birth injuries in children

1. BIRTH INJURIES
Payal Gakhar
I Year MSc Nursing

2. DEFINITION
 An impairment of the infants body function
or structure due to adverse influences that
occur at birth
 (National vital statistics report)

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

4.  Use of mid forceps or vaccum
extraction
 Versions and extractions
 Very low birth weight or extreme
prematurity
 Fetal macrosomia or large fetal head
 Fetal anomalies

5. TYPES
 Head and neck injuries
 Nerve injury
 Facial injuries
 Fractures
 Intra-abdominal injury
 Soft tissue injuries

6. HEAD AND NECK INJURIES

7. EXTRACRANIAL INJURIES
 CAPUT SUCCEDANEUM
• CEPHALHEMATOMA
• SUBGALEAL HEMORRHAGE

9. 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.

10.  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.

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

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

13. 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.

14. Diagnosis
 Physical examination
 Skull radiograph
 cranial computed tomography

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

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

18. 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.

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

20. 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

21. CRANIAL INJURIES
 LINEAR SKULL FRACTURES
• DEPRESSED SKULL FRACTURES

22. 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.

23. 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.

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

25. INTRACRANIAL INJURY
 Intracranial haemorrhage
 Epidural hemorrhage
 Subdural hemorrhage
 Subarachnoid hemorrhage
 Intraparenchymal haemorrhage
 Germinal matrix hemorrhage /
intraventricular haemorrhage

27. 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

28. RISK FACTORS
 forceps delivery
 vacuum extraction
 precipitous deliver
 prolonged second stage of labor
 macrosomia

29. SYMPTOMS
 apnea
 seizures

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

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

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

33. MANAGEMENT
 Surgical management
 Aspiration of blood from the accompanying
cephalhaematoma

34. SUBDURAL HEMORRHAGE
 most frequent intracranial hemorrhage
related to birth trauma

35.  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

36.  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

37. CLINICAL FEATURES
 Respiratory symptoms such as apnea
 Seizures
 Focal neurologic deficits
 Lethargy
 Hypotonia
 Other neurologic symptoms

38. DIAGNOSIS
 Cranial computed tomography
 Cranial ultrasonography
 MRI.
 Coagulation profile

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

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

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

42. MANAGEMENT
 Resolves without intervention
• Monitoring head growth

43. 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

44.  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

45. 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

46. DIAGNOSIS
 CT Scans
 MRI
 Cranial ultrasonography

47. MANAGEMENT
 Symptomatic treatment and support
 Neurosurgical intervention

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

49. 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

50.  Vascular factors
 Tenuous involuting capillaries with large
diameter lumen
 Extra vascular factors
 Deficient vascular support
 Excessive fibrinolytic activity

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

52. In term newborns
 Seizures
 Irritability
 Apnea
 Lethargy
 Vomiting with dehydration
 Full fontanels

53. DIAGNOSIS
 Cranial ultra sonography
 CT or MRI

54. MANAGEMENT
 Prevention
 Supportive care
 Careful monitoring
 Surgical intervention

55. NERVE INJURY

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

57. BRACHIAL PLEXUS INJURY
 Risk factors
 Macrosomia
 shoulder dystocia
 instrumented deliveries
 malpresentation

58. 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

59.  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.

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

61.  The grasp reflex is absent but the biceps
reflex is present.
 Flaccid extremity with absent reflexes.

62. 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.

63. 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

64. DIAGNOSIS
 Physical examination.
 Radiographs of the shoulder and upper
arm

65. 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

66. FACIAL NERVE PALSY
(BELL’S PALSY)
 Risk factors
 forceps delivery
 prolonged second stage of labor

67. 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.

68.  lacerations and bruising
 neurologic findings

69. 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

70. 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.

71. 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

72. 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

73. LARYNGEAL NERVE INJURY
 Symptoms
 Stridor
 respiratory distress
 hoarse cry
 dysphagia,
 Aspiration

74.  Diagnosis is made by direct
laryngoscopy

75. 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

76. 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.

77.  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

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

79. FACIAL INJURIES

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

81. 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.

82. 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

83. 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

84. 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.

85. 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.

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

87. TREATMENT
 active and passive stretching
 surgery

88. FRACTURES

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

90. Risk factors
 higher birth weight
 prolonged second stage of labor
 shoulder dystocia
 instrumented deliveries

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

92. LONG BONE FRACTURES
Risk factors
 breech presentation
 cesarean delivery
 low birthweight

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

94. DIAGNOSIS
 Diagnosis is made radiographically
• Ultrasonography

95. 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

96. 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

97. 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.

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

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

100. 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.

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

102. NURSE’S ROLE…

103. THANK YOU….