neonatal birth trauma

1. Fetal Birth Injuries
BY MERGA B.
3/19/2023 By Merga B. 1

2. Definition
• The term birth injury is used to denote:
avoidable and unavoidable mechanical,
hypoxic and ischemic injury affecting the
infant during labor and delivery.
• Birth injuries may result from :
1.Inappropriate or deficient medical skill or
attention.
2.They may occur, despite skilled and competent
obstetric care.
3/19/2023 By Merga B. 2

3. Cont. ….
• Some medical errors that may happen
–Medication error
–Improper resuscitation
–Improper forceps or vacuum use
–Failure to identify fetal distress
–Delayed cesarean section
–Untreated pregnancy disorders.
3/19/2023 By Merga B. 3

4. Incidence
• Has been estimated at 2-7/1,000 live births.
predisposing factors:
– Macrosomia,
– Prematurity,
– Cephalopelvic disproportion,
– Dystocia,
– Prolonged labor, and
– Breech presentation.
3/19/2023 By Merga B. 4

5. Incidence…
• 5-8/100,000 infants die of birth trauma,
and
• 25/100,000 die of anoxic injuries;
Such injuries represent 2-3% of infant
deaths.
3/19/2023 By Merga B. 5

6. Cranial Injuries
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7. Erythema, abrasions, ecchymosis
• Of facial or scalp soft tissues may be seen after
forceps or vacuum-assisted deliveries.
• Their location depends on the area of
application of the forceps.
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8. Subconjunctival ,retinal hemorrhages and
petechiae of the skin of the head and neck
• All are common.
• All are probably secondary to a sudden
increase in intrathoracic pressure during
passage of the chest through the birth canal.
• Parents should be assured that they are
temporary and the result of normal hazards
of delivery.
3/19/2023 By Merga B. 8

9. Molding
• Molding of the head and overriding of the
parietal bones are frequently associated with
caput succedaneum and become more evident
after the caput has receded but disappear
during the first weeks of life.
• Rarely, a hemorrhagic caput may result in
shock and require blood transfusion.
3/19/2023 By Merga B. 9

10. Caput succedaneum
• Diffuse, sometimes ecchymotic, edematous
swelling of the soft tissues of the scalp
involving the portion presenting during vertex
delivery.
• It may extend across the midline and across
suture lines.
• The edema disappears within the first few days
of life.
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11. Caput succedaneum…
• Analogous swelling, discoloration, and
distortion of the face are seen in face
presentations.
• No specific treatment is needed, but if there
are extensive ecchymosis, phototherapy for
hyperbilirubinemia may be indicated.
3/19/2023 By Merga B. 11

12. Cephalhaematoma
• It is a subperiosteal hematoma most
commonly lies over one parietal bone.
• It may result from difficult vacuum or
forceps extraction .
Management:
• It usually resolves spontaneously.
• Vitamin K 1 mg IM is given.
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15. Cephalohematoma
• Is a subperiosteal hemorrhage, so it is always
limited to the surface of one cranial bone.
• There is no discoloration of the overlying
scalp, and swelling is usually not visible until
several hours after birth, because
subperiosteal bleeding is a slow process.
• An underlying skull fracture, usually linear
and not depressed, is occasionally associated
with cephalohematoma.
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16. Cont. …
Cranial meningocele is differentiated from
cephalohematoma by:
1. Pulsation,
2. Increased pressure on crying, and the
3. Radiologic evidence of bony defect.
– Most Cephalohematomas are resorbed within 2
wk-3 mo, depending on their size.
– They may begin to calcify by the end of the 2nd
wk.
3/19/2023 By Merga B. 16

17. Cephalohematoma
• A sensation of central depression
suggesting( but not indicative )of an
underlying fracture or bony defect is
• Cephalohematomas require no treatment,
although phototherapy may be necessary to
ameliorate hyperbilirubinemia.
3/19/2023 By Merga B. 17

18. Cephalohematoma
• Incision and drainage are contraindicated
because of the risk of introducing infection in
a benign condition.
• A massive cephalohematoma may rarely
result in blood loss severe enough to require
transfusion.
• It may also be associated with a skull
fracture, coagulopathy, and intracranial
hemorrhage.
3/19/2023 By Merga B. 18

19. Diagnosis and Differential Diagnosis
3/19/2023 By Merga B. 19

20. Fractures of the skull
May occur as a result of pressure from:
1. Forceps or from
2. The maternal symphysis pubis.
3. Sacral promontory, or
4. Ischial spines.
3/19/2023 By Merga B. 20

