2. At the end of this session the students will be able to:
• Diagnose different types of birth trauma
• Investigate
• Manage properly
24-Aug-22 by GA 2
Objectives
3. • Birth injuries are those sustained during the birth
process, which includes labour and delivery.
• They may be avoidable or unavoidable.
• It is a common problem with significant neonatal
morbidity and mortality.
24-Aug-22 by GA 3
Definition
4. Risk Factors
• The risk factors for may be divided into three
categories:
1. Neonatal
2. Maternal
3. Labor-related factors
24-Aug-22 by GA 4
5. Neonatal Risk factors
• Prematurity
• High birth weight ( > 4 kg )
• *Breach fetal position
24-Aug-22 by GA 5
6. Maternal Risk factors
• *Age ( > 35 years )
• Small maternal stature (CPD)
• *Gestational Diabetes Mellitus ( results in
Macrosomia )
• *Post date gestation
24-Aug-22 by GA 6
7. • Increased duration of 2nd stage of labour Prolonged or
precipitated labour
• *Induction of labour
• -Oxytocin augment
• *Operative vaginal deliveries
-Vacuum extraction
-Direct compression of fetal neck during delivery by forceps
• Mal presentation and malposition
24-Aug-22 7
Labor-related
Risk Factors
by GA
8. • Thorough examination , including a detailed
neurologic evaluation
• Examine the neonate for asymmetry of
structure and function, cranial nerves, range of
motion of individual joints, and integrity of the
scalp and skin
24-Aug-22 by GA 8
Evaluation
9. • Cranial Injuries
• Peripheral Nerve Injuries
• CLAVICLE
• Other injuries
24-Aug-22 by GA 9
Types of injury
11. • It is a commonly occurring under subcutaneous extra
periosteal fluid collection that is occasionally
hemorrhagic
• It has poorly defined margins and can extend over the
midline and across suture lines.
24-Aug-22 by GA 11
Caput succedaneum
12. • It extends over the presenting portion of the scalp
and is usually associated with molding
• The lesion usually resolves spontaneously without
sequelae over first several days after birth.
• It rarely causes significant blood loss or jaundice
24-Aug-22 by GA 12
Caput succedaneum Cont.
13. • It is a subperiosteal collection of blood
resulting from rupture of the superficial veins
between the skull and periostum
• It is always confined by suture lines and cannot
cross the suture lines
24-Aug-22 by GA 13
Cephalohematoma
14. • An Extensive cephalohematoma can result in
significant hyperbilirubinemia and rarely serious
enough to necessitate blood transfusion
• The risk of infection is very rare
• Skull fractures have been associated with 5 –
20% of cases.
24-Aug-22 by GA 14
17. • Observation in most cases
• Incision and aspiration is contraindicated
• Anemia and jaundice should be treated as
needed
24-Aug-22 by GA 17
Management
18. It is hemorrhage under the aponeurosis of the scalp
Because subaponeurotic space extends from the
orbital ridges to the neck and laterally to the ears;
The hemorrhage can spread across the entire
calvarium or Skull
24-Aug-22 by GA 18
Subgaleal hemorrhage
19. • The initial presentation typically includes pallor, poor
tone, and a fluctuant swelling on the scalp which cross
the suture lines
• The hematoma may grow slowly or increase rapidly
and result in shock.
• With progressive spread the ears may be displaced
anteriorly and peirorbital swelling can occur.
24-Aug-22 by GA 19
20. • Ecchymosis of the scalp may develop and it is very
painful on manipulation
• The blood is desorbed slowly and swelling resolves
gradually
• A Subgaleal hemorrhage associated with skin
abrasions may become infected, it should be treated
with antibiotics and may need drainage.
