Seminar

on
Birth Injury

Summited To: Summited By:

Mrs Sowmya V.R Bharti Singh
MSc nursing 1styear 2018
Introduction:
Occasionally during the birth process, the bay may suffer a physical injury that
is simply the result of being born. This is sometimes called birth injury or birth
trauma. Many new-borns have minor injuries during birth. Infrequently, nerves
are damaged or bones are broken. Most injuries get better without treatment.

Definition:

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

Causes:

A difficult birth or injury to the baby can occur because of the baby’s size or the
position of the baby during labour and delivery conditions that may be
associated with a difficult birth include, but are not limited.

Some causes of birth injury are: -

 Large babies – Birthweight over about 4000 grams (8 pounds, 13 ounces)

 Prematurity – Babies born before 37 weeks
 Cephalopelvic disproportion – The size and shape of the mother’s pelvis
is not adequate for the baby to be born vaginally.
 Dystocia – Difficult labour or childbirth.
 Prolonged labour
 Abnormal birthing presentation – Such as breech presentation.

Classification of birth injuries:

 Soft tissue injury

 Head trauma
 Caput succedaneum
 Cephalhematoma
 Subgaleal haemorrhage
  FRACTURES
 Long bones
 Fracture neonatal skull
 PARALYSIS
 Facial Paralysis
 Brachial Palsy
 Phrenic Nerve Paralysis

Soft tissue injury: - Soft tissue injury may be sustained during the process of
birth, primarily in the form of bruises or abrasions secondary to dystocia. Soft
tissue injury usually occurs when there is some degree of disproportion between
the presenting part and the maternal pelvis (cephalopelvic disproportion).

Causes:

 The use of forceps to facilitate a difficult vertex delivery may produce

bruising or abrasion on the sides of the neonate’s face.
 After a difficult or precipitous delivery, the sudden release of pressure on
the head can produce scleral haemorrhages or generalized petechiae over
the face and head.
 When a vacuum suction cup is applied during delivery.

HEAD TRAUMA: - Trauma to the head and scalp that occurs during the birth
process is usually benign but occasionally results in more serious injury. The
injuries that produce serious trauma, such as intracranial haemorrhage and
subdural hematoma. The three most common types of extra cranial
haemorrhagic injury are caput succedaneum, cephalhematoma, and subgaleal
haemorrhage.
 Caput succedaneum: - The most commonly observed scalp lesion is
caput succedaneum, a vaguely outlined area of oedematous tissue situated
over the portion of the scalp that presents in a vertex delivery. The
swelling consists of serum, blood, or both accumulated in the tissues
above the bone, and it often extends beyond the bone margins. The
swelling may be associated with overlying petechial or ecchymosis. No
specific treatment is needed, and the swelling subsides within a few days.
 Cephalhematoma: - Infrequently, a cephalhematoma is formed when
blood vessels rupture during labour or delivery to produce bleeding into
the area between the bone and its periosteum. The injury occurs most
often with primiparous delivery and is often associated with forceps
delivery and vacuum extraction. Unlike caput succedaneum, the
boundaries of the cephalhematoma are sharply demarcated and do not
extend beyond the limits of the bone (suture lines). The cephalhematoma
may involve one or both parietal bones. The occipital bones are less
commonly affected, and the frontal bones are rarely affected. The
swelling is usually minimal or absent at birth and increases in size on the
second or third day. Blood loss is usually not significant.
 Subgaleal haemorrhage: - Subgaleal hemorrhage is bleeding into the
subgaleal compartment The subgaleal compartment is a potential space
that contains loosely arranged connective tissue; it is located beneath the
galea aponeurosis, the tendinous sheath that connects the frontal and
occipital muscles and forms the inner surface of the scalp. The injury
occurs as a result of forces that compress and then drag the head through
the pelvic outlet. Instrumented delivery, particularly vacuum extraction
and forceps delivery, increase the risk of subgaleal hemorrhage.
Additional risk factors include prolonged second stage of labour, foetal
distress, macrosomia, failed vacuum extraction, and maternal primiparity.
The bleeding extends beyond bone, often posteriorly into the neck, and
 continues after birth, with the potential for serious complications such as
anaemia or hypovolemic shock.

