Fetal Birth Injuries

Dr. Ashraf Fouda

Domiatte General Hospital
 Definition
The term birth injury is used to
denote:
avoidable and unavoidable
mechanical, hypoxic and
ischemic injury
affecting the infant
during
labor and delivery.
 Definition
• Birth injuries may result from :
1.Inappropriate or deficient medical
skill or attention.
2.They may occur, despite skilled
and competent obstetric care.
 Incidence
Has been estimated at 2-7/1,000
live births. Predisposing
factors:
1.Macrosomia,
2.Prematurity,
3.Cephalopelvic disproportion,
4.Dystocia,
5.Prolonged labor, and
6.Breech presentation.
 Incidence
•5-8/100,000 infants die of
birth trauma, and
•25/100,000 die of anoxic
injuries;
Such injuries represent 2-
3% of infant deaths.
Cranial Injuries
 Erythema, abrasions,
ecchymoses,
•Of facial or scalp soft tissues may
be seen after forceps or vacuum-
assisted deliveries.
•Their location depends on the
area of application of the forceps.
 Subconjunctival ,retinal hemorrhages
and petechiae of the skin of the head and
neck
• All are common.
• All are probably secondary to a sudden
increase in intrathoracic pressure during
passage of the chest through the birth
canal.
• Parents should be assured that they are
temporary and the result of normal
hazards of delivery.
 Molding
•Molding of the head and overriding of the
parietal bones are frequently associated
with caput succedaneum and become more
evident after the caput has receded but
disappear during the first weeks of life.
• Rarely, a hemorrhagic caput may result in
shock and require blood transfusion.
 Caput succedaneum
• Diffuse, sometimes ecchymotic,
edematous swelling of the soft
tissues of the scalp involving the
portion presenting during vertex
delivery.
• It may extend across the midline
and across suture lines.
• The edema disappears within the
first few days of life.
 Caput succedaneum
•Analogous swelling, discoloration, and
distortion of the face are seen in face
presentations.
•No specific treatment is needed, but if
there are extensive ecchymoses,
phototherapy for hyperbilirubinemia
may be indicated.
 Cephalhaematoma
•It is a subperiosteal
haematoma most commonly
lies over one parietal bone.
•It may result from difficult
vacuum or forceps
extraction .
 Cephalhaematoma
Management:
- It usually resolves
spontaneously.
- Vitamin K 1 mg IM is given.
 Cephalohematoma
• Is a subperiosteal hemorrhage, so it is
always limited to the surface of one cranial
bone.
• There is no discoloration of the overlying
scalp, and swelling is usually not visible until
several hours after birth, because
subperiosteal bleeding is a slow process.
• An underlying skull fracture, usually linear
and not depressed, is occasionally
associated with cephalohematoma.
 Cephalohematoma
Cranial meningocele
is differentiated from cephalohematoma
by:
1. Pulsation,
2. Increased pressure on crying, and the
3. Radiologic evidence of bony defect.
• Most cephalohematomas are resorbed
within 2 wk-3 mo, depending on their
size.
• They may begin to calcify by the end
of the 2nd wk.
 Cephalohematoma
•A sensation of central depression
suggesting( but not indicative )of an
underlying fracture or bony defect is
•Cephalohematomas
require no treatment, although
phototherapy may be necessary to
ameliorate hyperbilirubinemia.
 Cephalohematoma
• Incision and drainage are
contraindicated because of the risk of
introducing infection in a benign
condition.
• A massive cephalohematoma may
rarely result in blood loss severe
enough to require transfusion.
• It may also be associated with a skull
fracture, coagulopathy, and
intracranial hemorrhage.
Diagnosis and Differential Diagnosis
Fractures of the skull
May occur as a result of pressure
from :
1.Forceps or from
2.The maternal symphysis
pubis.
3.Sacral promontory, or
4.Ischial spines.
 Fracture Skull:
Usually occurs due to difficult forceps delivery.
It may be:
(1) Vault fracture:
• Usually affecting the frontal or parietal bone.
• It may be linear or depressed fracture.
• It needs no treatment unless there is intracranial
haemorrhage.
(2) Fracture base:
• Usually associated with intracranial haemorrhage.
 Fractures of the skull
1. Linear fractures, the most common,
cause no symptoms and require no
treatment.
2. Depressed fractures are usually
indentations similar to a dent in a
Ping-Pong ball; they usually are a
complication of forceps delivery or
fetal compression.
