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Birth Injuries -A Review of Incidence, Perinatal Risk Factors and Outcome

Article  in  The Bombay Hospital journal · April 2012

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Original/Research Articles
Birth Injuries - A Review of Incidence, Perinatal Risk
Factors and Outcome
Charusheela Warke*, Sushma Malik**, Manish Chokhandre***, Ashwin Saboo****
Abstract
Introduction : Birth injuries are avoidable or unavoidable forms of birth trauma
which occur during the process of labour and delivery. Incidence of birth injuries is 6-
8 per 1000 live births. Predisposing factors were instrumentation (forceps/vacuum),
macrosomia, difficult labour, shoulder dystocia, maternal pelvic anomalies. Current
study focuses on determination of incidence, risk factor and outcome of mechanical
birth injuries in all live born neonates admitted at our tertiary level NICU.
Methods : In this retrospective study, medical records of all neonates in our NICU and
postnatal ward in our hospital during year January 2009 to December 2010 were
reviewed. Data were analysed to calculate rates for all birth trauma and specific types
of birth injuries. Parameters including type of delivery, birth weight, gender, known
risk factors in mother and type of birth injuries were recorded.
Setting : Level III NICU in a tertiary care referral centre.
Results : Incidence of birth trauma (19 cases amongst 5837 live born) in our institute
was found to be 3.26 per 1000 live births in 2 years study period. Medical records of
all newborns with birth injuries were analysed. Most common birth injury being
bleeds (51.16%) of which cephal haematoma (38.7%) was commonest. Higher
incidence being noticed in vaginal deliveries (83.9 %) as compared to caesarean
deliveries (16.1%) and 25.8% birth injury cases were associated with
instrumentation (forceps and vacuum). The predisposing factors were difficult
labour (41.9%), difficult breech extraction, macrosomia, shoulder dystocia, maternal
pelvic anomalies, 25.8% were associated with instrumentation (forceps/vacuum)
and no risk factor was found in 32.3%.
Conclusion : Regular follow up during ANC period, early identification of risk factor
for difficult delivery, stoppage and avoidance of traumatising manoeuvres and
instrumental deliveries and early intervention in form of LSCS when indicated are
key factors in reducing traumatic birth injuries.

Introduction suggested to be mostly due to difficult

B irth injury is damage sustained to the

baby during the birth process,
usually during transit through birth
canal. 1,2 Birth related trauma was
*Associate Professor,** Professor, ***Resident, ****
Assistant Professor Division of Neonatology, Dept. of
Paediatrics, BYL Nair Ch. Hospital and TN Medical
College, Mumbai-400 008.
vaginal delivery especially with the
shoulder in the vertex presentation or
extended arms in a breech delivery,
macrosomia, shoulder dystocia, and use of
instruments like forceps or vacuum
during delivery. The average incidence of
birth injuries is 6-8 cases per 1000 live

202 Bombay Hospital Journal, Vol. 54, No. 2, 2012

births.1-3 Birth injuries in newborns may Results
range from minor soft tissue injuries at During the study, there were 5837 live
birth, long bone fractures and broken births at our centre and among these 19
collar bone,4-5 bleeds (cephalhaematoma, infants were delivered with birth injuries,
subgaleal bleed, and intracranial bleed) giving an incidence of 3.26/1000 live
and peripheral nerve injuries.2,6 Our study births and 12 cases were referred from
was done to determine incidence, risk peripheral hospitals
factors and outcome of birth injuries. Table-1-Demographic Distribution, Type of Delivery
and Outcome
Material and Methods
Para- Gender Birth Type Of Outcome
This was a retrospective study which meters Weight Delivery
included all preterm, full term live born M F <2 Kg >2kg Vaginal LSCS Disch- Ex-
delivered (inborn babies) at or admitted at arged pired

