Neonatal birth trauma power point

1. Birth Trauma
By Gadisa T
5/9/2023
Birth trauma by Gadisa T 1

2. Objectives
At the end of this presentation you will be able to:
 Discus different types of birth trauma
 understand the risk and cause of birth trauma
 Diagnose different types of birth trauma
Investigate and Manage Birth trauma
List complication of birth trauma
5/9/2023
Birth trauma by Gadisa T 2

3. BIRTH TRAUMA
Introduction
 Birth trauma is a neonatal injury caused by prolonged,obstructed labor
and difficult instrumental deliveries.
They may be avoidable .
 It is a common problem with significant neonatal morbidity and mortality.
most common neonatal injuries affect a baby’s head, neck, and shoulders .
with an average of 6-8 injures per 1000 live birth.
In Ethiopia tertiary referral hospital 3.26 per1000 live birth,83.9% vaginal delivery
and 16.1% c/s delivery.
5/9/2023
Birth trauma by Gadisa T 3

4. Risk Factors
 Maternal factor ; premigravida ,cephalo pelvic disproportion ,Small
maternal height
 Fetal factor ; low birth weight, Fetal macrosomia or large fetal head, Mal
presentation and malposition ,fetal anomalies.
 Delivery factor; Prolonged or precipitated labour ,Instrumental delivery,
Versions and extraction.
5/9/2023
Birth trauma by Gadisa T 4

5. Types of birth trauma
Head injury
 caput succedaneum
Cephalhematoma
subgaleal hematoma
skull fracture
Brachial plexus injury
 Erb’s palsy
 Klumpke’s palsy
Facial nerve injury
Laryngeal nerve injury
Bone injury
 clavicular fracture
 long bone fracture
Intra abdominal injuries
 Hepatic injury
 Splenic injury
5/9/2023
Birth trauma by Gadisa T
5

6. Head trauma
Head trauma can include superficial lesions, exteracranial and intracranial
hemorrhages, and fractures of the skull bone.
Caput succedaneum
• It is a commonly occurring subcutaneous extra periosteal fluid collection that
is occasionally hemorrhagic.
• It has poorly defined margins and can extend over the midline and across suture lines.
5/9/2023
Birth trauma by Gadisa T 6

7. Caput succedaneum....
• 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.
• Dx ,clinical
• Mgt, not needed
5/9/2023
Birth trauma by Gadisa T 7

8. Caput succedaneum
5/9/2023
Birth trauma by Gadisa T 8

9. Cephalhematoma
It is a sub periosteal collection of blood resulting from rupture of the
superficial veins between the skull and periosteum.
 It is always confined by suture lines and cannot cross the suture lines.
Extensive cephalhematoma 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.
5/9/2023
Birth trauma by Gadisa T 9

10. Cephalhematoma
5/9/2023
Birth trauma by Gadisa T 10

11. Cephalhematoma....
• Management:-
- Observation in most cases
- Incision and aspiration is contraindicated.
- Anemia and jaundice should be treated as needed
5/9/2023
Birth trauma by Gadisa T 11

12. Subgaleal hemorrhage
 It is Collection of blood in the soft tissue space between the aponeurosis and the
periosteum of the skull .
 subaponeurotic space extends from the orbital ridges to the nap of the
neck and laterally to the ears.
 The hemorrhage can spread across the entire calvarium.
 The clinical presentation typically includes pallor, poor tone, and a fluctuant
swelling
on the scalp which cross the suture lines and fontanels.
 The hematoma may grow slowly or increase rapidly and result in shock.
5/9/2023
Birth trauma by Gadisa T 12

13. Subgaleal hemorrhage.....
 With progressive spread the ears may be displaced anteriorly and periorbital
swelling can occur.
 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.
5/9/2023
Birth trauma by Gadisa T 13

14. Subgaleal hemorrhage.....
5/9/2023
Birth trauma by Gadisa T 14

15. Subgaleal hemorrhage.....
• Management
1. New born with this lesion should be admitted
2. Assess and treat shock
3. Daily HC measurement and HCT follow-up
4. Minimize manipulation because it is painful
5. Manage anemia and jaundice if needed.
• N.B.: SGH should be considered in infants who show signs of
hypoperfusion and falling Hct after attempted or successful vacuum
delivery, even in the absence of a detectable fluctuant mass.
5/9/2023
Birth trauma by Gadisa T 15

16. Skull fracture
 Skull fracture may be either linear or depressed
 Depressed skull fractures are usually associated with forceps use
 Most infants are asymptomatic unless there is an associated intracranial
hemorrhage (eg, subdural or subarachnoid hemorrhage)
diagnosis
 made by skull X-ray
 If there is suspicion of intracranial injury or neurologic symptoms Head CT scan
or MRI is recommended.
5/9/2023
Birth trauma by Gadisa T 16

17. Skull fracture.....
Management
 Uncomplicated linear fractures usually requires no therapy.
 Depressed fractures require neurological evaluation for possible elevation needed.
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
5/9/2023
Birth trauma by Gadisa T 17

18. Brachial plexus injury
• 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.
5/9/2023
Birth trauma by Gadisa T 18

19. Erb’s palsy
 Involves the upper trunks (C5,C6 and occasionally C7) and is the most common
type of brachial plexus injury.
Clinical presentation
• 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 is absent on the affected side
• The grasp reflex is intact and sensation is variably affected 5/9/2023
Birth trauma by Gadisa T
19

20. Kulmpke’s palsy
• 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 .
Management of brachial plexus injury
 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.
5/9/2023
Birth trauma by Gadisa T
20