24-Aug-22 by GA 20
22. • New born with this lesion should be admitted
• Assess and treat shock
• Daily HCT measurement and HCT follow-up
• Minimize manipulation because it is painful
• Manage anemia and jaundice if needed
24-Aug-22 by GA 22
Management and follow up
24. • The cause is excessive traction on the head,
neck, and arm during birth
• Risk factors include macrosomia, shoulder
dystocia, breech presentation
• Injury usually involves the nerve root, specially
where the roots come together to form the nerve
trunk of the plexus
24-Aug-22 by GA 24
Brachial plexus injury
29. • Involves the upper trunks (C5,C6 and occasionally
C7) and is the most common type of brachial plexus
injury
24-Aug-22 by GA 29
Duchenne-Erb’s palsy
32. • The arm is typically adducted and internally rotated at
the shoulder
• There is extension and pronation at the elbow and
flexion at the wrist and fingers in the characteristic
“waiter’s tip” posture
• Moro reflex is absent on the affected side
• The grasp reflex is intact and sensation is variably
affected
24-Aug-22 by GA 32
Clinical presentation
34. • involves injury C7/C8 to T1 and is the least common
injury
• In this case the grasp reflex is absent
• there is sensory impairment on the ulnar side of the
forearm and hand,
24-Aug-22 by GA 34
Klumpke’s palsy
35. • Physical therapy and passive range of motion exercises
prevent contractures
• It should be started at 7 -10 days when the post injury neuritis
recovered
• Splinting should be avoided as contractures in the shoulder
girdle may develop
• Wrist and digits splints may be useful
24-Aug-22 by GA 35
Management of brachial plexus injury
36. • Full recovery varies with the extent of injury.
• If the nerve roots are intact and not avulsed, prognosis for full
recovery is excellent
• Notable clinical improvement in the first two weeks indicates
that normal or near normal function will return
• Most infants recover fully by three months of age
• In case with slow recovery, electromyography and nerve
conduction studies are indicated.
24-Aug-22 by GA 36
Prognosis
37. • Phrenic nerve injury leading to paralysis of the
ipsilateral diaphragm may result from stretch injury due
to lateral hyperextension of the neck at birth
• Resulting in ipsilateral diaphragmatic paralysis causing a
decrease in thoracic space, tidal volume and vital
capacity.
• Risk factors include breech and difficult forceps
deliveries
• At least 75%of patients also have brachial plexus injury
24-Aug-22 by GA 37
Phrenic nerve injury (C3- C5 )
38. • Respiratory distress and cyanosis
• Some infants present with persistent tachypnea and
decreased breath sounds at the lung base
• There may be decreased movement of the affected
hemi thorax
24-Aug-22 by GA 38
Clinical features
39. PATHOGENESIS
Stretch, tear, compression or
avulsion of the nerves
usually after forceful lateral
deviation of the head from
the shoulders during delivery.
Recent studies suggest intrinsic
forces (uterine contractions).
24-Aug-22 by GA 39
40. • Confirmed by U/S or fluoroscopy that shows
paradoxical (upward) movement of the diaphragm
with inspiration.
• C-X-ray may show elevation of the affected hemi
thorax
24-Aug-22 by GA 40
Diagnosis
41. • The initial treatment is supportive
• CPAP or mechanical ventilation may be needed
• Careful air way care to avoid atelectasis and pneumonia
24-Aug-22 by GA 41
Management
43. • Skull fracture may be either linear or depressed
• Depressed skull fractures are usually associated with forceps
use
• Most infants with linear or depressed skull fractures are
asymptomatic unless there is an associated intracranial
hemorrhage (eg, subdural or subarachnoid hemorrhage).
24-Aug-22 by GA 43
Skull fracture
44. • The diagnosis is made by skull X-ray
• Head CT scan should be obtained if intracranial
injury is suspected
24-Aug-22 by GA 44
45. • Uncomplicated linear fractures usually requires no
therapy
• Depressed fractures require neurological evaluation for
possible elevation needed
• Comminuted or large fractures with neurologic findings
need immediate neurologic evaluation
• If leakage of CSF from the nares or ears is noted,
antibiotic therapy should be started and neurosurgical
consultation obtained.
