Common birth injuries

1. BIRTH INJURIES
By Okumu Atanas

2. DEFINITION
• An impairment of the infants body function
or structure due to adverse influences that
occur at birth

3. RISK FACTORS
• Primiparity
• Small maternal stature
• Maternal pelvic anomalies
• Prolonged or unusually rapid labor
• Oligohydramnios
• Malpresentation of the fetus

4. TYPES
• Head and neck injuries
• Nerve injury
• Facial injuries
• Fractures
• Intra-abdominal injury
• Soft tissue injuries

5. HEAD AND NECK INJURIES

6. EXTRACRANIAL INJURIES
• CAPUT SUCCEDANEUM
• CEPHALHEMATOMA
• SUBGALEAL HEMORRHAGE

8. CAPUT SUCCEDANEUM
• A caput succedaneum is a
serosanguinous fluid collection above the
periosteum. It presents as a soft tissue
swelling with purpura and ecchymosis
over the presenting portion of the scalp. It
may extend across the midline and across
suture lines.

9. • The edema disappears within the 1st few
days of life.
• Molding of the head and overriding of the
parietal bones disappear during the 1st
weeks of life.
• Rarely, a hemorrhagic caput may result in
shock and require blood transfusion.

10. MANAGEMENT
• No specific treatment is needed
• But if extensive ecchymoses are
present, hyperbilirubinemia may develop
• Shock – Blood transfusion

11. CEPHALHEMATOMA
• A cephalhematoma is a subperiosteal
blood collection caused by rupture of
vessels beneath the periosteum.

12. Clinical features
• Swelling, usually over a parietal or
occipital bone
• Swelling does not cross a suture line and
is often not associated with discoloration
of the overlying scalp.
• Limited to the surface of one cranial bone.

13. Diagnosis
• Physical examination
• Skull radiograph
• cranial computed tomography

14. • If infection is suspected, aspiration of the
mass
• If sepsis, antibiotics
• hyperbilirubinemia – photo therapy

16. SUBGALEAL HEMORRHAGE
• A subgaleal hemorrhage is bleeding
between the galea aponeurosis of the
scalp and the periosteum.

17. FEATURES
• A subgaleal hemorrhage presents as a
firm-to-fluctuant mass that crosses suture
lines.
• The mass is typically noted within 4 hours
of birth.

18. LABORATORY FINDINGS
• serial hemoglobin and hematocrit
monitoring,
• coagulation profile to investigate for the
presence of a coagulopathy.
• Bilirubin levels also need to be monitored

19. TREATMENT
• Supportive
• Transfusions may be required if blood loss
is significant.
• In severe cases, surgery may be required
to cauterize the bleeding vessels.
• These lesions typically resolve over a 2–3
week period

20. CRANIAL INJURIES
• LINEAR SKULL FRACTURES
• DEPRESSED SKULL FRACTURES

21. LINEAR SKULL FRACTURES
• Usually affect the parietal bones.
• The pathogenesis is related to
compression from the application of
forceps, or from the skull pushing against
the maternal symphysis or ischeal spines.
• Rarely, a linear fracture may be
associated with a dural tear, with
subsequent development of a
leptomeningeal cyst.

22. DEPRESSED SKULL FRACTURES
• Indications for surgery include
• radiographic evidence of bone
fragments in the cerebrum
• presence of neurologic deficits
• signs of increased intracranial pressure
• signs of cerebrospinal fluid beneath the
galea
• failure to respond to closed manipulation.

23. • Indications for nonsurgical management
include
• Depressions less than 2 cm in width and
depressions over a major venous sinus
• Without neurologic symptoms

24. INTRACRANIAL INJURY
• Intracranial haemorrhage
• Epidural hemorrhage
• Subdural hemorrhage
• Subarachnoid hemorrhage
• Intraparenchymal haemorrhage
• Germinal matrix hemorrhage /
intraventricular haemorrhage

26. INTRACRANIAL HAEMORRHAGE
• Bleeding can occur
– External to the brain into the
epidural, subdural or subarachnoid space
– In to the parenchyma of the cerebrum or
cerebellum
– Into the ventricles from the subependymal
germinal matrix or choroid plexus

27. RISK FACTORS
• forceps delivery
• vacuum extraction
• precipitous deliver
• prolonged second stage of labor
• macrosomia

28. SYMPTOMS
• apnea
• seizures

29. EPIDURAL HEMORRHAGE
• Epidural hemorrhage primarily arises from
injury to the middle meningeal artery, and
is frequently associated with a
cephalhematoma or skull fracture.

