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:
Birth injuries is an impairment of the infant’s body function or structure due to adverse influence that
occurred at birth. Injury commonly occurs during labour or delivery.
It is defined as those sustained during labor 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 labor
 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
SITE OF INJURY AND TYPE OF INJURY
SITE OF INJURY TYPE OF INJURY
Soft tissues Skin – lacerations, abrasions, fat necrosis
Muscles Sternocleidomastoid
Nerve Facial
Brachial plexus
Duchenne Erb(C5,C6)
Klumpke
Spinal Cord
Phrenic n
Horner’s Syndrome
Recurrent laryngeal nerve
Scalp Lacerations,abscess, hemorrhage
Skull Cephalo hematoma
Subgaleal hematoma
Fracture
Intra cranial Hemorrhage – Intraventricular
Subdural
Subarachnoid
Bones Fracture – clavicle
Hemerus
Femur
Skull
Nasal bones
Eye Hemorrhage
Subconjunctiva
Vitreous
Retina

Viscera Rupture of liver, adrenal gland, spleen testicular

injury

SOFT TISSUE INJURIES:

Abrasions, laceration, Subcutaneous fat necrosis
Clinical features :
 Appear in first two weeks of life
 Irregularly shaped , hard , non pitting, subcutaneous plaque with overlying dusky, red purple
discoloration
Sites:
Cheeks, arms, back , buttocks, thighs
MUSCLE INJURY
Sternocledomastoid (SCM )muscle injury
Sternocleidomastoid (SCM) injury (congenital torticollis) is characterized by a well circumscribed
immobile mass in the mid point of the SCM. The head tilts towards the involved side. The patient cannot
move the head normally.

Sternomastoid hematoma usually appears about 7-10 days after birth and is usually situated at the mid
position of the muscle. It is caused by rupture of the muscle fibers and blood vessels, followed by a
hematoma and cicatrical contraction. It may be associated with difficult breech delivery or attempted
delivery following shoulder dystocia or excessive lateral flexion of the neck even during normal
delivery. There is transient torticollis and it is wise not to massage.

Pathology:
Injury to the SCM muscle/ fascia disruption during delivery

haematoma formation

Affection of surrounding musculoskeletal structuresfibrosis

Torticollis

Management:
 Treatment is conservative.
 Stretching of the involved muscle should be done several times a day.
 Recovery is rapid in majority of cases. Surgery is needed if it persists after 6 months of physical
therapy.

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 so that 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
NERVE INJURIES:
Commonly associated with breech delivery
Cause- Hyper extension , traction,& over stretching with simultaneous rotation
Types- Facial palsy, Brachial Palsy, Erb’s palsy, Klumpke’s Palsy, Brachial plexus injury, phrenic nerve
injury (C3,4 and 5)
Facial palsy
Cause:Compression by the forceps blades. It is involved by direct pressure of the forceps blades or by
hemorrhage and edema around the nerve.
Clinical features:
 Assymmetrical crying facies, the eye of the affected side which remains open and eyelids are
immobile. On crying , the angle of the mouth is drawn over to the unaffected side. No nasolabial
fold is present. Sucking remains unaffected.
Mangement:
 Protection of the eye, which remains open even during sleep, with synthetic tears (1% methyl
cellulose drops).
 The condition usually disappears within weeks unless complicated by intracranial damage
 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
Brachial palsy
Either the nerve roots or the trunk of the brachial plexus are involved. The damage of the nerve is due to
stretching (common) or effusion or hemorrhage inside the sheath.
Causes :
 Undue traction on the neck during attempted delivery of the shoulder.
 hyperextension of neck to one side with forcible digital extension and abduction of the arm in an
attempt to deliver the shoulders
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
Brachial plexus injury
The incidence is about .1 to 0.2% of shoulder dystocia, even in normal delivery, macrosomia,
malpresentation and instrumental delivery.
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

SCALP 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
Definition: it is the collection of blood between the pericranium and the flat bones of the skull,usually
unilateral and over a parital bone.it is due to the rupture of a small emissary vein from the skull and may
be associated with fracture of the skull bone. This may be caused by forceps delivery but also may be
met with following normal labour. It is never present at birth but gradually develops after 12-24 hours.
Prognosis:
Prognosis is good.
Rarely suppuration occurs.
Complication:
 Hypotension
 Infection
 Associated skull fractures
Resolution:
Slow resolution occurs over 1-2 months , occasionally with residual calcification
Management:
 Observation
 No active reatment is required
 Prevention of infection is necessary
 A head CT should be taken if neurological symptoms are suspected
 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 hematoma
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

INTRACRANIAL HAEMORRHAGES:
Intracranial hemorrhage (ICH) may be—
(a) External to the brain (epidural, subdural or subarachnoid spaces);
(b) in the parenchyma of brain (cerebrum or cerebellum);
(c) into the ventricles from subependymal germinal matrix or choroid plexus.
TYPES:
TRAUMATIC
Extradural hemorrhage:
Usually associated with fracture skull bone.
Subdural :
Slight hemorrhage may occur following:
o fracture of skull bone
o rupture of the inferior sagittal sinus or
o rupture of small veins leaving the cortex.
Massive hemorrhage may occur following
o Tear of the tentorium cerebelli thereby opening up the straight sinus or rupture of the vein of
Galen or its Faix cerebri tributaries
o Injury to the superior sagittal sinus.
Clinical presentation:
 Nuchal rigidity
 Coma
 apnea
 bulging fontanelle (increased intracranial pressure) nonreactive pupils
 seizures may be present.
Pathophysiology:
Normally, the faix cerebri is attached to the tentorium cerebelli and both help in anchoring the base of
the skull to the vault.