Depressed
fractures
Ping-Pong
ball
 Fractures of the skull
•Affected infants may be
asymptomatic unless there is
associated intracranial injury.
•It is advisable to elevate
severe depressions to prevent
cortical injury from sustained
pressure.
 Fractures of the skull
•Fracture of the Occipital bone
almost causes fatal hemorrhage
due to disruption of the underlying
vascular sinuses.
•It may result during breech
deliveries from traction on the
hyperextended spine of the infant
with the head fixed in the maternal
pelvis.
 Intracranial Haemorrhage:
Causes:
1. Sudden compression and
decompression of the head as in
breech and precipitate labour.
2. Marked compression by forceps or in
cephalopelvic disproportion.
3. Fracture skull.
 Intracranial Haemorrhage:
Predisposing factors:
1. Prematurity due to physiological
hypoprothrombinaemia, fragile
blood vessels and liability to
trauma.
2. Asphyxia due to anoxia of the
vascular wall .
3. Blood diseases.
Intracranial Haemorrhage
Sites:
1. Subdural : results from damage to the superficial
veins where the vein of Galen and inferior sagittal
sinus combine to form the straight sinus.
2. Subarachnoid: The vein of Galen is damaged due
to tear in the dura at the junction of the falx cerebri
and tentorium cerebelli.
3. Intraventricular :into the brain ventricles.
4. Intracerebral : into the brain tissues .
• In (1) and (2) it is usually due to birth trauma,
• in (3) and (4) the foetus is usually a premature
exposed to hypoxia.
 Intracranial Haemorrhage:
Clinical picture:
1- Altered consciousness.
2- Flaccidity.
3- Breathing is absent, irregular and periodic or
gasping.
4- Eyes: no movement, pupils may be fixed and
dilated.
5- Opisthotonus, rigidity, twitches and convulsions.
6- Vomiting .
7- High pitched cry.   
8- Anterior fontanelle is tense and bulging.
9- Lumbar puncture reveals bloody C.S.F.
 Intracranial
Haemorrhage
Investigations:
1. Ultrasound is of value.
2. CT scan is the most reliable.
3. MRI
 Intracranial Haemorrhage:
Prophylaxis:
1. Vitamin K: 10 mg IM to the mother in
late pregnancy or early in labour.
2. Episiotomy: especially in prematures
and breech delivery.
3. Forceps delivery: carried out by an
experienced obstetrician respecting
the instructions for its use.
Intracranial Haemorrhage Treatment
1. Minimal handling, warmth and oxygen to the baby.
2. No oral feeding for 72 hours.
3. IV fluids.
4. Vitamin K 1mg IM.
5. Lumbar puncture: is diagnostic and therapeutic to
relieve the intracranial tension if the anterior fontanelle
is bulging.
6. Sedatives for convulsions.
7. 60 cc. of 10% sodium chloride per rectum to relieve
brain oedema.
8. 1 cc of 50% magnesium sulphate IM to relieve brain
oedema and convulsions.
9. Antibiotics : to guard against infections particularly
pulmonary.
ETIOLOGY AND EPIDEMIOLOGY
Intracranial hemorrhage may
result from:
1.Birth trauma or
2.Asphyxia and, rarely, from a
3.Primary hemorrhagic disturbance or
4.Congenital vascular anomaly.
ETIOLOGY AND EPIDEMIOLOGY
• Intracranial hemorrhages often
involve the ventricles
( intraventricular hemorrhage
[IVH]) of premature infants
delivered spontaneously without
apparent trauma.
 CLINICAL MANIFESTATIONS
The incidence of IVH increases with
decreasing birthweight:
1. 60-70% of 500- to 750-g infants and
2. 10-20% of 1,000- to 1,500-g infants.
IVH is rarely present at birth; however,
1. 80-90% of cases occur between birth and the
3rd day .
2. 50% occur on the 1st day.
3. 20% to 40% of cases progress during the 1st
wk of life.
4. Delayed hemorrhage may occur in 10-15% of
patients after the 1st wk of life.
CLINICAL MANIFESTATIONS
The most common symptoms
are:
1.Diminished or absent Moro
reflex.
2.Poor muscle tone.
3.Lethargy.
4.Apnea.
5.Somnolence.
 CLINICAL MANIFESTATIONS
1. Periods of apnea,
2. Pallor, or cyanosis;
3. Failure to suck well;
4. Abnormal eye signs;
5. A high-pitched cry;
6. Muscular twitches, convulsions,
decreased muscle tone, or paralyses;
7. Metabolic acidosis; shock, and a
8. Decreased hematocrit or its failure to
increase after transfusion may be the
first indications.