our tertiary care centre NICU and No. 17 14 6 25 26 5 28 3

postnatal ward, from 1st January 2009 to Percentage 54 46 19.4 80.6 83.9 16.1 90.4 9.6
31st December 2010 and data of 5837 (%)

inborn newborn were analysed. The

neonates who were referred from other We encountered various birth injuries in
hospitals (outborns) to our tertiary care our NICU, ranging from cephal
centre were also included in our study; haematomas -12, followed by 4 cases of
however these babies were not included in sub galeal haematomas, 3 cases of
the calculation of the incidence and this clavicular fractures, 3 cases of facial
was calculated per 1000 births. palsies, 3 cases of superficial injuries on
The newborns were examined after face, 2 cases of Erb's palsies, 1 case each of
birth by a paediatrician, and relevant fracture humerus, femur, bilateral
specialty consultations were taken. In humerus with clavicle, and a case of
cases of fracture, diagnosis was confirmed superficial injury to eye.
Table-2 Percentage distribution of type of injury
by radiography of affected part,
Type Of Injury No. Percentage
pathological fractures being excluded. We
Fractures 6 19.3
reviewed the medical files with respect to Clavicular -1 3 9.6
parameters like type of delivery (vaginal or Humerus 1 3.2
caesarean section), presentation (vertex or Bilat Humerus With Clavicle-1 1 3.2
Femur-1 1 3.2
Breech), dystocia, difficult birth,
Neurological Injuries 5 16.12
instrumentation, maturity, birth weight,
Facial Palsy-2 3 9.67
relevant investigations and outcome was Erb's Palsy-1 2 6.4
recorded. Detailed maternal history noted Bleeds 16 51.6

and thorough examination of the newborn Cephal- Haematoma-4 12 38.7

Subgaleal -Haematoma-2 4 12.9
was done.
Superficial Injuries 4 12.8
Setting Marks On Face 3 9.6

Level III NICU in a tertiary care referral Injury To Eye 1 3.2

Total 31
centre.

Bombay Hospital Journal, Vol. 54, No. 2, 2012 203

 Photo-1: Right sided facial nerve palsy

Photo-4 Cephalhaematoma in a forceps delivery

Photo-2: Bilateral fracture humerus

Photo -5-Forceps mark on forehead

Most common birth injury

encountered was bleeds (51.16%) of which
cephalhaematoma (38.7%) was the
commonest followed by subgaleal bleed
(12.9%) and clavicular fractures (9.6%).
Birth injuries, in our series, were more
frequent in vaginal deliveries (26/31) i.e.
(83.9 %) as compared to caesarean
deliveries (5/31) i.e. (16.1%) and 25.8% of
all our birth injury cases were associated
with instrumental deliveries (forceps and
vacuum). Amongst the five patients
Photo-3: Large subgaleal haematoma