21. Fracture Skull:
Usually occurs due to difficult forceps delivery.
It may be:
(1) Vault fracture:
• Usually affecting the frontal or parietal bone.
• It may be linear or depressed fracture.
• It needs no treatment unless there is intracranial
haemorrhage.
(2) Fracture base:
• Usually associated with intracranial
haemorrhage.
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22. Fractures of the skull
1. Linear fractures, the most common, cause
no symptoms and require no treatment.
2. Depressed fractures are usually indentations
similar to a dent in a Ping-Pong ball; they
usually are a complication of forceps
delivery or fetal compression.
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23. Depressed
fractures
Ping-Pong ball
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24. Fractures of the skull
• Affected infants may be asymptomatic unless there
is associated intracranial injury.
• It is advisable to elevate severe depressions to
prevent cortical injury from sustained pressure.
• Fracture of the Occipital bone almost causes fatal
hemorrhage due to disruption of the underlying
vascular sinuses.
• It may result during breech deliveries from traction
on the hyperextended spine of the infant with the
head fixed in the maternal pelvis.
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25. Intracranial Intraventricular
hemorrhage
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26. Intracranial Haemorrhage:
Causes:
1. Sudden compression and decompression of
the head as in breech and precipitate labour.
2. Marked compression by forceps or in
Cephalopelvic disproportion.
3. Fracture skull.
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27. Intracranial Haemorrhage:
Predisposing factors:
1. Prematurity due to physiological
hypoprothrombinaemia, fragile blood
vessels and liability to trauma.
2. Asphyxia due to anoxia of the vascular
wall .
3. Blood diseases.
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28. Intracranial Haemorrhage Sites:
1. Subdural : results from damage to the
superficial veins where the vein of Galen and
inferior sagittal sinus combine to form the
straight sinus.
2. Subarachnoid: The vein of Galen is damaged
due to tear in the dura at the junction of the falx
cerebri and tentorium cerebelli.
3. Intraventricular :into the brain ventricles.
4. Intracerebral : into the brain tissues .
• In (1) and (2) it is usually due to birth trauma,
• in (3) and (4) the foetus is usually a premature
exposed to hypoxia.
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29. Intracranial Haemorrhage:
Clinical picture:
1- Altered consciousness.
2- Flaccidity.
3- Breathing is absent, irregular and periodic or
gasping.
4- Eyes: no movement, pupils may be fixed and dilated.
5- Opisthotonus, rigidity, twitches and convulsions.
6- Vomiting .
7- High pitched cry.
8- Anterior fontanelle is tense and bulging.
9- Lumbar puncture reveals bloody C.S.F.
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30. Intracranial Haemorrhage
Investigations:
1. Ultrasound is of value.
2. CT scan is the most reliable.
3. MRI
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31. Intracranial Haemorrhage:
Prophylaxis:
1. Vitamin K: 10 mg IM to the mother in late
pregnancy or early in labour.
2. Episiotomy: especially in premature and
breech delivery.
3. Forceps delivery: carried out by an
experienced obstetrician respecting
the instructions for its use.
3/19/2023 By Merga B. 31

32. Intracranial Haemorrhage Treatment
1. Minimal handling, warmth and oxygen to the baby.
2. No oral feeding for 72 hours.
3. IV fluids.
4. Vitamin K 1mg IM.
5. Lumbar puncture: is diagnostic and therapeutic to relieve
the intracranial tension if the anterior fontanelle is
bulging.
6. Sedatives for convulsions.
7. 60 cc. of 10% sodium chloride per rectum to relieve brain
oedema.
8. 1 cc of 50% magnesium sulphate IM to relieve brain
oedema and convulsions.
9. Antibiotics : to guard against infections particularly
pulmonary.
3/19/2023 By Merga B. 32

33. ETIOLOGY AND EPIDEMIOLOGY
Intracranial hemorrhage may result from:
1. Birth trauma or
2. Asphyxia and, rarely, from a
3. Primary hemorrhagic disturbance or
4. Congenital vascular anomaly.
Intracranial hemorrhages often involve the
ventricles (intraventricular hemorrhage [IVH])
of premature infants delivered spontaneously
without apparent trauma.
3/19/2023 By Merga B. 33

34. CLINICAL MANIFESTATIONS
The incidence of IVH increases with decreasing birth
weight:
1. 60-70% of 500- to 750-g infants and
2. 10-20% of 1,000- to 1,500-g infants.
IVH is rarely present at birth; however,
1. 80-90% of cases occur between birth and the 3rd
day .
2. 50% occur on the 1st day.
3. 20% to 40% of cases progress during the 1st wk
of life.
4. Delayed hemorrhage may occur in 10-15% of
patients after the 1st wk of life.
3/19/2023 By Merga B. 34

