Dr.M.Mani M.D.

(paeds)
Asst.Professor
Dept. of Paediatrics
GDMCH.
 An impairment of the infants body function
or structure due to adverse influences that
occur at birth.
 morbidity rate : 2.8 per 1,000 live births
 mortality rate : 0.5 per 100,000 live
births.
1. Primi parity
2. Short stature
3. Maternal pelvic anomalies
4. Prolonged or unusually rapid labor
5. Oligohydramnios
6. Malpresentation of the fetus
7. Use of midforceps or vacuum extraction
8. Versions and extraction
9. Very low birth weight or extreme prematurity
10. Fetal macrosomia or large fetal head
 Head and neck injuries.

 Cranial nerve, spinal cord, and peripheral

nerve injuries.

 Bone injuries.

 Intra-abdominal Injuries.

 Soft tissue injuries.

1. Injuries associated with intrapartum fetal
monitoring.
2. Extracranial haemorrhage.
3. Intracranial haemorrhage.
4. Skull fracture.
5. Facial or mandibular fractures.
6. Nasal injuries.
7. Ocular injuries.
8. Ear injuries.
9. Sternocleidomastoid (SCM) injury.
10. Pharyngeal injury
 EXTRACRANIAL INJURIES

• CAPUT SUCCEDANEUM

• CEPHALHEMATOMA

• SUBGALEAL HEMORRHAGE

Oedema of the presenting
part caused by pressure
during a vaginal delivery


This is a serosanguineous,
subcutaneous, extraperiosteal
fluid collection with poorly
defined margins and
non fluctuating.
 Subperiosteal collection of
blood between the skull and
the periosteum.
 It may be unilateral or
bilateral, and appears within
hours of delivery as a soft,
fluctuant swelling on the side
of the head.
 Never extends beyond the
edges of the bone or crosses
suture lines
 e

 Subgaleal hematoma is hemorrhage between

epicranial aponeurosis of the scalp and periosteum.
 The hemorrhage can spread across the entire
calvarium.

presentation:
 Pallor, poor tone, and a fluctuant swelling on
the scalp.
 Shock.
 Ecchymosis of the scalp.
 The mortality rate : 14% to 22%.
 No specific therapy.
 Hypovolemia – correction.
 hyperbilirubinemia - phototherapy .
 Infected hematoma –antibiotics.
 Evaluate for bleeding disorders.
A classic triad of clinical findings for SGH

• Tachycardia
• A falling hematocrit and
• Increasing OFC in the first 24 to 48 hours after
birth.
 INTRACRANIAL HAEMORRHAGE

• Epidural hemorrhage
• Subdural hemorrhage
• Subarachnoid hemorrhage
• Intraparenchymal haemorrhage
• Germinal matrix hemorrhage /
intraventricular haemorrhage
 Bleeding can occur

– External to the brain into the epidural,

subdural or subarachnoid space.

– Into the parenchyma of the cerebrum or

cerebellum.

– Into the ventricles from the subependymal

germinal matrix or choroid plexus.
 EPIDURAL HEMORRHAGE

• Epidural hemorrhage primarily arises from

injury to the middle meningeal artery, and
is frequently associated with a
cephalhematoma or skull fracture.
 SDH is due to rupture of the draining veins
and sinuses of the brain that occupy the
subdural space.
Clinical presentation :
 Nuchal rigidity or opisthotonus

posturing ,coma.
 Apnea, abnormal respiratory patterns.
 Unreactive pupils.
 Abnormal extraocular movements.
 Bulging fontanelle and/or widely split sutures.
 Seizures
Diagnosis :
 MRI brain .
 CT brain .
 Neurosonogram.
 LP contraindicated in large SDH.

Management :

Most infants with SDH do not require
surgical intervention.
 Management of shock.
 Management of seizures.
 Large SDH -Open surgical evacuation of the

Clot.
 Rule out sepsis or a bleeding diathesis.
 A common form of ICH among newborns.
 Source of bleeding is ruptured bridging veins of
SA space or ruptured small meningeal vessels.

Clinical presentation :
 Suspicion of SAH may result because of blood

loss or neurologic dysfunction.

 Seizures, irritability, mild alteration of mental

status.
Diagnosis :
 MRI brain
 CT brain
 Neurosonogram
 LP
Management :
 Requires only symptomatic therapy.
 Neurosurgical intervention.
 Hydrocephalus will develop after a

moderate- large SAH, thus follow-up

neurosonograms should be performed.
 Primary cerebral haemorrhage is uncommon.

 Secondary haemorrhage into a region of

hypoxic-ischemic brain injury.

 In infants undergoing ECMO.

 Intracerebellar haemorrhage occurs more

commonly in preterm infants.

 MRI is the best imaging modality.

Management :
 Acute management of IPH is similar to that for
SDH and SAH.

 Long-term prognosis largely relates to location

and size of the IPH and GA of the infant.
 IVH is found mainly in the preterm infant.

 Incidence :15% to 20% in infants born at

<32weeks of GA.

 IVH in the term infant is related to difficult

delivery or perinatal asphyxia.
COMPLICATIONS :
 Periventricular hemorrhagic infarction (PVHI).

 Posthemorrhagic ventricular dilation (PVD).

CLINICAL PRESENTATION :
 Clinically silent syndrome.

 Majority of IVH occur within 72 hours after birth.