30. CLINICAL MANIFESTATIONS
• Diffuse neurologic symptoms
• Increased intracranial pressure
• Bulging fontanels
• Localized symptoms,
• Lateralizing seizures
• Eye deviation.

31. DIAGNOSIS
• cranial computed tomography showing a
high-density lentiform lesion in the
temporoparietal region
• Skull radiographs

32. MANAGEMENT
• Surgical management
• Aspiration of blood from the accompanying
cephalhaematoma

33. SUBDURAL HEMORRHAGE
• most frequent intracranial hemorrhage
related to birth trauma

34. • Laceration of the tentorium, with rupture of
the straight sinus, vein of Galen transverse
sinus, or infratentorial veins causing a
posterior fossa clot and brainstem
compression
• Laceration of the falx, with rupture of the
inferior sagittal sinus resulting in a clot in
the longitudinal cerebral fissure

35. • Laceration of the superficial cerebral
vein, causing bleeding over the cerebral
convexity
• Occipital osteodiastasis, with rupture of
the occipital sinus, resulting in a posterior
fossa clot

36. CLINICAL FEATURES
• Respiratory symptoms such as apnea
• Seizures
• Focal neurologic deficits
• Lethargy
• Hypotonia
• Other neurologic symptoms

37. DIAGNOSIS
• Cranial computed tomography
• Cranial ultrasonography
• MRI.
• Coagulation profile

38. SUBARACHNOID HEMORRHAGE
• Subarachnoid hemorrhage is caused by
rupture of the bridging veins of the
subarachnoid space or small
leptomeningeal vessels

39. MANIFESTATIONS
• Seizures, often occurring on the second
day of life
• Irritability
• Depressed level of consciousness
• Focal neurologic signs.

40. DIAGNOSIS
• Cranial computed tomography.
• Cranial ultrasonography
• Lumbar puncture shows an increased
number of red blood cells

41. MANAGEMENT
• Resolves without intervention
• Monitoring head growth

42. INTRAPARENCHYMAL
HAEMORRHAGE
• TYPES
• Intra cerebral
Causes:
• rupture of an av malformation or aneurysm
• coagulation disturbances
• extracorporeal membrane oxygenation
therapy
• secondary to a large ICH in any other
compartment

43. • Intracerebellar :
more common in preterm than the
term babies. May be a primary
haemorrhage or may result from venous
hemorrhagic infarction or from extension
of GMH/ IVH

44. CLINICAL FEATURES
• In the preterm infant
– IPH is often clinically silent in either
intracranial fossa , unless the hemorrhage is
quite large
• In the term infant, manifestations are
– Seizures
– Hemiparesis
– Gaze preference
– Irritability
– Depressed level of consciousness

45. DIAGNOSIS
• CT Scans
• MRI
• Cranial ultrasonography

46. MANAGEMENT
• Symptomatic treatment and support
• Neurosurgical intervention

47. GERMINAL MATRIX
HEMORRHAGE
(INTRAVENTRICULAR HAEMORRHAGE)
• Causes:
• Trauma,
• Perinatal asphyxia
• Secondary to venous hemorrhagic
infarction in the thalamus

48. FACTORS IN THE PATHOGENESIS
• Intra vascular factors
– Ischemia / reperfusion
– Fluctuating cerebral blood flow
– Increase in CBF
– Increase in cerebral venous pressure
– Platelet dysfunction
– Coagulation disturbances

49. • Vascular factors
– Tenuous involuting capillaries with large
diameter lumen
• Extra vascular factors
– Deficient vascular support
– Excessive fibrinolytic activity

50. CLINICAL FEATURES
In the preterm newborn
• Usually clinically silent
• Decreased levels of consciousness and
spontaneous movement
• Hypotonia
• Abnormal eye movement
• Skew deviation

51. In term newborns
• Seizures
• Irritability
• Apnea
• Lethargy
• Vomiting with dehydration
• Full fontanels

52. DIAGNOSIS
• Cranial ultra sonography
• CT or MRI

53. MANAGEMENT
• Prevention
• Supportive care
• Careful monitoring
• Surgical intervention

54. NERVE INJURY

55. BRACHIAL PLEXUS INJURY
• Erb’s palsy
• Klumpke’spalsy
• Injury to the upper plexus,
• Erb-Duchenne paralysis

56. BRACHIAL PLEXUS INJURY
• Risk factors
• Macrosomia
• shoulder dystocia
• instrumented deliveries
• malpresentation

57. ERB-DUCHENNE PARALYSIS
• 5th and 6th cervical nerves injury
• The infant loses the power to abduct the
arm from the shoulder, rotate the arm
externally, and supinate the forearm
• Erb’s palsy may also be associated with
injury to the phrenic nerve,
which is innervated with
fibers from C3–C5

