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Common birth injuries part I

  1. 1. SKULL INJURIES AND SOFT TISSUE INJURIES Prepared by: Shraddha Dahal Roll no:25 B.Sc. Nursing 4th year
  2. 2. General Objective At the end of this session, B.Sc. Nursing 3rd year students will be able to explain about skull injuries and soft tissue injuries in newborn.
  3. 3. Specific Objectives At the end of this session, B.Sc. Nursing 3rd year students will be able to : • define birth injuries. • list out the risk factors for birth injuries. • list out the common birth injuries. • define skull injuries. • explain about caput succaedaneum. • explain about cephalohematoma.
  4. 4. • discuss about scalp injuries. • explain about skull fracture. • describe about intracranial injuries. • define soft tissue injuries. • explain the injury to skin and subcutaneous tissue. • explain about muscle trauma. • discuss about visceral injuries.
  5. 5. Birth Injuries  Birth injuries are an impairment of the infant’s body function or structure due to adverse influences that occurred at birth.  Birth injuries may be severe enough to cause neonatal deaths, still births or number of morbidities.
  6. 6. Risk Factors for Birth Injuries
  7. 7. Common Birth Injuries
  8. 8. Skull Injuries • Skull injuries are those injuries that impairs the structure of the skull and functions of the underlying organs in the skull. • The most common site of birth injury is head, because 96% babies are delivered by cephalic presentation.
  9. 9. I. Caput Succedaneum A caput succedaneum is an edematous swelling which forms normally in the soft tissues over the presenting part of the scalp due to infiltration of serosanguinous fluid by the pressure of girdle of contact.
  11. 11. Mechanism of Formation • It occurs due to compression of tissues in the girdle of contact which results interference of the venous return and lymphatic drainage from the unsupported area of scalp that causes stagnation of fluid and appearance of a swelling in the scalp.
  12. 12. CHIGNON
  13. 13. Clinical Features • It is present at or shortly after birth and doesn't tend to enlarge. • The swelling is diffuse , boggy, pits on pressure and may cross suture line.
  15. 15. Management • Reassure the mother that it disappears spontaneously within 2-3 days after birth, therefore no special care is needed. • Advice the woman and family to avoid applying pressure on caput and to return for care if signs and symptoms worsen or danger signs arise.
  16. 16. II. Cephalohematoma It is a subperiosteal collection of blood in between the pericranium/periosteum and the flat bone of the skull, usually unilateral and over a parietal bone.
  18. 18. Causes It is due to rupture of a small vein from the skull that may be from : • Friction between bones of maternal pelvis and fetal skull as in cephalopelvic disproportion or precipitate labour. • Complicated or forceps delivery but may also be seen following normal delivery and may be associated with fracture of the skull bone
  19. 19. Clinical Features • The swelling is usually never at birth, gradually develops a few hours after birth and may persist for weeks. • It is circumscribed, incompressible and never crosses the suture line.
  21. 21. ……contd • The overlying scalp may show discolouration. • The condition may be confused with caput succedaneum or meningocele. Meningocele lies over a suture line or fontanelle and there is impulse on crying. • Rarely suppuration occurs.
  22. 22. Management • No active treatment is necessary unless it becomes infected or complicated. • A head CT should be obtained if neurological symptoms are present. • Vitamin K 1-2 mg IM should be given to correct any co-existant coagulation defect.
  23. 23. ……..contd • In case of infected hematoma, the condition is treated with incision and drainage, systematic antibiotics and monitoring of hematocrit and bilirubin level. • Advice the woman and family to avoid hot compress by using oil and to return for care if signs and symptoms worsen or danger signs arise.
  24. 24. III. Scalp Injuries Scalp injuries are those injuries that are characterized by impairment in integrity of the scalp tissue.
  25. 25. Causes • Forceps delivery (tip of the blades) • Incised wound inflicted during cesarean section • Scalp-electrode placement • Episiotomy
  26. 26. Management • The wound should be dressed with an antiseptic solution like 2% mercurochrome. • On occasion, the incised wound may cause brisk hemorrhage and requires stitches.
  27. 27. IV. Skull Fracture Fracture of the vault of the skull (frontal bone or anterior part of the parietal bone) is defined as distortion in the continuity of skull bone which may be of fissure/linear or depressed type.
  30. 30. Causes • Effect of difficult forceps delivery or due to wrong application of forceps. • Projected sacral promontory of the flat pelvis.