 The term newbom with IVH presents with

seizures, apnea, irritability or lethargy, vomiting
with dehydration, or a full fontanelle.
MANAGEMENT :
 Prevention of IVH should be the primary goal.

 Premature newborn - supportive care.

 Term newborn - supportive care and treatment

of seizures during the acute phase.

 PVD - careful monitoring of ventricle size by

serial CUS and appropriate intervention
when needed to reduce CSF accumulation.
 BRACHIAL PLEXUS INJURY
• Erb’s palsy
• Klumpke’spalsy
• Injury to the upper plexus.
• Macrosomia.

• Shoulder dystocia.

• Instrumented deliveries.

• Malpresentation.
 The most common.

 Lack of shoulder movement.

 The involved arm is held in the ‘‘waiter’s tip’’

position :
 adduction and internal rotation of the shoulder.
 extension of the elbow.
 pronation of the forearm.
 flexion of the wrist and fingers.
 may be associated with injury to the phrenic
nerve.
 Biceps reflex is absent.

 Moro reflex is absent.

 Grasp reflex is present.

 Rare.
 Weakness of the intrinsic muscles of the hand;
and long flexors of the wrist and fingers.

 Grasp reflex is absent.

 Biceps reflex is present.

 If cervical sympathetic fibers of the Th 1 are

involved, Horner syndrome is present (ptosis,
miosis, and anhydrosis).
 Physical examination.

 Radiographs of the shoulder and upper arm.

 Initial treatment is conservative.

 The arm is immobilized across the upper

abdomen as elevated in abduction external
rotation of shoulder during the first week.
 Physio therapy with passive range-of-motion
exercises at the shoulder, elbow and wrist
should begin after the first week.

 Infants without recovery by 3 to 6 months of

age may be considered for surgical exploration.
 The phrenic nerve arises from the third through
fifth cervical nerve roots.

 Injury to the phrenic nerve leads to paralysis of

the ipsilateral diaphragm.

 Respiratory distress, with diminished breath

sounds on the affected side.
 Chest radiographs show elevation of the
affected diaphragm, with mediastinal shift to
the contralateral side.

 Ultrasonography or fluoroscopy can confirm the

diagnosis by showing paradoxical
diaphragmatic movement during inspiration.
 Initial treatment is supportive Oxygen.

 Respiratory failure may be treated with

continuous positive airway pressure
or mechanical ventilation.

 Gavage feedings.

 Plication of the diaphragm

Symptoms :
 Stridor.
 Respiratory distress.
 Hoarse cry.
 Dysphagia.
 Aspiration.

Diagnosis :
 By direct
laryngoscopy
TREATMENT :
 Small frequent feedings may be required to

decrease the risk of aspiration.

 Intubation.

 Tracheostomy.
Causes :
 pressure on the facial nerves during birth.
 by the use of forceps during birth.

Clinical features :
 The affected side of the face droops and the

infant is unable to close the eye tightly on that

side.
 When crying the mouth is pulled across to the

normal side.
Management :
 protection of the
involved eye by
application of artificial
tears and taping to
prevent corneal injury.

 neurosurgical repair
of the nerve should
be considered only
after lack of
resolution during 1
year of observation
Clinical findings :
 decreased or absent spontaneous movement.

 absent deep tendon reflexes.

 absent or periodic breathing.

 lack of response to painful stimuli below the level

of the lesion.

 Lesions above C4 are almost always associated with

apnea.

 Lesions between C4 and T4 may have respiratory

distress.
Management :
If cord injury is suspected in the delivery room :
 The head, neck, and spine should be

immobilized.
 Therapy is supportive.
 Clavicle is the most frequently injured bone in
the neonate during birth.

 The infant may present with pseudoparalysis.


Examination may reveal crepitus,
palpable bony irregularity, and
sternocleidomastoid muscle spasm.

 Desault's bandage should be used for 7 - 1 0

days.
 Tearing of the muscle fibers or fascial sheath with
hematoma formation and subsequent fibrosis.

 Atrophic muscle fibers surrounded by collagen and

fibroblasts.

 The head is tilted toward the side of the lesion

and rotated to the contralateral side, chin is
slightly elevated.
Diagnosis :
 physical examination.

 Radiographs should be obtained to rule out

abnormalities of the cervical spine.

 Ultrasonography may be useful both

diagnostically and prognostically.
Treatment :
 Active and passive stretching
 Surgery < 2years
 Liver injury is the most common.

 Three potential mechanisms

lead to intra abdominal injury:
(1) direct trauma.
(2) compression of the chest against
the surface of the spleen or
liver.
(3) chest compression leading to tearing of the
ligamentaous insertions of the liver or spleen
Clinical manifestations :
 With hepatic or splenic rupture, patients

develop sudden pallor, hemorrhagic shock,

abdominal distention, and abdominal
discoloration.

 Subcapsular hematomas may present more

insidiously, with anemia, poor feeding,
tachypnea, and tachycardia.
Diagnosis :
 Abdominal ultrasound.

 Computed tomography.


Abdominal radiographs may show
nonspecific intraperitoneal fluid or
hepatomegaly.

 Abdominal paracentesis is diagnostic ,if a

hemoperitoneum is present.
Treatment :
 Volume replacement.

 Correction of any coagulopathy.


Hemodynamically stable infant,
conservative management is indicated.


With rupture or hemodynamic instability, a
laparotomy is required to control the bleeding.