9. The fontanel may be tense and bulging.
 DIAGNOSIS
Intracranial hemorrhage is
diagnosed on the basis of the:
1.History,
2.Clinical manifestations,
3.Transfontanel cranial
ultrasonography or
4.Computed tomography (CT), and
 DIAGNOSIS
Lumbar puncture
is indicated in the presence of signs of:
1. Increased intracranial pressure or
2. Deteriorating clinical condition
to identify gross subarachnoid hemorrhage
or to rule out the possibility of bacterial
meningitis
 PROGNOSIS
Neonates with:
( massive hemorrhage
associated with tears of
the tentorium or falx
cerebri)
rapidly deteriorate and
may die after birth.
 PREVENTION
The incidence of traumatic
intracranial hemorrhage may
be reduced by:
judicious management of
cephalopelvic disproportion
and operative delivery.
 PREVENTION
Fetal or neonatal hemorrhage due to:
1.Maternal idiopathic thrombocytopenic
purpura (ITP) or
2.Alloimmune thrombocytopenia
may be prevented by maternal treatment
with:
1.Steroids,
2.Intravenous immunoglobulin, or
3.Fetal platelet transfusion.
 PREVENTION
•The incidence of IVH may be
reduced by antenatal steroids and
by postnatal administration of low-
dose indomethacin.
•Vitamin K should be given before
delivery to all women receiving
phenobarbital or phenytoin during
the pregnancy.
 TREATMENT
•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.
 TREATMENT
Symptomatic subdural
hemorrhage in large term
infants should be treated by
removing the subdural fluid
collection by means of a
spinal needle placed
through the lateral margin
of the anterior fontanel.
 Spine and Spinal Cord
Strong traction exerted:
1. When the spine is hyperextended or
2. When the direction of pull is lateral, or
3. Forceful longitudinal traction on the trunk
while the head is still firmly engaged in the
pelvis:
(may produce fracture and
separation of the vertebrae).
 Spine and Spinal Cord
•Such injuries, rarely diagnosed clinically,
are most likely to occur with shoulder
dystocia.
•The injury occurs most commonly at the
level of the 4th cervical vertebra with
cephalic presentations and
•The lower cervical-upper thoracic
vertebrae with breech presentations.
 Spine and Spinal Cord
•Transection of the cord may occur
with or without vertebral fractures.
•Hemorrhage and edema may
produce neurologic signs that are
not distinguished from those of
transection
(except that they may not be
permanent).
 Spine and Spinal Cord
1.Areflexia,
2.Loss of sensation, and
3.Complete paralysis of
voluntary motion
Occur below the level of
injury
 Spine and Spinal Cord
• If the injury is severe, the infant,
(who may be in poor condition
owing to respiratory depression,
shock, or hypothermia),
May deteriorate rapidly to death
within several hours before
neurologic signs are obvious.
 Spine and Spinal Cord
•The course may be protracted,
with symptoms and signs
appearing at birth or later in the
1st wk; may not be recognized
for several days.
• Constipation may also be present.
 Spine and Spinal Cord
•The diagnosis is confirmed by :
Ultrasonography or MRI.
•Treatment of the survivors is:
supportive, including home
ventilation; patients often remain
permanently injured.
Peripheral Nerve
Injuries
 Brachial Plexus Palsy:
It is due to over traction on
the neck as in:
1. Shoulder dystocia.
2. After-coming head in breech delivery.
 Brachial Plexus Palsy:
(1)Erb's palsy:
2.It is the common, due to injury
to C5 and C6 roots.
3.The upper limb drops beside
the trunk, internally rotated
with flexed wrist
(policeman’s or waiter’s tip
hand).
 Brachial Plexus Palsy:
(2) Klumpke’s palsy:
- It is less common,
- Due to injury to C7 and C8 and 1st
thoracic roots.
- It leads to paralysis of the muscles
of the hand and weakness of the
wrist and fingers' flexors.
 Brachial Plexus Palsy:
Treatment
• Support to prevent
stretching of the paralyzed
muscles.
• Physiotherapy: massage,
exercise and faradic
stimulation.
 BRACHIAL PALSY
• Injury to the brachial plexus
may cause paralysis of the
upper arm with or without
paralysis of the forearm or hand
or, more commonly, paralysis of
the entire arm.
• Approximately 45% are
associated with shoulder
dystocia.