58. • Adduction and internal rotation of the arm
with pronation of the forearm.
• Biceps reflex is absent
• Moro reflex is absent on the affected side.
• The involved arm is held in the ‘‘waiter’s
tip’’ position, with adduction and internal
rotation of the shoulder, extension of the
elbow, pronation of the forearm, and
flexion of the wrist and fingers.

59. KLUMPKE’SPALSY
• Involves the C8 and T1 nerves, resulting in
weakness of the intrinsic hand muscles
and long flexors of the wrist and fingers

60. • The grasp reflex is absent but the biceps
reflex is present.
• Flaccid extremity with absent reflexes.

61. ASSOCIATED LESIONS
• Hematomas of the sternocleidomastoid
muscle, and fractures of the clavicle and
humerus.
• Ipsilateral Horner’s syndrome
(ptosis, miosis, and anhydrosis) when
there is accompanying injury to the
sympathetic fibers of T1.

62. TYPES
• Neuropraxia with temporary conduction
block
• Axonotmesis with a severed axon, but with
intact surrounding neuronal elements
• Neurotmesis with complete postganglionic
disruption of the nerve
• Avulsion with preganglionic disconnection
from the spinal cord

63. DIAGNOSIS
• Physical examination.
• Radiographs of the shoulder and upper
arm

64. MANAGEMENT
• Initial treatment is conservative.
• The arm is immobilized across the upper
abdomen during the first week
• Physical therapy with passive range-of-
motion exercises at the shoulder, elbow
and wrist should begin after the first week.
• Infants without recovery by 3 to 6 months
of age may be considered for surgical
exploration

65. FACIAL NERVE PALSY
(BELL’S PALSY)
• Risk factors
– forceps delivery
– prolonged second stage of labor

66. Clinical manifestations
• weakness of both upper and lower facial
muscles.
• At rest, the nasolabial fold is flattened and
the eye remains persistently open on the
affected side.
• During crying, there is inability to wrinkle
the forehead or close the eye on the
ipsilateral side, and the mouth is drawn
awayfrom the affected side.

67. • lacerations and bruising
• neurologic findings

68. TREATMENT
• protection of the involved eye by
application of artificial tears and taping to
prevent corneal injury.
• neurosurgical repair of the nerve should
be considered only after lack of resolution
during 1 year of observation

69. PHRENIC NERVE INJURY
• The phrenic nerve arises from the third
through fifth cervical nerve roots.
• Injury to the phrenic nerve leads to
paralysis of the ipsilateral diaphragm.

70. CLINICAL MANIFESTATIONS
• respiratory distress, with diminished breath
sounds on the affected side.
• Chest radiographs show elevation of the
affected diaphragm, with mediastinal shift
to the contralateral side.
• Ultrasonography or fluoroscopy can
confirm the diagnosis by showing
paradoxical diaphragmatic movement
during inspiration

71. TREATMENT
• Initial treatment is supportive
• Oxygen
• Respiratory failure may be treated with
continuous positive airway pressure or
mechanical ventilation.
• Gavage feedings.
• Plication of the diaphragm

72. LARYNGEAL NERVE INJURY
• Symptoms
• Stridor
• respiratory distress
• hoarse cry
• dysphagia,
• Aspiration

73. • Diagnosis is made by direct
laryngoscopy

74. Treatment
• Small frequent feedings may be required
to decrease the risk of aspiration.
• Intubation
• Tracheostomy
• Bilateral paralysis tends to produce more
severe distress, and therefore requires
intubation and tracheostomy placement
more frequently

75. SPINAL CORD INJURY
• Clinical findings
• decreased or absent spontaneous
movement
• absent deep tendon reflexes
• absent or periodic breathing
• lack of response to painful stimuli below
the level of the lesion.

76. • Lesions above C4 are almost always
associated with apnea
• Lesions between C4 and T4 may have
respiratory distress secondary to varying
degrees of involvement of the phrenic
nerve and innervation to the intercostal
muscles

77. MANAGEMENT
• If cord injury is suspected in the delivery
room, the head, neck, and spine should be
immobilized.
• Therapy is supportive.