204 Bombay Hospital Journal, Vol. 54, No. 2, 2012

delivered by LSCS, four cases were done trauma incidence of 3.26 per 1000 births
after vaginal deliveries had failed to deliver without any risk factors in 32.2% of cases
the baby, thereby resulting in birth injury. suggesting that even during an
Common predisposing factors included uncomplicated natural vaginal delivery
prolonged labour (41.9%), instrumental the neonate is exposed to several forces as
deliveries (25.8%), difficult breech it passes through the birth canal that can
extraction, macrosomia, shoulder cause birth trauma.2,8
dystocia and maternal pelvic anomalies. Epidemiological factors
No risk factor was found in 32.3% of all
The incidence of birth trauma has
birth trauma cases.
reportedly decreased over time because of
Table-3: Major Risk Factors Involved in Birth Injuries
improvements in obstetric care and
Risk Factors No. Percentage (%)
prenatal diagnosis however, it still occurs
Instrumentation 8 25.8
even in the presence of highly skilled
Forceps 6 19.3
Vacuum 2 6.4 obstetric and neonatal care.3 Studies have
Difficult Labour 13 41.9 also documented a marked racial variation
None 10 32.2
in the occurrence of birth injuries; namely
in the Asian or Pacific Islander race.3 All of
In our cohort, 3 babies died due to
our cases belonged to the lower middle
secondary causes like sepsis and severe
class Asian population. Besides racial
birth asphyxia. Among these three babies,
differences in incidence there is also male
one LBW newborn was a case of birth
sex preponderance noted in birth injuries.
asphyxia with multiple limb fractures and
Possible environmental factors include
sepsis, another neonate with a large
geographic location, commoner in urban
subgaleal haematoma had severe birth
or wealthy areas and being born in
asphyxia and hypovolaemic shock and the
Western, urban and/or teaching hospital.
third case was an FT home delivery with
The above mentioned factors along with a
facial palsy with hyper echoic foci in
co-diagnosis of high birth weight,
bilateral basal ganglia and sepsis.
instrument delivery, malpresentation and
Discussion other complications during labour and
Birth injuries are defined by the delivery are significant univariable
National Vital Statistics report as "an predictors for birth trauma.3
impairment of the infant's body function or
Aetiopathogenesis and Risk Factors
structure due to adverse influences that
Risk factors that make a baby more
occurred at birth." It can occur
vulnerable to birth trauma include large-
antenatally, intrapartum or during
for-date infants, particularly infants who
resuscitation.7 Different studies have
weigh more than 4000 g, instrumental
reported varying incidence of birth trauma
deliveries, especially forceps (mid cavity),
ranging from 0.2 to 2 per 1000 births as
or vacuum, vaginal breech delivery,
per Hankins et al. in 20067 to as high as 37
precipitous labour, various obstetric
per 1000 births.3 Our study reported birth
version manoeuvres and abnormal or