  31. 31. Clinical Features • Fissure fracture if uncomplicated is usually symptomless. • Depressed fracture may be associated with neurological manifestations. • Signs of associated complications such as intracranial hemorrhage, raised intracranial pressure, leakage of CSF.
  32. 32. Diagnosis • History of type of delivery, other injuries to head during birth. • Physical examination • X-ray can confirm diagnosis.
  33. 33. Management • Linear or fissure fracture requires no treatment. • Depressed fracture may require surgical elevation. • If there is leakage of cerebral fluid through nose, antibiotic therapy is indicated.
  35. 35. V. Intracranial Injuries Intracranial injuries are the injuries to the structures inside the cranium during the process of the birth that is characterized by abnormal neurological manifestations within first 48 hours of life.
  36. 36. Types of Intracranial Hemorrhage Intracranial Hemorrhage (ICH) Traumatic ICH Extradural Hemorrhage Subdural Hemorrhage Anoxic ICH Intraventricular Hemorrhage Subarachnoid Hemorrhage Intracerebral Hemorrhage
  37. 37. 1. Traumatic Intracranial Hemorrhage It is defined as hemorrhage inside cranium due to trauma and it can be extradural or subdural hemorrhage.  Extradural hemorrhage: It is defined as hemorrhage in space between cranial bones and outer layer of duramater. It is usually associated with fractured skull bone.
  39. 39. …..contd Subdural hemorrhage: It is defined as hemorrhage in the space between arachnoid mater and inner layer of duramater.  Slight subdural hemorrhage may occur following fracture of skull bone ,rupture of the inferior sagittal sinus and rupture of small veins leaving the cortex.
  40. 40. ……contd  Massive subdural hemorrhage usually results from tear of tentorium cerebelli thereby opening up the straight sinus and injury to superior sagittal sinus.
  41. 41. Causes of Traumatic ICH • Excessive moulding in deflexed vertex.
  42. 42. • Rapid compression of the head during delivery of the after-coming head of breech or in precipitate labor.
  43. 43. • Forcible forceps traction following wrong application of the blades
  44. 44. Clinical Features of Traumatic ICH • The hemorrhage may be fatal and the baby is delivered stillborn or with severe respiratory depression(APGAR score:0-3). • Gradually, the features of cerebral irritation appear. • Hydrocephalus and mental retardation may be a late sequelae.
  45. 45. 2. Anoxic Intracranial Hemorrhage • It is defined as hemorrhage inside the cranium due to perinatal asphyxia, trauma and ischemia. • It can be intraventricular, subarachnoid and intracerebral.
  46. 46. ANOXIC ICH
  47. 47. ……contd • Causes : Perinatal asphyxia, trauma and ischemia • Clinical features:  Altered level of consciousness  Focal neurological defecits  Seizures
  48. 48. Diagnosis of ICH • Doppler ultrasonography can detect any change in cerebral circulation. • CT scan is useful to detect cortical neuronal injury. • Magnetic resonance imaging (MRI) is used to evaluate any hypoxic ischemic brain injury. • CSF analysis: Elevated RBCs, WBCs and protein.
  49. 49. Management of ICH • The baby should be nursed in quiet ,warm and well ventilated environment. • Maintain cleanliness of the air passage, suction immediately after birth to remove the secretion that occludes the pharynx. And supply oxygen as necessary. • Frequently monitor the baby for skin colour, vital signs and neurological manifestations.
  50. 50. …..contd • Feeding by nasogastric tube is advisable, fluid balance is to be maintained, if necessary by parenteral route. • Administer Vitamin K 1mg IM to prevent further bleeding due to hypoprothrombinaemia. • Prophylactic antibiotics are to be administered. • Anticonvulsants like phenobarbitone, phenytoin and diazepam can be given for seizures.
  51. 51. ……contd • Surgical management:  Surgical evacuation of hematoma • Subdural tapping and extradural tapping • Open surgical evacuation Rarely ventricular- peritoneal shunt and subdural-peritoneal shunt is required.
  52. 52. Prognosis of ICH Prognosis depends on the severity of ICH, brain lesions, birth weight and gestational age of the infant. ICH is having poor prognosis with high mortality. Survivors may develop mental retardation and neurological disorders.
  53. 53. 2. Soft Tissue Injuries Soft tissue injuries are the injuries to skin, subcutaneous tissues, muscles and visceral organs due to some degree of disproportion between the presenting part and the maternal pelvis during the birth process and also from forcep blades, vacuum extractor cups, scalp electrodes and scalpels.
