain, seizures, cognitive disabilities, and more.

The type of medication will depend the type and severity of the birth injury. The most
common types of medication include:

 Pain management and anti-inflammatory medications, such as aspirin and

corticosteroids
 Anti-spastic medication, such as baclofen, tazidine, and dantrolene
 Seizure medication, such as gabapentin and topiramate
 Anticholinergic medication, including trihexyphenidyl hydrochloride and
benzotropine mesylate
 Botox, to weaken injured muscles in an attempt the “catch up” the injured
muscles to the other muscles
 Stool softeners

Physical Therapy

Physical therapy is one of the most common treatment options for children who have
brachial plexus injuries, cerebral palsy (CP), shoulder dystocia, and any injury that
resulted in weakened muscles, coordination problems, lack of voluntary muscle
control, and more.
Physical therapy is a form of treatment that helps people move better, decrease pain,
and in some cases, restore physical functions. It has been shown to help children with
birth injuries have an easier time with daily tasks and activities, such as walking,
getting out of bed, eating, moving around, and playing.

Trained and licensed physical therapists who specialize in working with babies and
children will generally work diligently with their patients and their parents to help
with:

 Strength and balance

 Coordination
 Flexibility
 Reducing physical limitations
 Increasing fitness, gait, and posture
Physical therapy sessions may include strength training, joint mobilization,
specialized exercises, balance ball practice, and more, depending on the child’s
condition and individualized plan. Sessions can take place in a doctor’s office, a
physical therapy center, hospitals, nursing centers, classrooms, and at home with the
trained therapist.

Hyperbaric Oxygen Therapy

In recent years, studies and research have suggested that hyperbaric oxygen therapy
(HBOT) can help reduce the symptoms associated with brain damage in infants who
experienced oxygen deprivation during childbirth. When oxygen deprivation occurs,
babies are at a heightened risk for brain damage, especially if there is not immediate
medical intervention.

HBOT consists of placing an infant in a hyperbaric chamber that’s filled with 100%
pure oxygen. The air pressure is generally raised up to at least three times normal air
pressure, allowing the the baby to breathe in pure oxygen three times higher than
normal.

Although more research is needed to understand how effective HBOT is for infants,
there is indication that it may play an important role in treating symptoms associated
with CP and autism. However, it’s important to note that the U.S. Department of
Health and Human Services states that HBOT has not been clinically proven to treat
traumatic brain injuries and health conditions.

For more information, refer to our article Hyperbaric Oxygen Therapy

Neonatal Therapeutic Hypothermia

Neonatal therapeutic hypothermia is a clinical treatment that reduces an infant’s body

temperature in attempt to slow down injuries and diseases. It’s most often used for
newborn babies who are at a heightened risk of developing severe brain damage.

Neonatal therapeutic hypothermia works by placing the infant in a cooling blanket.

The temperature of the blanket is lowered significantly so that the infant’s entire body
temperature is lowered. The therapy usually takes place in a neonatal intensive care
unit.
By reducing the baby’s temperature, research suggests that it will help reduce the
chances of severe brain injury development.

“We have found that therapeutic hypothermia can reduce the chance of severe brain
injury by 25 percent in term-born babies with poor transition or low Apgar scores
after birth,” said Dr. Inder, of the Washington University School of Medicine.

Occupational Therapy

Occupational therapy is a form of treatment that focuses on helping children with

cognitive, physical, and sensory disabilities. Occupational therapists who specialize in
working with children with disorders and disabilities focus on a variety of treatments,
including:

 Developing fine motor skills

 Learning basic skills tasks such as brushing teeth and hair
 Developing positive behavior
 Reducing outbursts and impulsiveness
 Improving focus skills and social skills
 Developing and improving hand-eye coordination
 Assisting with learning disabilities

Occupational therapy can take place in a myriad of settings, including hospitals,

special education classrooms, at-home sessions, rehabilitation facilities, mental health
centers, doctor’s offices, outdoor camps, and more.

NURSING ASSESSMENT:

Recognition of trauma and birth injuries is imperative so that early treatment can be
initiative. Review the laor and birth history for risk factors, sucha s prolonged or
abrupt labor, abnormal or difficult presentation.