Bombay Hospital Journal, Vol. 54, No. 2, 2012 205

excessive traction during delivery.8-10
Prolonged or too short labour, maternal
pelvic anomalies and skills of obstetrician
may also contribute in occurrence of these
injuries.
Common risk factors found in our
series were instrumentation, like
application of forceps or vacuum (25.8%)
and difficult labour (difficult breech
extraction, shoulder dystocia, prolonged
labour/CPD, macrosomia) in (41.9%) of all
our cases. Birth injuries, in our series,
were more frequent in vaginal deliveries
(26/31) as compared to caesarean
deliveries (5/31) which correlated with
that observed by Mosavat et al4 and 25.8%
of all our birth injury cases were
associated with instrumental deliveries
(forceps and vacuum). Also we observed a
higher incidence of injuries with newborns
weighing > 2 kg as found by Benjamin et al
in 1993.9 We also had a male
preponderance as described by Erin et al
in 2003 with male: female ratio being
17:14.
Clinical presentation, Complications,
Diagnosis and Management
The spectrum of the common types of
birth injuries ranges from CNS trauma,
extra cranial or intracranial haematoma,
soft tissue injuries, nerve palsies,
fractures of limb bones and haematomas
in solid abdominal organs.2 Complications
of birth injuries can be of two types, acute,
with haematoma formation, anaemia,
shock, sepsis, jaundice spinal shock,
paralysis, and chronic like deformity,
contractures, loss of function,
hydrocephalus and delayed milestones
etc. These usually occur if the nature of the
206
injuries is extensive with massive blood
loss, septicaemia or damage to vital
organs. The most commonly found
extracranial bleeds which disappear over
weeks to months but can also cause
jaundice and anaemia in the neonate if
size increases,11 were cephalhaematomas
(38.7%) where blood accumulates below
the periosteum, with increase in size after
birth, followed by subgaleal bleed (12.9%),
i.e. bleeding under the Galea
Aponeurotica, which is a boggy swelling
leading to shock, if massive.11
Subconjunctival haemorrhage, which
is caused by rupture of small blood
vessels, is benign7 generally resolving
without intervention or complication after
one to two weeks. Oedema and ecchymosis
often follow soft-tissue injuries,
particularly of the periorbital and facial
tissues in face presentations and of the
scrotum or labia during breech deliveries.
Among the long bone fractures, fracture
clavicle, reported in 0.2% to 10% of
deliveries,5 is the most common site
followed by fracture humerus.1 It is a
greenstick fracture, with callus formation
in one week, rapid healing with
remodelling uneventfully,5 and is treated
by making a sling by pinning the shirt
sleeve of the involved side to the opposite
side of the infant's shirt.
We had three cases of clavicular
fractures (9.6 %), (two males and one
female), all more than 2 kg in birth weight,
all born of vaginal delivery, with one case
having breech presentation and one case
requiring forceps instrumentation. All
other cases of fractures can be diagnosed
clinically by deformity, swelling, crepitus,
Bombay Hospital Journal, Vol. 54, No. 2, 2012
pseudo-paralysis, loss of contiguity,
tenderness, and confirmed radiologically1
or by ultrasonography showing
interruption of the hyperechogenic zone of
the bone, axial deviation, visible periosteal
lesions and haematomas.5 Fractures of
femur and humerus which are a rare
occurrence, can result in traumatic
lacerations of the major blood vessels and
adjoining tissues leading to gangrene,
haematoma formation and shock with
sepsis, incidence being 0.13 per 1000 live
birth according to Morris et al.1
Rarely, nerve injuries occur,
consisting of facial nerve palsy (9.67% in
our study) resulting from pressure on the
facial nerve due to forceps application
causing facial asymmetry and weakness of
the muscles11 on one side of the face,
usually resolves by 2 to 3 months of age,
followed by Brachial plexus injuries due to
shoulder dystocia, breech extraction, or
hyper abduction of the neck in cephalic
presentations.11 Commoner ones include
Erb's palsy (6.45% in our study), an upper
brachial plexus injury involving the 5th and
6th cervical nerves, and Klumpke's palsy, a
lower plexus injury involving the 7th and 8th
cervical nerves, which are treated by
immobilisation and later passive range-of-
motion exercises of the arm to prevent
contractures.11 MRI may be done to
determine the extent of injury to the nerve
plexus, roots, and cervical spinal cord.11
Infants should receive vitamin K, platelets
or FFP, blood transfusion, appropriate
fluid management and ionotropes for
massive bleeds and shock and appropriate
antibiotics for septicaemia.
Bombay Hospital Journal, Vol. 54, No. 2, 2012
Prevention
The occurrence of major birth trauma
requires careful study and preventive
efforts to better promote newborn health
as it contributes to increased neonatal
morbidity and mortality.9 Regular audit of
delivery practices, greater care in
excluding cephalopelvic disproportion and
judicious use of forceps and vacuum
extraction are recommended to reduce the
morbidity.8 Primigravida mothers should
be evaluated carefully during ANC follow-
up.12 Early identification of obstetric
factors and stoppage of traumatising
manoeuvres would reduce the incidence
and severity of this disability.8 A newborn
who has sustained birth injury is a great
concern for the parents, obstetrician and
paediatrician. And such event may initiate
litigation and legal action against the
doctor2 and requires proper counselling
and communication by the hospital staff.
Conclusions
Our incidence of birth injuries at our
hospital (3.26/1000 live births) was much
lower than the average. Bleeds was the
commonest injury, followed by fractures
and neuropraxia. Frequency of injuries
was much more in vaginal and
instrumental deliveries. In our series risk
factors were encountered in 2/3rd of
subjects and 1/3rd had no risk factors.
Carry home messages
1. Identification of the high risk mothers,
the foetus, and also the appropriate
labour management may be effective
to reduce the rate of birth injuries.
2. Early and regular antenatal visits to
identify high risk mothers.
207
 3. In difficult and prolonged labour and
in risk associated labour, caesarean
section may be selected as an
alternative safe method for delivery to
avoid birth injuries.
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208 Bombay Hospital Journal, Vol. 54, No. 2, 2012

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