 BRACHIAL PALSY
• These injuries occur in :
1.Macrosomic infants and when lateral
traction is exerted on the head and neck
during delivery of the shoulder in a
vertex presentation,
2. When the arms are extended over the
head in a breech presentation, or
3.When excessive traction is placed on the
shoulders.
ANATOMY OF THE BRACHIAL PLEXUS

2
3
4
5
Roots 6
9
8
Trunks
7
Cords

Nerves
1 Upper 4 Lateral 7 Ulnar
2 Middle 5 Posterior 8 Median
3 Lower 6 Medial 9 Radial
In Erb-Duchenne paralysis
•The injury is limited to the 5th and 6th
cervical nerves.
•The characteristic position consists of:
( Adduction and internal rotation of
the arm with pronation of the
forearm).
•Moro reflex is absent on the affected side
In Erb-Duchenne paralysis
•There may be some sensory
impairment on the outer aspect of the
arm.
•The power in the forearm and the hand
grasp are preserved unless the lower
part of the plexus is also injured;
(the presence of the hand grasp is a
favorable prognostic sign).
 Klumpke's paralysis
•Is a rarer form of brachial palsy;
•Injury to the 7th and 8th cervical nerves
and the 1st thoracic nerve produces a
paralyzed hand,
(Horner syndrome)
• If the sympathetic fibers of the 1st thoracic
root are also injured : paralyzed hand
and ipsilateral ptosis and miosis.
 Klumpke's paralysis
• The mild cases may not be detected
immediately after birth.
• Differentiation must be made from :
1. Cerebral injury;
2. Fracture, dislocation, or epiphyseal
separation of the humerus;
3. Fracture of the clavicle.
MRI demonstrates nerve root rupture or
avulsion
 common uncommon
edema and hemorrhage Laceration
 The prognosis
•Depends on whether the nerve was
merely injured or was lacerated.
•If the paralysis was due to edema and
hemorrhage about the nerve fibers,
function should return within a few
months;
•If due to laceration, permanent damage
may result.
 The prognosis
•Involvement of the deltoid is
usually the most serious problem
and may result in a shoulder drop
secondary to muscle atrophy.
•In general, paralysis of the upper
arm has a better prognosis than
paralysis of the lower arm.
 Treatment
•Partial immobilization and appropriate
positioning to prevent development of
contractures.
•In upper arm paralysis: the arm should
be abducted, with external rotation at the
shoulder and with full supination of the
forearm and slight extension at the wrist
with the palm turned toward the face.
 Treatment
•In lower arm or hand paralysis: the
wrist should be splinted in a
neutral position and padding
placed in the fist.
•Gentle massage and range of motion
exercises may be started by 7-10 days
of age.
 Treatment
If the paralysis persists
without improvement for 3-6
months: neuroplasty,
neurolysis, end-to-end
anastomosis, or nerve grafting
offers hope for partial recovery.
PHRENIC NERVE PARALYSIS
•Phrenic nerve injury (3rd, 4th, 5th
cervical nerves) with diaphragmatic
paralysis must be considered when
cyanosis and irregular and labored
respirations develop.
•Such injuries, usually unilateral, are
associated with ipsilateral upper brachial
palsy.
PHRENIC NERVE PARALYSIS
•The diagnosis
is established by ultrasonography or
fluoroscopic examination, which reveals
elevation of the diaphragm on the
paralyzed side
•There is no specific treatment:
infants should be placed on the involved
side and given oxygen if necessary.
PHRENIC NERVE PARALYSIS

• Recovery usually occurs

spontaneously by 1-3
months; rarely, surgical
plication of the diaphragm
may be indicated.
 Facial Palsy (Bell’s palsy):
- It is usually due to pressure by the forceps blade
on the facial nerve at:
1. Its exit from the stylomastoid foramen or
2. In its course over the mandibular ramus.
- It appears within 1-2 days after delivery due to
resultant oedema and haemorrhage around the
nerve.
Facial Palsy (Bell’s palsy):
Manifestations:
1. There is paresis of the facial muscles on
the affected side with:
2. Partially opened eye and:
3. Flattening of the nasolabial fold.
4. The mouth angle is deviated towards
the healthy side.
Spontaneous recovery usually occurs
within 14 days.
 FACIAL NERVE PALSY
•When the infant cries, there is movement
only on the non paralyzed side of the face,
and the mouth is drawn to that side.
•On the affected side the forehead is
smooth, the eye cannot be closed, the
nasolabial fold is absent, and the corner of
the mouth drops.
