Fetal Birth Injuries

BY ABHISHEK JAGUESSAR

Definition
The term birth injury is used to denote: avoidable and unavoidable mechanical, hypoxic and ischemic injury affecting the infant during

Definition
Birth injuries may result from : 1.Inappropriate or deficient medical skill or attention. 2.They may occur, despite

Incidence
Has been estimated at 27/1,000 live births.
1.Macrosomia, 2.Prematurity, 3.Cephalopelvic disproportion, 4.Dystocia, 5.Prolonged labor, and

Predisposing factors:

Incidence
5-8/100,000 infants die of birth trauma, and 25/100,000 die of anoxic injuries; Such injuries represent 23% of infant deaths.

Cranial Injuries

Erythema, abrasions, ecchymoses, Of facial or scalp soft tissues may be seen after forceps or vacuumassisted deliveries. Their location depends on the area of

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.

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

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

Cephalhaematoma
It is a subperiosteal haematoma most commonly lies over one parietal bone. It may result from

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

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,

Cephalohematoma
A sensation of central depression suggesting( but not indicative )of an underlying fracture or bony defect is Cephalohematomas require no treatment,

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.

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

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

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

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

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

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: damage to the 1. Subdural : results from

2.

3. 4.

superficial veins where the vein of Galen and inferior sagittal sinus combine to form the straight sinus. Subarachnoid: The vein of Galen is damaged due to tear in the dura at the junction of the falx cerebri and tentorium cerebelli. Intraventricular :into the brain ventricles. Intracerebral : into the brain tissues . In (1) and (2) it is usually due to birth

Intracranial Haemorrhage:
123456Clinical picture: Altered consciousness. Flaccidity. Breathing is absent, irregular and periodic or gasping. Eyes: no movement, pupils may be fixed and dilated. Opisthotonus, rigidity, twitches and convulsions. Vomiting .

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

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

ETIOLOGY AND EPIDEMIOLOGY

Intracranial hemorrhage may result from:

1.Birth trauma 2.Asphyxia from a or and, rarely,

ETIOLOGY AND EPIDEMIOLOGY

Intracranial hemorrhages often involve the ventricles ( intraventricular hemorrhage [IVH]) of premature infants

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

CLINICAL MANIFESTATIONS

The most common symptoms are:

1.Diminished or absent Moro reflex. 2.Poor muscle tone. 3.Lethargy. 4.Apnea.

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.

DIAGNOSIS
Intracranial hemorrhage is diagnosed on the basis of the: 1.History, 2.Clinical manifestations, 3.Transfontanel cranial ultrasonography or

DIAGNOSIS
Lumbar puncture
is indicated in the presence of signs of:
1. Increased intracranial pressure or 2. Deteriorating clinical condition

PROGNOSIS
Neonates with: ( massive hemorrhage associated with tears of the tentorium or falx cerebri) rapidly deteriorate and

PREVENTION
The incidence of traumatic intracranial hemorrhage may be reduced by: judicious management of cephalopelvic

PREVENTION
Fetal or neonatal hemorrhage due to: 1.Maternal idiopathic thrombocytopenic purpura (ITP) or 2.Alloimmune thrombocytopenia may be prevented by maternal treatment with:

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

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

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

Spine and Spinal Cord

Strong traction exerted:
1. When the spine is hyperextended or 2. When the direction of pull is lateral, or 1. Forceful longitudinal traction on the trunk while the head is still firmly engaged in the pelvis:

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

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

Spine and Spinal Cord 1.Areflexia, 2.Loss of sensation, and 3.Complete paralysis of voluntary motion Occur below the level

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

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.

Spine and Spinal Cord The diagnosis is confirmed by : Ultrasonography or MRI. Treatment of the survivors is: supportive, including

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:
1.It is the common, due to injury to C5 and C6 roots. 2.The upper limb drops beside the trunk, internally rotated with flexed wrist (policemans or waiters tip

Brachial Plexus Palsy:

(2) Klumpkes 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

Brachial Plexus Palsy: Treatment

Support to prevent stretching of the paralyzed muscles. Physiotherapy: massage, exercise and

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.

 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, 1. When the arms are extended over the head in a breech presentation, or

BRACHIAL PALSY

ANATOMY OF THE BRACHIAL PLEXUS

1 2 3 4

Roots Trunks

5 6 9 8 7

Cords Nerves
1 2 3

Upper Middle Lower

4 5 6

Lateral Posterior Medial

7 8 9

Ulnar Median 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

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

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

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;

common
edema and hemorrhage

uncommon
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;

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

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

Treatment

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

Treatment
If the paralysis persists without improvement for 3-6 months:
neuroplasty, neurolysis, end-to-end anastomosis, or nerve grafting

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

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:

PHRENIC NERVE PARALYSIS

Recovery usually occurs spontaneously by 13 months; rarely, surgical plication of

Facial Palsy (Bells 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.

Facial Palsy (Bells palsy):

1. 2. 3. 4. Manifestations: There is paresis of the facial muscles on the affected side with: Partially opened eye and: Flattening of the nasolabial fold. The mouth angle is deviated towards the healthy side.

Spontaneous recovery usually occurs

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

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

FACIAL NERVE PALSY

Improvement occurs within few weeks. Neuroplasty may be indicated when the

Other peripheral nerves are seldom injured in utero or at birth except when they are involved in

V) VISCERAL INJURIES (Liver, spleen and kidney) may be injured in breech delivery which should be avoided by holding the fetus from

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.

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

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.

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

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:

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

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

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

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.

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

EXTREMITIES (Humerus)

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.

EXTREMITIES
Healing is usually accompanied by excess callus formation. The prognosis is excellent for fractures of the extremities.

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,

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

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