35. CLINICAL MANIFESTATIONS
The most common symptoms are:
1. Diminished or absent Moro reflex.
2. Poor muscle tone.
3. Lethargy.
4. Apnea.
5. Somnolence.
3/19/2023 By Merga B. 35

36. CLINICAL MANIFESTATIONS
1. Periods of apnea,
2. Pallor, or cyanosis;
3. Failure to suck well;
4. Abnormal eye signs;
5. A high-pitched cry;
6. Muscular twitches, convulsions, decreased
muscle tone, or paralyses;
7. Metabolic acidosis; shock, and a
8. Decreased hematocrit or its failure to
increase after transfusion may be the first
indications.
9. The fontanel may be tense and bulging.
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37. DIAGNOSIS
Intracranial hemorrhage is diagnosed on the
basis of the:
1. History,
2. Clinical manifestations,
3. Trans fontanel cranial ultrasonography or
4. Computed tomography (CT), and
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38. DIAGNOSIS
Lumbar puncture is indicated in the presence of
signs of:
1. Increased intracranial pressure or
2. Deteriorating clinical condition to identify
gross subarachnoid hemorrhage or to rule out
the possibility of bacterial meningitis
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39. PROGNOSIS
• Neonates with: (massive hemorrhage
associated with tears of the tentorium or falx
cerebri) rapidly deteriorate and may die after
birth.
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40. PREVENTION
• The incidence of traumatic intracranial hemorrhage
may be reduced by: judicious management of
Cephalopelvic disproportion and operative delivery.
Fetal or neonatal hemorrhage due to:
1. Maternal idiopathic thrombocytopenic purpura
(ITP) or
2. Alloimmune thrombocytopenia
3. may be prevented by maternal treatment with:
Steroids,
4. Intravenous immunoglobulin, or
5. Fetal platelet transfusion
3/19/2023 By Merga B. 40

41. PREVENTION
• The incidence of IVH may be reduced by antenatal
steroids and by postnatal administration of low-dose
indomethacin.
• Vitamin K should be given before delivery to all
women receiving phenobarbital or phenytoin during
the pregnancy.
3/19/2023 By Merga B. 41

