This document discusses birth injuries, including definitions, risk factors, types, and descriptions of specific injuries. Some key points: - Birth injuries occur in about 0.7% of births and account for under 2% of neonatal deaths. Factors like difficult delivery or fetal positioning can increase risk. - Types of injuries include head/neck trauma, nerve injuries, fractures, and internal organ damage. Specific injuries discussed include brachial plexus injuries, skull fractures, intracranial hemorrhages, and others. - Injuries are described in detail, along with typical presentations, diagnostic methods, and treatment approaches depending on severity. Head injuries commonly involve skull fractures or bleeding, while nerve injuries often affect the

1. • An impairment of the infants
body function or structure due to
adverse influences that occur at
birth
• Injuries to the infant may result
from mechanical forces (i.e.,
compression, traction) during the
birth process
Birth Injuries
BIRTH INJURIES
Aruna. A P
I Year MSc Nursing

2. • 0.7% (Seven of every 1,000) births
result in birth injuries. though most
women give birth in modern
hospitals surrounded by medical
professionals
• Birth injuries account for fewer than
2% of neonatal deaths
• Infant mortality resulting from birth
trauma fell from 64.2 to 7.5 deaths
per 100,000 live births from 1970-
1985
Birth Injuries
BIRTH INJURIES
Aruna. A P
I Year MSc Nursing

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

4. • Primiparity
• Small maternal stature
• Maternal pelvic anomalies
• Prolonged or unusually rapid labor
• Oligohydramnios
• Malpresentation of the fetus (breech)
• Cephalopelvic disproportion
• Deep transverse arrest of presenting part of
the fetus
Factors predisposing to injury include the
following

5. • Use of mid forceps or vaccum
extraction
• Versions and extractions
• Very low birth weight or extreme
prematurity
• Fetal macrosomia birth weight over
about 4,000 grams
• Fetal macrocephali (Large head)
• Fetus anomalies
Factors predisposing to injury include the
following

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

7. • 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

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

9. HEAD AND NECK INJURIES

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

12. 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.

13. • 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.

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

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

16. 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.

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

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

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

21. 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.

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

23. 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

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

25. 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.

26. 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.

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

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

30. 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

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

32. SYMPTOMS
• apnea
• seizures

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

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

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

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

37. • 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

38. • 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

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

40. • Cranial computed tomography
• Cranial ultrasonography
• MRI.
• Coagulation profile

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

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

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

44. MANAGEMENT
• Resolves without intervention
• Monitoring head growth

45. 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

46. • 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

47. 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

48. DIAGNOSIS
• CT Scans
• MRI
• Cranial ultrasonography

49. MANAGEMENT
• Symptomatic treatment and support
• Neurosurgical intervention

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

51. 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

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

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

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

55. DIAGNOSIS
• Cranial ultra sonography
• CT or MRI

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

57. NERVE INJURY

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

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

60. 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

61. • 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.

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

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

64. 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.

65. 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

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

67. 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

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

69. 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.

70. • lacerations and bruising
• neurologic findings

71. 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

72. 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.

73. 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

74. 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

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

76. • Diagnosis is made by direct
laryngoscopy

77. 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

78. 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.

79. • 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

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

81. FACIAL INJURIES

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

83. 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.

84. 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

85. 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

86. 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.

87. 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.

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

89. TREATMENT
• active and passive stretching
• surgery

90. FRACTURES

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

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

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

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

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

96. DIAGNOSIS
• Diagnosis is made radiographically
• Ultrasonography

97. 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

98. 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

99. 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.

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

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

102. 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.

103. NURSE’S ROLE…

104. THANK YOU….