 FACIAL NERVE PALSY
•The prognosis depends on
whether the nerve was
injured by pressure or
whether the nerve fibers
were torn.
•Care of the exposed eye is
essential.
FACIAL NERVE PALSY
•Improvement occurs
within few weeks.
•Neuroplasty may be
indicated when the
paralysis is persistent.
 Other peripheral
nerves
are seldom injured in utero
or at birth except when
they are involved in
fractures or hemorrhages.
V) VISCERAL INJURIES
(Liver, spleen and kidney)
may be injured in breech
delivery which should be
avoided by holding the fetus
from its hips.
 Viscera (The liver )
•The liver is the only internal organ
other than the brain that is injured
with any frequency during birth.
•The damage usually results from
pressure on the liver during delivery
of the head in breech presentations.
•Incorrect cardiac massage is a less
frequent cause.
 Viscera (The liver )
•Hepatic rupture may result in the
formation of a subcapsular
hematoma.
•The hematoma may be large
enough to cause anemia.
•Shock and death may occur if the
hematoma breaks through the
capsule into the peritoneal
cavity.
 Viscera (The liver )
•A mass may be palpable in the right
upper quadrant; the abdomen may
appear blue.
•Early suspicion by means of
ultrasonographic diagnosis and
prompt supportive therapy can
decrease the mortality of this
disorder.
•Surgical repair of a laceration may
be required.
Rupture of the spleen
• May occur alone or in
association with rupture of the
liver.
• The causes, complications,
treatment, and prevention are
similar.
 Adrenal hemorrhage
• Occurs with some frequency, especially
after breech delivery in LGA infants or
infants of diabetic mothers.
• 90% are unilateral; 75% are right sided.
• The symptoms are profound shock and
cyanosis
• If suspected, abdominal ultrasonography
may be helpful, and treatment for acute
adrenal failure may be indicated
Fractures
 BONE INJURIES
These usually occur during
difficult breech delivery.
(A) Vertebral Column Injuries:
• These are fatal if associated with spinal cord
transection above C4 ,due to diaphragmatic
paralysis.
(B) Femur, Humerus and Clavicle:
• Managed by splint to the long bone and a
sling for clavicular fracture.
 CLAVICLE
This bone is fractured during labor and
delivery
more frequently than any other bone;
It is particularly vulnerable when there is:
1. Difficulty in delivery of the shoulder in
vertex presentations and of
2. The extended arms in breech deliveries.
 CLAVICLE
•The infant characteristically does
not move the arm freely on the
affected side;
•Crepitus and bony irregularity
may be palpated, and
•Discoloration is occasionally
visible over the fracture site.
 CLAVICLE
•Treatment, consists of immobilization
of the arm and shoulder on the
affected side.
•A remarkable degree of callus
develops at the site within a week
and may be the first evidence of the
fracture.
•The prognosis is excellent.
 EXTREMITIES
•In fractures of the long bones,
spontaneous movement of the
extremity is usually absent.
•The Moro reflex is also absent
from the involved extremity.
•There may be associated nerve
involvement.
 EXTREMITIES
(Humerus)
•Satisfactory results of treatment for
a fractured humerus are obtained
with
2-4 wk of immobilization
(during which the arm is
strapped to the chest).
•A triangular splint and a bandage
are applied, or a cast is applied.
 EXTREMITIES
•In fracture femur : good results are
obtained with traction-suspension of both
lower extremities, even if the fracture is
unilateral;
•The legs, immobilized in a cast, are
attached to an overhead frame.
•Splints are effective for treatment of
fractures of the forearm or leg.
 EXTREMITIES
•Healing is usually accompanied by
excess callus formation.
•The prognosis is excellent for
fractures of the extremities.
•Fractures in preterm infants may
be related to osteopenia
 Dislocations and
epiphyseal separations
•Rarely result from birth trauma.
•The upper femoral epiphysis may be
separated by forcible manipulation of
the infant's leg, as, for example, in
breech extraction or after version.
 Dislocations and epiphyseal
separations
•The affected leg shows swelling,
slight shortening, limitation of
active motion, painful passive
motion, and external rotation.
•The diagnosis is established
radiologically
•The prognosis is good for the
milder injuries.
 MUSCLE INJURIES
Strenomastoid injury
Due to :
•Exaggerated lateral flexion of
the neck leading to torticollis
and swelling in the muscle.
•It is usually improved within 2
weeks but permanent torticollis
may continue.