21. 5/9/2023
Birth trauma by Gadisa T 21

22. Prognosis
 clinical improvement in the first two weeks indicates that normal or near normal
function will return.
 Most infants full recovery.
 Most infants recover fully by three months of age.
 Recovery varies with the extent of injury.
 If the nerve roots are intact and not avulsed, prognosis for full recovery is excellent.
 In case with slow recovery, electromyography and nerve conduction studies are indicated.
5/9/2023
Birth trauma by Gadisa T 22

23. Phrenic nerve injury (C3, 4 or 5 )
• Phrenic nerve injury leading to paralysis of the ipsilateral diaphragm may result from
stretch injury due to lateral hyperextension of the neck at birth.
• Risk factors include breech and difficult forceps deliveries
• At least 75%of patients also have brachial plexus injury
Clinical features
• Respiratory distress and cyanosis
• Some infants present with persistent tachypnea and decreased breath sounds at the
affected side.
• There may be decreased movement of the affected hemi thorax 5/9/2023
Birth trauma by Gadisa T
23

24. Diagnosis
• confirmed by U/S that shows paradoxical (upward) movement of the diaphragm
with inspiration
• C-X-ray may show elevation of the affected hemi thorax
Management
 the initial treatment is supportive
 CPAP or mechanical ventilation may be needed
 Careful air way care to avoid atelectasis and pneumonia
5/9/2023
Birth trauma by Gadisa T 24

25. Facial Nerve injury
 Is the most common cranial nerve injured with a traumatic
birth.
it occurs in up to 10 per 1000 live birth
 usually a result of pressure on the facial nerve by forceps or from a prominent
maternal sacral promontory during descent.
Clinical manifestations
 include diminished movement or loss of motion on the affected side of the face.
The prognosis in traumatic facial nerve injury is good, with
spontaneous resolution usually noted within the first few weeks of life. 5/9/2023
Birth trauma by Gadisa T
25

26. Facial Nerve injury
5/9/2023
Birth trauma by Gadisa T 26

27. Management
 observation
 provide the eye drop to lubricating
resolve with in a week if doesn't consult
5/9/2023
Birth trauma by Gadisa T 27
Facial Nerve injury.....

28. laryngeal Nerve injury
• Associated with abnormal intrauterine position and excessive lateral flexion
or traction or traction of head during delivery.
Clinical manifestations
baby will have a hoarse cry as well as inspiratory stridor due to inability to
open the vocal cord on the affected side.
There may also be problems with feeding.
Diagnosis
If suspected direct laryngoscopy
5/9/2023
Birth trauma by Gadisa T 28

29. Management
primary concern is feeding and risk of aspiration.
 Do smaller and risk more frequent feeing to reduce risk of aspiration.
 Typically self resolves within 4 to 6 wks.
5/9/2023
Birth trauma by Gadisa T 29

30. Bone injuries
Clavicular fracture
• 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.
5/9/2023
Birth trauma by Gadisa T 30

31. Con...
Clinical manifestations
 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 sternocleidomastoid muscle.
 The affected arm may have a pseudo paralysis because of pain on
movement.
 Absent Moro reflex on the involved side
5/9/2023
Birth trauma by Gadisa T 31

32. Con...
Diagnosis
 An x-ray confirms the diagnosis.
Management-
• decreasing pain with analgesics.
• Immobilize the affected arm and shoulder for 7-10 days.
5/9/2023
Birth trauma by Gadisa T 32

33. Long bone injuries
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.
Clinical manifestations
 Loss of spontaneous arm movement on affected side
 Followed by swelling and pain on passive motion
5/9/2023
Birth trauma by Gadisa T 33

34. Con...
Diagnosis
Confirmed by x-ray of the affected arm
Management-
The fractured humorous requires splinting for two weeks
 Displaced fracture require closed reduction and casting
Prognosis
complete healing is expected with the above managements
5/9/2023
Birth trauma by Gadisa T 34

35. Con...
Femoral fracture
This fracture follows usually a breech delivery
Clinical manifestations
 obvious deformity of the thigh and swelling of thigh
 decreased movement and pain on palpation or passive motion
5/9/2023
Birth trauma by Gadisa T 35

36. Con...
Diagnosis
• conformed by x-ray
Management-
• 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.
5/9/2023
Birth trauma by Gadisa T 36

37. Intra abdominal injuries
Hepatic injury
Liver is the most commonly injured solid organ during birth.
Risk factors include macrosomia, hepatomegaly, and breech
presentation.
The etiology is thought to be direct pressure on the liver .
5/9/2023
Birth trauma by Gadisa T 37

38. Con...
Clinical manifestations
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
 Serial HCT decline may suggest blood loss
 Rupture of the hematoma results discoloration of the abdominal wall and
circulatory collapse with shock
5/9/2023
Birth trauma by Gadisa T 38

39. Con...
Management-
Restoration of blood volume
 Correction of coagulation disturbances
 Surgical consultation for possible laparatomy
 Every diagnosis and correction of volume loss increases survival
5/9/2023
Birth trauma by Gadisa T 39

40. Con...
Splenic injury
 Risk factors include macrosomia, breech presentation and
splenomegally (eg- congenital syphilis, erythroblastosis fetalis etc).
Clinical manifestations
Similar with hepatic rupture
A mass is sometimes palpable in the RUQ
Management-
volume replacement and correction of coagulation disorders
 Obtain surgical consultation
5/9/2023
Birth trauma by Gadisa T
40

41. Summery
• 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
5/9/2023
Birth trauma by Gadisa T 41

42. 5/9/2023
Birth trauma by Gadisa T 42

43. References
• Nelson text book of pediatrics 20th ed.
• NICU nurses training manual,20014.
• Neonatal Care Pocket Guide for Hospital Physicians,2010
• WHO. managing new born problems: a guide for doctors, nurses, and mid wives.
WHO 2003
• Manual of neonatal care,7th ed.
5/9/2023
Birth trauma by Gadisa T 43