Signs of Subgaleal haemorrhage: -

 A boggy fluctuant mass over the scalp that crosses the suture line and
moves as the baby is repositioned is an early sign of subgaleal
hemorrhage.
 An early sign of subgaleal hemorrhage is a forward and lateral
positioning of the new-born’s ears because the hematoma extends
posteriorly. Disseminated intravascular coagulation (DIC) has also been
reported in association with subgaleal hemorrhage.
 Other signs include pallor, tachycardia, and increasing head
circumference.
Nursing Care Management: -

Nursing care is directed toward assessment and observation of the common

scalp injuries and vigilance in observing for possible associated complications
such as infection or, as in the case of subgaleal hemorrhage, acute blood loss
and hypovolemia. Nursing care of a newborn with a subgaleal hemorrhage
includes careful monitoring for signs of hemodynamic instability and shock.
Because caput succedaneum and cephalhematoma usually resolve
spontaneously, parents need reassurance of their usual benign nature.

FRACTURE: - The clavicle, or collarbone, is the bone most frequently

fractured during the birth process. It is often associated with shoulder dystocia
or a difficult vertex or breech delivery of infants who are large for gestational
age. A palpable, spongy mass, representing localized oedema and hematoma,
may also be a sign of a fractured clavicle. The infant may be reluctant to move
the arm on the affected side, and the Moro reflex may be asymmetric.
Fracture of skull: - Fractures of the neonatal skull are uncommon. The bones,
which are less mineralized and more compressible than bones in older infants
and children, are separated by membranous seams that allow sufficient
alteration in the head contour so that it adjusts to the birth canal during delivery.
Skull fractures usually follow a prolonged, difficult delivery or forceps
extraction. Most fractures are linear, but some may be visible as depressed
indentations that compress or decompress like a ping-pong ball.

Nursing Care Management: -

Often, no intervention is needed other than maintaining proper body alignment,

careful dressing and undressing of the infant, and handling and carrying that
support the affected bone. The infant is carefully observed for signs of
neurologic complications. The parents of infants with a fracture of any bone
should be involved in caring for the infant during hospitalization as part of
discharge planning for care at home.

DIAGNOSTIC EVALUATION:

 History collection
 Physical examination
 Clinical manifestation
 Transfontanel cranial ultrasonography
 Computed tomography(CT)

 MRI
 Lumbar puncture: is indicated in the presence of signs of-
Increased intracranial pressure or
Deteriorating clinical condition to identify gross subarachnoid
haemorrhage or to rule out the possibility of bacterial meningitis.
  EEG
 Blood clotting studies
 CBC

TREATMENT:

 Vitamin K should be given

 Quite environment
 Incubator care
 Clear the air passage
 Restrict handling
 NG feeds and IV fluids
 Antibiotics to treat bacterial infection
 Seizures are treated with anticonvulsant drugs
 Anemia-shock, requires transfusion with packed red blood cells or fresh
frozen plasma
 Acidosis is treated with slow administration of sodium bicarbonate.

PARALYSIS

Facial Paralysis: - Pressure on the facial nerve (cranial nerve VII) during
delivery may result in injury to that nerve. The primary clinical manifestations
are loss of movement on the affected side, such as an inability to completely
close the eye, drooping of the corner of the mouth, and absence of wrinkling of
the forehead and nasolabial fold The paralysis is most noticeable when the
infant cries. The mouth is drawn to the unaffected side, the wrinkles are deeper
on the normal side, and the eye on the involved side remains open.
Management: - No medical intervention is necessary. The paralysis usually
disappears spontaneously in a few days but may take as long as several months.
Nursing Care Management: -
 Nursing care of an infant with facial nerve paralysis involves aiding the
infant in sucking and helping the mother with feeding techniques.
Because part of the mouth cannot close tightly around the nipple, the use
of a soft rubber nipple with a large hole may be helpful.
 The infant may require gavage feeding to prevent aspiration.
 Breastfeeding is not contraindicated, but the mother will need additional
assistance in helping the infant grasp and compress the areolar area.
 If the eyelid of the eye on the affected side does not close completely,
artificial tears can be instilled daily to prevent drying of the conjunctiva,
sclera, and cornea.
 The eyelid is often taped shut to prevent accidental injury.