42. TREATMENT
• Seizures are treated with anticonvulsant
drugs.
• Anemia-shock, requires transfusion with
packed red blood cells or fresh frozen
plasma.
• Acidosis is treated with slow
administration of sodium bicarbonate.
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43. TREATMENT
• Symptomatic subdural hemorrhage in large
term infants should be treated by removing
the subdural fluid collection by means of a
spinal needle placed through the lateral
margin of the anterior fontanel.
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44. Spine and Spinal Cord
Strong traction exerted:
1. When the spine is hyperextended or
2. When the direction of pull is lateral, or
3. Forceful longitudinal traction on the trunk
while the head is still firmly engaged in the
pelvis: (may produce fracture and
separation of the vertebrae).
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45. Spine and Spinal Cord
• Such injuries, rarely diagnosed clinically, are most
likely to occur with shoulder dystocia.
• The injury occurs most commonly at the level of the
4th cervical vertebra with cephalic presentations and
• The lower cervical-upper thoracic vertebrae with
• Transection of the cord may occur with or without
vertebral fractures.
• Hemorrhage and edema may produce neurologic
signs that are not distinguished from those of
transection (except that they may not be permanent).
beech presentations.
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47. Spine and Spinal Cord
1. A reflexia,
2. Loss of sensation, and
3. Complete paralysis of voluntary motion
Occur below the level
of injury
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48. Spine and Spinal Cord
• If the injury is severe, the infant, (who may be
in poor condition owing to respiratory
depression, shock, or hypothermia), May
deteriorate rapidly to death within several
hours before neurologic signs are obvious.
• The course may be protracted, with symptoms
and signs appearing at birth or later in the 1st
wk; may not be recognized for several days.
• Constipation may also be present.
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49. Spine and Spinal Cord
• The diagnosis is confirmed by
:Ultrasonography or MRI.
• Treatment of the survivors is: supportive,
including home ventilation; patients often
remain permanently injured.
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50. Peripheral Nerve
Injuries
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51. Brachial Plexus Palsy:
It is due to over traction on the neck as in:
1. Shoulder dystocia.
2. After-coming head in breech delivery.
(1) Erb's palsy:
1. It is the common, due to injury to C5 and C6
roots.
2. The upper limb drops beside the trunk,
internally rotated with flexed wrist
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52. Brachial Plexus Palsy:
(2) Klumpke’s palsy:
- It is less common,
- Due to injury to C7 and C8 and 1st thoracic roots.
- It leads to paralysis of the muscles of the hand and
weakness of the wrist and fingers' flexors.
Treatment
• Support to prevent stretching of the paralyzed
muscles.
• Physiotherapy: massage, exercise and faradic
stimulation
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54. BRACHIAL PALSY
• Injury to the brachial plexus may cause paralysis of
the upper arm with or without paralysis of the
forearm or hand or, more commonly, paralysis of
the entire arm.
• Approximately 45% are associated with shoulder
dystocia.
These injuries occur in :
• Macrosomic infants and when lateral traction is
exerted on the head and neck during delivery of the
shoulder in a vertex presentation,
• When the arms are extended over the head in a
breech presentation, or
• When excessive traction is placed on the shoulders.
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55. In Erb-Duchenne paralysis
• The injury is limited to the 5th and 6th
cervical nerves.
• The characteristic position consists of:
( Adduction and internal rotation of the arm with
pronation of the forearm).
• Moro reflex is absent on the affected side
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57. In Erb-Duchenne paralysis
• There may be some sensory impairment on the
outer aspect of the arm.
• The power in the forearm and the hand grasp
are preserved unless the lower part of the
plexus is also injured; (the presence of the
hand grasp is a favorable prognostic sign).
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58. Klumpke's paralysis
• Is a rarer form of brachial palsy;
• Injury to the 7th and 8th cervical nerves and
the 1st thoracic nerve produces a paralyzed
hand, (Horner syndrome)
• If the sympathetic fibers of the 1st thoracic
root are also injured : paralyzed hand and
ipsilateral ptosis and miosis.
• The mild cases may not be detected
immediately after birth.
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59. Cont….
• Differentiation must be made from :
1. Cerebral injury;
2. Fracture, dislocation, or epiphyseal separation
of the humerus;
3. Fracture of the clavicle.
4. MRI demonstrates nerve root rupture or
avulsion
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60. The prognosis
• Depends on whether the nerve was merely
injured or was lacerated.
• If the paralysis was due to edema and
hemorrhage about the nerve fibers, function
should return within a few months;
• If due to laceration, permanent damage may
result.
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61. The prognosis
• Involvement of the deltoid is usually the
most serious problem and may result in a
shoulder drop secondary to muscle atrophy.
• In general, paralysis of the upper arm has a
better prognosis than paralysis of the lower
arm.
3/19/2023 By Merga B. 61

62. Treatment
• Partial immobilization and appropriate
positioning to prevent development of
contractures.
• In upper arm paralysis: the arm should be
abducted, with external rotation at the shoulder
and with full supination of the forearm and
slight extension at the wrist with the palm
turned toward the face.
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63. Treatment
• In lower arm or hand paralysis: the wrist should
be splinted in a neutral position and padding
placed in the fist.
• Gentle massage and range of motion exercises
may be started by 7-10 days of age.
• If the paralysis persists without improvement
for 3-6 months: neuroplasty, neurolysis, end-to-
end anastomosis, or nerve grafting offers hope
for partial recovery.
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64. PHRENIC NERVE PARALYSIS
• Phrenic nerve injury (3rd, 4th, 5th cervical
nerves) with diaphragmatic paralysis must be
considered when cyanosis and irregular and
labored respirations develop.
• Such injuries, usually unilateral, are associated
with ipsilateral upper brachial palsy.
The diagnosis
• is established by ultrasonography or fluoroscopic
examination, which reveals elevation of the
diaphragm on the paralyzed side
3/19/2023 By Merga B. 64

65. PHRENIC NERVE PARALYSIS
• There is no specific treatment: infants should
be placed on the involved side and given
oxygen if necessary.
• Recovery usually occurs spontaneously by 1-3
months; rarely, surgical plication of the
diaphragm may be indicated.
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66. Facial Palsy (Bell’s palsy):
- It is usually due to pressure by the forceps blade
on the facial nerve at:
1. Its exit from the stylomastoid foramen or
2. In its course over the mandibular ramus.
- It appears within 1-2 days after delivery due to
resultant oedema and haemorrhage around the
nerve.
3/19/2023 By Merga B. 66