78. FACIAL INJURIES

79. NASAL SEPTAL
DISLOCATION
• Nasal septal dislocation involves
dislocation of the triangular cartilaginous
portion of the septum from the vomerine
groove

80. CLINICAL FEATURES
• airway obstruction.
• deviation of the nose to one side
• The nares are asymmetric, with flattening
of the side of the dislocation (Metzenbaum
sign).
• Application of pressure on the tip of the
nose (Jeppesen and Windfeld test) causes
collapse of the nostrils, and the deviated
septum becomes more apparent.

81. MANAGEMENT
• Definitive diagnosis can be made by
rhinoscopy
• manual reduction performed by an
otolaryngologist using a nasal elevator.
• Reduction should be performed by 3 days
of age

82. OCULAR INJURIES
• Rupture of Descemet’s membrane of the
cornea
• lid lacerations
• hyphema (blood in anterior chamber)
• vitreous hemorrhage
• Purtscher’s retinopathy
• corneal edema,
• corneal abrasion

83. CONGENITAL MUSCULAR
TORTICOLLIS
• atrophic muscle fibers surrounded by
collagen and fibroblasts.
• tearing of the muscle fibers or fascial
sheath with hematoma formation and
subsequent fibrosis.

84. CLINICAL FEATURES
• The head is tilted toward the side of the
lesion and rotated to the contralateral side,
• chin is slightly elevated.
• If a mass is present, it is firm, spindle-
shaped, immobile, and located in the
midportion of the sternocleidomastoid
muscle, without accompanying
discoloration or inflammation.

85. DIAGNOSIS
• physical examination
• Radiographs should be obtained to rule
out abnormalities of the cervical spine.
• Ultrasonography may be useful both
diagnostically and prognostically.

86. TREATMENT
• active and passive stretching
• surgery

87. FRACTURES

88. CLAVICULAR FRACTURE
• clavicle is the most frequently fractured
bone during birth

89. Risk factors
• higher birth weight
• prolonged second stage of labor
• shoulder dystocia
• instrumented deliveries

90. MANAGEMENT
• Asymptomatic incomplete fractures require
no treatment.
• Complete fractures are treated with
immobilization of the arm for 7 to 10 days

91. LONG BONE FRACTURES
Risk factors
• breech presentation
• cesarean delivery
• low birthweight

92. CLINICAL FEATURES
• decreased movement of the affected
extremity, swelling, pain with passive
movement, and crepitus

93. DIAGNOSIS
• Diagnosis is made radiographically
• Ultrasonography

94. TREATMENT
• immobilization and splinting
• Closed reduction and casting are required
only when the bones are displaced.
• Proximal femoral fractures may require a
spica cast or use of a Pavlik harness

95. INTRA-ABDOMINAL INJURY
Liver injury is the most common
• Three potential mechanisms lead to intra-
abdominal injury:
• (1) direct trauma,
• (2) compression of the chest against the
surface of the spleen or liver
• (3) chest compression leading to tearing of
the ligamentaous insertions of the liver or
spleen

96. CLINICAL MANIFESTATIONS
• With hepatic or splenic rupture, patients
develop sudden pallor, hemorrhagic
shock, abdominal distention, and
abdominal discoloration.
• Presentation of a liver rupture with scrotal
swelling and discoloration has been
described.

97. • Subcapsular hematomas may present
more insidiously, with anemia, poor
feeding, tachypnea, and tachycardia.
• Adrenal hemorrhage may present as a
flank mass

98. DIAGNOSIS
• abdominal ultrasound
• Computed tomography
• Abdominal radiographs may show
nonspecific intraperitoneal fluid or
hepatomegaly.
• Abdominal paracentesis is diagnostic if a
hemoperitoneum is present

99. TREATMENT
• volume replacement and correction of any
coagulopathy.
• If the infant is hemodynamically
stable, conservative management is
indicated.
• With rupture or hemodynamic instability, a
laparotomy is required to control the
bleeding.
• Patients with adrenal hemorrhage may
require hormone replacement therapy.

100. SOFT TISSUE INJURIES
• Petechiae and ecchymoses
• Lacerations and abrasions
• Subcutaneous fat necrosis

101. Assignment
• What are some of the nursing diagnoses related to birth injuries?
• What nursing care would you offer to a newborn with caput
succedaneum?