During excessive moulding, there is compression of the diameter of engagement (occipitofrontal In

detlexed head) with elongation of the diameter at right angle to it (mentoivertical).

This results in upward movement of the vault from the base. As a result, too much strain is put on the
vertical fibetri of tentorium cerebelli—called stress fibers.

If the moulding is excessive or applied suddenly, these fibers are torn.

As a result, it allows excessive elongation of the vault until the tear etends to involve the straight sinus
or vein of Galen or its tributaries.

The resulting hemorrhage may be supratentorial or bublentoriid.

Excessive moulding of the head lead to elongation of the mentovertical diamtter tear of the tentorium
cerebelli
Causes:
 Excessive moulding in deflexed vertex with gross disproportion
 Rapid compression of the head during delivery of the after-coming head of breech or in
precipitate labour
 Forcible forceps traction following wrong application of blades
Clinical features: The hemorrhage may be fatal and the baby is delivered stillborn or with severe
respiratory depression. In lesser affection, the baby recovers from the respiratory depression. Gradually,
the feature of cerebral irritation appears such as, frequent high pitch cry, neck retraction, incoordinate
ocular movements, convulsion, vomiting and bulging of anterior fontanelle.
ANOXIC
Intraventricular Hemorrhage-The pathogenesis of IVH in the term infant is more likely due to trauma
(difficult delivery) or perinatal asphyxia. In the preterm infant IVH is mainly due to
ischemia/reperfusion.
Clinical presentation:
clinically silent, seizures, apnea, irritability, lethargy, vomiting or a full fontanelle.
Diagnosis:
 neuroimaging studies: Real time portable cranial ultrasonography is the procedure of choice in
the term newborn.
 IVH is diagnosed by head CT or CUS.
 MRI is also helpful.
Subarachnoid—This may be due to tear of some tributary veins running from the brain to one of the
sinuses. The symptoms may appear late (one week).
Clinical presentations are:
Seizures
irritability and lethargy with focal neurological signs.
Intracerebral- Small petechial hemorrhage may occur in the brain substance (parenchyma) due to
anoxia. It usually occurs in mature babies following prolonged labor.
Clinical features are vague
 loss of weight
 flaccid limbs
 worried and anxious expression.
Risk factors for GMHAVH:
 Extreme prematurity
 birth asphyxia
 the need for vigorous resuscitation at birth
 presence of neonatal seizures
 sudden elevation of blood pressure.
PREVENTION:
Comprehensive antenatal and intranatal care is the key to success in the reduction of intracranial
injuries-
Antenatal prevention of IVH/GMH:
 Tocolysis with indomethacin should be avoided.
 In utero transfer of preterm labor to a center with NICU.
 Cesarean delivery before active phase of labour in preterm infants.
 Antenatal steroids can reduce the risk by three fold.
 To prevent or to detect at the earliest, intrauterine fetal asphyxia by intensive fetal monitoring.
 To avoid traumatic vaginal delivery in preference to cesarean section.
 Difficult forceps should be avoided.
 Administration of vitamin K 1 mg intramuscularly soon after birth in susceptible babies.
Postnatal prevention:
 Avoid birth asphyxia
 fluctuation of blood pressure
 correct acid base abnormalities
 Surfactant therapy is found helpful
INVESTIGATIONS:
Ultrasionography is used to detect intraventricular hemorrhage;
Doppler ultrasonography can detect any change in cerebral circulation;
CT scan is useful to detect cortical neuronal injury;
Magnetic resonance imaging( MRI) is used to evaluate any hypoxic ischemic brain injury;
CSF — Elevated RBCs, WBCs and protein

MANAGEMENT:
  Supportive care: To maintain normal circulatory volume, cerebral perfusion, serum electrolytes
and blood gases.
 Packed red blood cells transfusion may be needed where IVH is large.
 Thrombocytopenia and coagulation parameters should be corrected, seizures should be treated.
TREATMENT:
 Follow-up with serial neuroimaging cranial ultrasound (CUS or CT) to detect any progressive
hydrocephalus.
 Anticonvulsant
 Phenobarbitone-3-5 mg/kg/day in divided doses at 12 hourly intervals intramuscularly or
orally
 Phenytoin 20 mg/kg intravenously as loading dose at the rate of 1 mg/kg/min followed by
maintenance dose of 5 mg/kg/day with cardiac monitoring;
 Diazepam 0.1 mg/kg intravenously thrice daily.
 Open surgical evacuation—Serial CT is indicated before surgical intervention.
 The infant should be monitored for any hydrocephalus.
 Surgical removal of the clot including the capsule may have to be done to prevent development
of neurological sequelae;
 Rarely subdural-peritoneal shunting may be needed.
 Neurosurgeon is consulted.
PROGNOSIS:
 Depends upon the severity, brain lesion, birth weight and gestational age of the infant

FRACTURES
skull
Bones involved- Frontal, parital, occipital
complications:
 Brain contusions
 Disruption of blood vessels
 seizures
 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
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

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

EYE INJURIES
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

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

NURSING MANAGEMENT IN BIRTH INJURIES

Nursing Diagnoses
(a) Injury related to birthtrauma
(b) Impaired physical mobility related to brachial plexus injury
 (c) Impaired gas exchange related to diaphragmatic paralysis
(d) Acute pain related to injury
Nursing Interventions
 Nursing interventions for birth injuries include:
 Administering treatment to the new born 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 theinjury.
Promoting parent-newborn bonding.

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.

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