Data Collection
  Monitor the newborn for signs and symptoms of birth injuries, which include:
Irritability, seizures, and depression. These are all signs of a subarachnoid
hemorrhage.

 Facial flattening and unresponsiveness to grimace that accompanies crying or

stimulation, and the eye remaining open are symptoms to assess for facial
paralysis.

 Weak or hoarse cry, which is characteristic of laryngeal nerve palsy from

excessive traction on the neck.

 Flaccid muscle tone, which may signal joint dislocations and separation during
birth.

 Flaccid muscle tone of the extremities, which is suggestive of nerve plexus

injuries or long bone fractures.

 Limited motion of an arm, crepitus over a clavicle, and absence of Moro reflex
on the affected side, which are symptoms of clavicular fractures.

 Flaccid arm with the elbow extended and the hand rotated inward, absence of
the Moro reflex on the affected side, sensory loss over the lateral aspect of the
arm, and intact grasp reflex, which are symptoms of Erb-Duchenne paralysis
(brachial paralysis).

 Localized discoloration, ecchymosis, petechiae, and edema over the presenting

part. These are seen with soft tissue injuries.

Nursing assessments for birth injuries include:

 Reviewing maternal history and looking for factors that may predispose the
newborn to injuries.

 Apgar scoring that might indicate a possibility of birth injury.

 Neonates in need of immediate resuscitation should be identified. Initial head

to toe physical assessment and continued assessment upon each contact with
the neonate. Vital signs and temperature.

NANDA Nursing Diagnoses

  Injury related to birth trauma

 Impaired physical mobility related to brachial plexus injury

 Impaired gas exchange related to diaphragmatic paralysis

 Acute pain related to injury

Nursing Interventions

Nursing interventions for birth injuries include:

Administering treatment to the newborn based on the injury and according to the
primary care provider’s prescriptions.

Preventing further trauma by decreasing stimuli and movement.

Educating the infant’s parents and family regarding the injury and the management of
the injury.

Promoting parent-newborn bonding

PREVENTION OF INJURIES IN NEWBORN

Comprehensive antenatal and intra natal Care is the key to success in the reduction of
birth injuries.

ANTENATAL PERIOD

To screen out the at risk babies likely to be traumatized during vaginal delivery and to
employ liberal use of elective caesarean section. Contracted pelvis and CPD or
malpresentation like breech or transverse lie are included.

INTRA NATAL PERIOD

Normal delivery

 Continuous fetal monitoring to prevent traumatic cerebral anoxia.

 Episiotomy.

 The neck should not be unduly stretched while delivering the shoulder to
prevent injuries to brachial plexus or sterno mastoid.
  Special care to pre term babies to prevent anoxia, avoid strong sedatives ,
liberal episiotomy and to administer Inj.Vit.K 1 mg IM to prevent
haemorrhage from the traumatized site.

Forceps delivery

 Difficult forceps are to be avoided in preference to safer LSCS.

 Never apply traction unless the traction applied is a correct one.

Ventouse delivery

 It is relatively less traumatic but should be avoided in preterm.

Vaginal breech delivery

 Proper selection of cases and utmost care and gentleness are to be executed
while conducting the breech delivery. Most crucial period of breech delivery is
the delivery of after coming head.

CONCLUSION:

Since many birth injuries do not require treatment, the nurse can help to clear up the
misconceptions and alleviate anxiety by simple explanations. Assisting the parents to
cope with serious injuries requires the support from all the members of the health
team.

BIBLOIOGRAPHY

 John cloherty.P, Eric Eichenwald C, Annie, Hansen R. Manual of

neonatal care. 7th edition. South east asia: Lippincott Williams and
Wilkins;2012.

 Santosh Kumar .A. Manual of newborn care . 2nd edition.

Newdelhi:Paras Medical Publication; 2011.

 Tauesch, Ballard, Gleason. Avery’s diseases of the new born. 8th

edition. Philadelphia: Elsevier Publication; 2005
  DuttaD.C. Text book of Obstetrics.Culcutta.New central book agency:
2004

SEMINAR ON

BIRTH INURIES
SUBMITTED TO SUBMITTED BY
MRS. Saira George MS. Sreekala.R
Assistant professor 1st Year Msc Nursing student
Govt. College Of Nursing Govt. College of Nursing
Alappuzha Alappuzha.

Submitted on
28-04-2015