The document discusses various types of birth trauma including head injuries like cephalohematoma and subgaleal hemorrhage, brachial plexus injuries like Erb's palsy, bone fractures, and intra-abdominal injuries. It describes the risk factors, clinical presentation, diagnosis, and management of each type of birth trauma. Subgaleal hemorrhage is identified as the most severe form requiring strict monitoring for shock and anemia and proper treatment.

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
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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.
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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.
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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
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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.
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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
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8. Caput succedaneum
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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.
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10. Cephalhematoma
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11. Cephalhematoma....
• Management:-
- Observation in most cases
- Incision and aspiration is contraindicated.
- Anemia and jaundice should be treated as needed
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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.
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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.
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14. Subgaleal hemorrhage.....
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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.
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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.
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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
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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.
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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
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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.
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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.
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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
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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
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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
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26. Facial Nerve injury
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27. Management
 observation
 provide the eye drop to lubricating
resolve with in a week if doesn't consult
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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
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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.
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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.
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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
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32. Con...
Diagnosis
 An x-ray confirms the diagnosis.
Management-
• decreasing pain with analgesics.
• Immobilize the affected arm and shoulder for 7-10 days.
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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
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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
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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
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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.
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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 .
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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
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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
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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
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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
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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.
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