Birth trauma.

Injuries to the infant that result from mechanical forces (i.e., compression, traction) during the birth process are categorized as birth trauma.

Even though most women give birth in modern hospitals surrounded by medical professionals, seven of every 1,000 births result in birth injuries.

Birth injuries account for fewer than 2% of neonatal deaths.

From 1970-1985, rates of infant mortality resulting from birth trauma fell from 64.2 to 7.5 deaths per 100,000 live births

Factors predisposing to injury include the following:

Prolonged or rapid delivery Cephalopelvic disproportion, small maternal stature, maternal pelvic anomalies Deep transverse arrest of presenting part of the fetus Oligohydramnios Abnormal presentation (breech)

Use of midcavity forceps or vacuum extraction Very low birth weight infant or extreme prematurity weeks Large babies – birth weight over about 4,000 grams Cephalopelvic disproportion Fetus 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

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

Management consists of careful cleaning, application of antibiotic ointment, and observation. Lacerations occasionally require suturing.

Subcutaneous fat necrosis. Irregular, hard, nonpitting, subcutaneous

induration 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.

Caput succedaneum

is oedema of the presenting part caused by pressure during a vaginal delivery. This is a serosanguineous, subcutaneous, extraperiosteal fluid collection with poorly defined margins, non fluctuating

Cephalhematoma is a 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. A cephalhaematoma never extends beyond the edges of the bone

Cranial X-ray of the girl with cephalohematoma

Subgaleal hematoma is bleeding in the potential space between the skull periosteum and the scalp galea aponeurosis.

(і) Shock and pallor: tachycardia, a low blood pressure, within 30 minutes of the haemorrhage the haemoglobin and packed cell volume start to fall rapidly.

(ii) Diffuse swelling of the head. Sutures usually are not palpable. The amount of blood under the scalp is far more than is estimated. Within 48 hours the blood tracks between the fibres of the occipital and frontal muscles causing bruising behind the ears, along the posterior hair line and around the eyes.

Intracranial hemorrhages. Extradural (epidural) Subdural

(i) Shock and/or anaemia due to blood loss.

(ii) Neurological signs due to brain compression, e.g. convulsions, apnoea, a dilated pupil or a depressed level of consciousness.

(iii) A full fontanelle and splayed sutures due to raised intracranial pressure.

Subarachnoid hemorrhages (SAH)

(i) Attacks of secondary asphyxia and apnoe, irregular breathing, bradycardia.

(ii) Hyperestesia, tremor, seizures, bulging of fontanella. “Sunset” and Grefe symptoms are positive.

(iii) Changes of spinal fluid in lumbar puncture: it becomes xanthochromic or/and contains blood Intraventricular (IVH) hemorrhages

Periventricular hemorrhage, intraventricular hemorrhage. Periventricular hemorrhagic infarction (PVHI) on MRI.

Periventricular hemorrhage, intraventricular hemorrhage. Severe or grade III hemorrhage (subependymal with significant ventricular enlargement) in ultrasonography.

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.

Brachial plexus injury 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. Grasp reflex is usually present. Klumpke paralysis (C 7-8, T1) is rare and results in weakness of the intrinsic muscles of the hand; grasp reflex is absent. If cervical sympathetic fibers of the Th 1 are involved, Horner syndrome is present.

- This baby presents with an asymmetric posture of the arms.

- The left arm is not flexed and hangs limply.

- The baby demonstrates the findings of a left-sided ERB PARALYSIS.

The total plexus palsy (Kerer’s paralyses) is the most disturbing of all. Its clinical features are:

adynamy muscle hypotony positive “scarf” symptom

Kofferate syndrom (C 3-4) is the diaphragm paralysis. Because of irregular breathing, cyanosis pneumonia can be suggested mistakenly.

Facial paralysis can be caused by pressure on the facial nerves during birth or by the use of forceps during birth. 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.

Spinal cord injury incurred during delivery results from excessive traction or rotation.

failure to establish adequate respiratory function,

the baby usually is posing as frog, “oscillation” symptom is positive

(if to prick leg of the newborn with needle leg will flex and extense in all joints several times).

The clavicle fracture is the most frequently bone injure in the neonate during birth and most often is an unpredictable unavoidable complication of normal 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 7-10 days.

Conclusion Recognition of trauma necessitates

a careful physical and neurologic evaluation of the infant to establish whether additional injuries exist. Occasionally, injury may result from resuscitation. Symmetry of structure and function should be assessed as well as specifics such as cranial nerve examination, individual joint range of motion, and scalp/skull integrity.