Brachial Palsy: - Plexus injury results from forces that alter the normal position
and relationship of the arm, shoulder, and neck.
 Erb palsy: - (Erb-Duchene paralysis) is caused by damage to the upper
plexus and usually results from stretching or pulling away of the shoulder
from the head, as might occur with shoulder dystocia or with a difficult
vertex or breech delivery.

Risk factor of erb palsy:

 An infant with birth weight of more than 4000 g (8.8 pounds).

 A second stage of labour of less than 15 minutes.
 Maternal body mass index greater than 29.
 A vacuum-assisted extraction, prolonged labour.
 A previous history of brachial plexus injury.
Clinical manifestations of Erb palsy:
 The paralysis of the affected extremity and muscles.
 The arm hangs limp alongside the body while the shoulder and arm are
adducted and internally rotated.
 The elbow is extended, and the forearm is pronated, with the wrist and
fingers flexed.
 A grasp reflex may be present because finger and wrist movement remain
normal.

Nursing Care Management: -

 The affected arm should be gently immobilized on the upper abdomen;
passive range of motion exercises of the shoulder, wrist, elbow, and
fingers are initiated at 7 to 10 days of age.
 Wrist flexion contractures may be prevented with the use of supportive
splints. In dressing the infant, preference is given to the affected arm.
 Teach parents to use the “football” position when holding the infant and
to avoid picking up the child from under the axillae or by pulling on the
arms.

Klumpke’s palsy: - Results from severe stretching of the upper extremity

while the trunk is relatively less mobile.

Clinical manifestations of Klumpke palsy:

 The muscles of the hand are paralyzed, with consequent wrist drop and
relaxed fingers.
 In a third and more severe form of brachial palsy, the entire arm is
paralyzed and hangs limp and motionless at the side.
 The Moro reflex is absent on the affected side for all forms of brachial
palsy.
Phrenic Nerve Paralysis: - Phrenic nerve paralysis which shows paradoxical
chest movement and an elevated diaphragm. The injury sometimes occurs in
conjunction with brachial palsy. Because injury to the phrenic nerve is usually
unilateral, the lung on the affected side does not expand, and respiratory efforts
are ineffectual. Breathing is primarily thoracic, and cyanosis, tachypnea, or
complete respiratory failure may be seen. Pneumonia and atelectasis on the
affected side may also occur.

Clinical manifestations of phrenic nerve paralysis:

 Respiratory distress is the most common and important sign of injury.

Nursing Care Management: -
 The infant with phrenic nerve paralysis requires the same nursing care as
any infant with respiratory distress. Mechanical ventilation may be
required to prevent further respiratory compromise.
 The family’s emotional needs are also an important part of nursing care;
the family will need reassurance regarding the neonate’s progress toward
an optimal outcome.

PREVENTION OF INJURIES IN THE NEWBORN:

 Comprehensive care during antenatal and intra-natal period.

 ANTE NATAL PERIOD:-
 To screen out the high ride babies.
 Liberal use of LSCS.
 INTRA-NATAL PERIOD:-
 Normal Labour
 Continuos fetal monitoring
 Episiotomy
 The neck should not be stretched
  PRETERM LABOUR:-
 To prevent anoxia
 Avoid strong sedatives
 Use of episiotomy and use of forceps to reduce the compression
 To administer vitamin-K
 FORCEPS:-
 Difficult forceps are to be avoided
 Never apply the traction unless is properly placed
 VENTOUSE:-
 Avoid in preterm babies.
 BREECH:-
 Gently and skilfully conducting the deliveries.

CONCLUSION:

Many newborns have minor injuries during birth. Infrequently, nerves are
damaged or bones are broken. Most injuries get better without treatment. A
difficult delivery, with the risk of injury to the fetus, may occur when the birth
canal is too small or the fetus is too large (as sometimes occurs when the mother
has diabetes). Injury is also more likely when the fetus is lying in an abnormal
position in the uterus before birth. Overall, the rate of birth injuries is much
;ower now then in previous decades because of improved prenatal assessment
with ultrasonography and because cesarean delivery may be done in certain
circumstances.