67. Facial Palsy (Bell’s palsy):
Manifestations:
1. There is paresis of the facial muscles on the
affected side with:
2. Partially opened eye and
3. Flattening of the nasolabial fold.
4. The mouth angle is deviated towards the
healthy side.
Spontaneous recovery usually occurs
within 14 days.
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68. FACIAL NERVE PALSY
• When the infant cries, there is movement only
on the non paralyzed side of the face, and the
mouth is drawn to that side.
• On the affected side the forehead is smooth, the
eye cannot be closed, the nasolabial fold is
absent, and the corner of the mouth drops.
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69. FACIAL NERVE PALSY
• The prognosis depends on whether the nerve
was injured by pressure or whether the nerve
fibers were torn.
• Care of the exposed eye is essential.
• Improvement occurs within few weeks.
• Neuroplasty may be indicated when the
paralysis is persistent.
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70. V) VISCERALINJURIES
(Liver, spleen and kidney)
may be injured in breech
delivery which should be
avoided by holding the
fetus from its hips.
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71. Viscera (The liver )
• The liver is the only internal organ other than
the brain that is injured with any frequency
during birth.
• The damage usually results from pressure on the
liver during delivery of the head in breech
presentations.
• Incorrect cardiac massage is a less frequent
cause.
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72. Viscera (The liver )
• Hepatic rupture may result in the formation of
a subscapular hematoma.
• The hematoma may be large enough to cause
anemia.
• Shock and death may occur if the hematoma
breaks through the capsule into the peritoneal
cavity.
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73. Viscera (The liver )
• A mass may be palpable in the right upper
quadrant; the abdomen may appear blue.
• Early suspicion by means of ultrasonographic
diagnosis and prompt supportive therapy can
decrease the mortality of this disorder.
• Surgical repair of a laceration may be required.
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74. Rupture of the spleen
• May occur alone or in association with rupture
of the liver.
• The causes, complications, treatment, and
prevention are similar.
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75. Adrenal hemorrhage
• Occurs with some frequency, especially after
breech delivery in LGA infants or infants of
diabetic mothers.
• 90% are unilateral; 75% are right sided.
• The symptoms are profound shock and
cyanosis
• If suspected, abdominal ultrasonography may
be helpful, and treatment for acute adrenal
failure may be indicated
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76. Fractures
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77. BONE INJURIES
These usually occur during difficult breech
delivery.
(A) Vertebral Column Injuries:
• These are fatal if associated with spinal cord
transection above C4 ,due to diaphragmatic
paralysis.
(B) Femur, Humerus and Clavicle:
• Managed by splint to the long bone
and a sling for clavicular fracture.
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78. CLAVICLE
This bone is fractured during labor and delivery
more frequently than any other bone;
It is particularly vulnerable when there is:
1. Difficulty in delivery of the shoulder in
vertex presentations and of
2. The extended arms in breech deliveries.
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80. CLAVICLE
• The infant characteristically does not move the
arm freely on the affected side;
• Crepitus and bony irregularity may be palpated,
and
• Discoloration is occasionally visible over the
fracture site.
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81. CLAVICLE
• Treatment, consists of immobilization of the
arm and shoulder on the affected side.
• A remarkable degree of callus develops at the
site within a week and may be the first
evidence of the fracture.
• The prognosis is excellent.
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82. EXTREMITIES
• In fractures of the long bones, spontaneous
movement of the extremity is usually absent.
• The Moro reflex is also absent from the
involved extremity.
• There may be associated nerve involvement.
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83. EXTREMITIES (Humerus)
• Satisfactory results of treatment for a fractured
humerus are obtained with
2-4 wk of immobilization
(during which the arm is
strapped to the chest).
• A triangular splint and a bandage are applied, or a
cast is applied.
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84. EXTREMITIES
• In fracture femur : good results are obtained with
traction-suspension of both lower extremities, even
if the fracture is unilateral;
• The legs, immobilized in a cast, are attached to an
overhead frame.
• Splints are effective for treatment of fractures of the
forearm or leg.
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85. EXTREMITIES
• Healing is usually accompanied by excess callus
formation.
• The prognosis is excellent for fractures of the
extremities.
• Fractures in preterm infants may be related to
osteopenia
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86. Dislocations and epiphyseal separations
• Rarely result from birth trauma.
• The upper femoral epiphysis may be separated by
forcible manipulation of the infant's leg, as, for
example, in breech extraction or after version.
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87. Dislocations and epiphyseal separations
• The affected leg shows swelling, slight
shortening, limitation of active motion,
painful passive motion, and external rotation.
• The diagnosis is established Radiologically
• The prognosis is good for the milder injuries.
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88. MUSCLE INJURIES
Strenomastoid injury
Due to :
• Exaggerated lateral flexion of the neck leading to
torticollis and swelling in the muscle.
• It is usually improved within 2 weeks but permanent
torticollis may continue.
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