24-Aug-22 by GA 45
Management
46. • Is the most commonly injured bone during delivery
• This fracture is seen in vertex presentations with
shoulder dystocia or in breech deliveries when the arms
are extended
• Macrosomia is a risk factor
• A green stick or incomplete fracture may be
asymptomatic at birth
24-Aug-22 by GA 46
Clavicular fracture
47. • The first clinical sign may be a callus at 7 – 10 days of
age.
• Signs of a complete fracture include crepitus, palpable
bony irregularity, and spasm of the sternocleidomasteoid
muscle.
• The affected arm may have a pseudo paralysis because of
pain on movement.
Diagnosis
• Confirmed by chest X-ray
24-Aug-22 by GA 47
48. • Should be directed at decreasing pain with analgesics
• The infant’s sleeve should be pinned to the shirt to limit
movement until the callus begins to form
• Complete healing is expected and counsel the family
24-Aug-22 by GA 48
Management:
49. Humeral fracture
• This fracture usually occurs during a difficult
delivery of the arms in the breech presentation
and/or of the shoulder in vertex presentation
• Direct pressure on the hummers may also
result in fracture.
24-Aug-22 by GA 49
Long bone injuries
50. • Loss of spontaneous arm movement on affected
side
• Followed by swelling and pain on passive motion
24-Aug-22 by GA 50
Clinical presentation
51. • Confirmed by x-ray of the affected arm
24-Aug-22 by GA 51
Diagnosis
52. • The fractured humorous requires splinting for
two weeks
• Displaced fracture require closed reduction
and casting
24-Aug-22 by GA 52
Management
53. • complete healing is expected with the above
managements
24-Aug-22 by GA 53
Prognosis
54. • This fracture follows usually a breech delivery
• Infants with congenital hypotonia are at increased
risk
24-Aug-22 by GA 54
Femoral fracture
55. • Obvious deformity of the thigh and swelling of thigh
• Decreased movement and paint on palpation or passive
motion
24-Aug-22 by GA 55
Clinical features
57. • Fractures, even if bilateral, should be treated with
traction and suspension of both legs with a spica cast.
• Casting is maintained for about four weeks.
• Complete healing without limb shortening is
expected.
24-Aug-22 by GA 57
Management
58. Hepatic injury
• Liver is the most commonly injured solid organ during
birth
• Risk factors include macrosomia, hepatomegally, and
breech presentation
• The etiology is thought to be direct pressure on the liver
24-Aug-22 by GA 58
Intra- abdominal injuries
59. • Sub capsular hematoma are not symptomatic at
birth
• Non specific signs of blood loss such as poor
feeding, pallor, tachypnea, tachycardia, and
onset of jaundice develop during first 1 – 3 days
of birth
• HCT decline may suggest blood loss
• Rupture of the hematoma results discoloration
of the abdominal wall and circulatory collapse
with shock
24-Aug-22 by GA 59
Clinical features
60. • Restoration of blood volume
• Correction of coagulation disturbances
• Surgical consultation for possible laparatomy
• Every diagnosis and correction of volume loss
increases survival
24-Aug-22 by GA 60
Management
61. • Risk factors include macrosomia, breech presentation
and splenomegally (eg- congenital syphilis,
erythroblastosis fetalis etc).
24-Aug-22 by GA 61
Splenic injury
62. • Similar with hepatic rupture
• A mass is sometimes palpable in the RUQ
24-Aug-22 by GA 62
Clinical features
63. • volume replacement and correction of coagulation
disorders
• Obtain surgical consultation
24-Aug-22 by GA 63
Management
64. • Birth injuries are common problem in neonate
• The common ones are as follow:
cephalohematoma
subgalialhemorrage
Erb’s palsy
Clavicular fractures
skull fracture
• subgalialhemorrage is the most sever form and
needs strict follow up for shock and severe anemia
and need proper management
24-Aug-22 by GA 64
Summery
65. • Nelson text book of pediatrics 19th ed.
• WHO. managing new born problems: a guide
for doctors, nurses, and mid wives. WHO
2003
• FANAROFF
• Manual of neonatal care,7th edk.
24-Aug-22 by GA 65
References