  54. 54. A. Injury to Skin and Subcutaneous Tissue  Erythema and abrasions: Erythema and abrasion during birth are superficial reddening of the skin with impaired integrity that usually are the result of the application of forceps, discoloration is same configuration as the instrument.
  55. 55. ….contd • Petechiae: Non raised pinpoint hemorrhages( less than 3mm in diameter) caused by a sudden increase and then release of pressure during passage through birth canal are called petechiae. It may be seen on the chest, face and head. • Ecchymosis: Ecchymosis are small hemorrhagic areas( greater than 10 mm in diameter) that may occur after traumatic or breech delivery.
  57. 57. ……contd • Subconjunctival (scleral) hemorrhage: It is defined as the collection of blood between the sclera and conjunctiva due to rupture of capillaries in the sclera from pressure on the fetal head during delivery and the most common location is the limbus of iris.
  59. 59. Management • Spontaneous recovery occurs within 2 to 3 days. • Abrasions and lacerations should be kept clean and dry. • Local application of antiseptic lotion can prevent infection of the area. • If there is any indication of infection, medical advice should be sought and antibiotics may be required. • Deeper lacerations may require closure with suture materials. • Explain to the mother to bring the baby back if she sees signs of local infections.
  60. 60. B. Muscle Trauma  Injury to muscle are those trauma to muscle that can occur when it is torn or when its blood supply is disrupted.  Torticollis and sternomastoid hematoma are common muscle trauma during birth.
  61. 61. ….contd 1. Torticollis Torticollis or twisted neck is defined as damage and spasm of sternomastoid muscle during the birth of the anterior shoulder when the fetus presents by the vertex or during rotation of the shoulders when the fetus is being born by breech.
  62. 62. …..contd  Clinical features: The head tilts towards the affected side constantly and the chin points towards one shoulder. One shoulder may be higher in the body than the other shoulder. Neck muscle swelling right after the birth.
  64. 64.  Management: Muscle stretching exercises and neck braces. The uncomplicated swelling will resolve within 7-10 days. If it doesn't resolve even after 6 months of muscle stretching exercise then muscle release surgery is required.
  66. 66. …..contd 2. Sternomastoid hematoma It is sternomastoid muscle injury caused by rupture of the muscle fibers and blood vessels, followed by a hematoma and cicatrical contraction and may be associated with difficult breech delivery or attempted delivery following shoulder dystocia or excessive lateral flexion of the neck even during normal delivery .
  68. 68. …..contd  Clinical Features: It usually appears few days after birth and is usually situated at the mid position of the muscle. Small moderately dense or rather small consistency of mass of with the size of walnut appears There is transient torticollis.  Management: Muscle stretching exercises. Surgery is indicated if hematoma fails to get reabsorbed.
  69. 69. C. Visceral Injuries • Injuries to organs like liver, spleen ,kidney, adrenals or lungs are called visceral injuries . • Visceral organs are commonly injured during breech delivery. • The most common result of the injury is hemorrhage. The hemorrhage may remain concealed as subcapsular hematoma or capsule may rupture with the blood flowing into peritoneal cavity. Prognosis is usually poor.
  71. 71. …….contd  Clinical Features: Pallor , tachycardia, shock and symptoms according to the organs being injured.  Management: • Correction of hypovolemia, anemia and coagulation disorders. • Management may be needed to repair injured viscera surgically .
  72. 72. Any Queries???
  73. 73. References • Subedi, D.,& Gautam ,S.(2017) .Midwifery nursing part III ( 3rd ed.). Medhavi Publication ,Baneshwor, Kathmandu,Nepal (pp:334-344). • Koner,H.(Eds.).(2013).DC Dutta's textbook of obstetrics(7th ed.).Jaypee brothers medical publishers,New Delhi,India(pp:483- 486). • Sharma,R. (2013). Essential Paediatrics for Nurses( 2nd ed.). Jyapee Brothers Medical Publisher , New Delhi,India( pp:199-200). • Jacob, A.(2012). Comprehensive textbook of midwifery and gynaecological nursing(3rd ed.). Jaypee brothers medical publishers,New Delhi, India (pp:513-519). • Thakur, L .(2012).Advanced child health nursing (3rd ed.).Ultimate Marketing ,Lazimpat ,Kathmandu,Nepal (pp: 52-54). • Managing newborn problems.(2003).Geneva: Department of reproductive health and research,WHO.
  74. 74. THANK YOU