The document discusses various types of birth trauma that can occur during delivery, including injuries to the head and brain. It describes injuries such as cephalohematoma (swelling of blood under the scalp), subaponeurotic hemorrhage (bleeding under the connective tissue layer), skull fractures, and intracranial hemorrhages including subdural, epidural, subarachnoid, intraventricular, and parenchymal hemorrhages. It discusses causes such as difficult delivery due to disproportion between fetal and pelvic sizes. It also outlines signs, symptoms, and treatment for different types of birth injuries.

1. BIRTH TRAUMAS

2. Birth trauma mechanical damage to the integrity of one or more organs of a newborn child
during childbirth or labor pains. The incidence of birth trauma is 2-7 per 1000 births.
Birth trauma most often occurs during vaginal delivery. A large fetus, a discrepancy in the
size of the fetal head and pelvis, a pathological position of the fetus (breech presentation,
facial presentation), a pathological course of labor (premature, prolonged, instrumental
labor) are predisposed to it.
Damage to the fetus is also possible during a cesarean section (if the fetus is in the wrong
position, the wrong technique of the operation).
Birth damage can be in the form of abrasions, compression, fracture of the bones of the
limbs and pelvis, intracranial hemorrhage. Many birth injuries are not severe and have a
good prognosis: damage to the skin and soft tissues during the application of forceps,
petechiae, fracture of the clavicle, transient paralysis (damage to the brachial plexus).

3. HEAD INJURIES
Traumatic head injuries include mechanical damage to tissue structures in the form of
rupture, fracture, compression – cephalohematoma, subaponeurotic bleeding, fracture of
the skull bones, fracture of the facial bones, traumatic damage to the facial nerves, eyes,
vocal folds, damage to brain structures (intracranial hemorrhage).
Subcutaneous hematoma of the head (caput succedaneum) – subcutaneous accumulation
of blood, usually after vaginal delivery. ICD code 10: P12.3 Hematoma of the hairy part of
the tin due to birth trauma.
Pathogenesis is caused by compression of the presenting part by the uterus or cervix.
Hematoma occurs in 20-40% of deliveries using a vacuum extractor. It is characterized by
mild, superficial edema, unrestricted cranial suture lines, and is usually accompanied by a
marked change in the shape of the head. This hematoma usually resolves spontaneously
within weeks or months.

4. Subaponeurotic hemorrhage bleeding under the epicranal aponeurosis, where a large
amount of blood can accumulate (up to 240 ml). ICD code 10: P12.2 Subaponeurotic
hemorrhage due to birth injury.
The frequency is 1 in 2500 births. It has no clear boundaries, it can be located from the
frontal part to the child’s neck. Trauma occurs as a result of repeated attempts to extract
the fetus using a vacuum extractor (when the aponeurosis comes off the bone with rupture
of the veins), against the background of coagulopathy (factor IX deficiency), prematurity,
rapid delivery, macrosomia. Excessive bleeding can lead to acute anemia and even
hemorrhagic shock.
Treatment is conservative and symptomatic. In severe cases, it is necessary to transfuse
blood or erythrocyte mass, fresh frozen plasma, and treat shock. The mortality rate in this
condition is quite high. In mild cases, the hematoma resolves within 2-3 weeks.

5. Cephalohematoma – periosteal bleeding, which is limited by the sutures
between the bones and clearly limited to the edges of the bone. ICD code
10: P12.0 Cephalohematoma with birth trauma.
It occurs in 1-2% of live births, more often in boys. Typical localization over
the parietal or occipital bone, bilateral localization is possible. Bulging
appears several hours after birth. Blood usually resolves within a few weeks
(up to 3 months), thereby increasing the period of neonatal jaundice.
Cephalohematoma does not require any treatment. Due to the risk of new
bleeding and infection, it does not interfere with early attachment to the
breast.

6. Fracture of the bones of the skull. ICD 10 code: P13.0 Fracture of the skull
bones during birth trauma.
In a newborn baby, the bones of the skull are elastic and the sutures are
open, so damage to the bones of the skull is rare. This can happen with
prolonged protracted labor, especially when using forceps or a vacuum
extractor, if the fetus is in the wrong position. Linear and compression
fractures are characteristic, which usually do not have clinical manifestations.
Linear fractures occur at the site of a large cephalohematoma (in 10-25% of
cases). If you suspect a fracture of the skull bones, it is necessary to make a
craniogram in two projections, conduct a thorough neurological examination.
Fractures require no special treatment other than pain relief

7. A fracture of the base of the skull can occur in difficult childbirth, with
manifestations of hemorrhagic shock and severe neurological disorders. In
this case, the prognosis sharply worsens, the mortality rate is very high.
Damage to the face of the skull occurs in the form of damage to the bones,
nerves, and eyes. Damage to the facial nerve occurs with a frequency of up
to 1% of all births and is accompanied by the disappearance of the mobility
of the damaged facial part with a drooping mouth corner, an open eye, lack
of emotion, and inability to raise an eyebrow. This damage usually resolves
spontaneously and does not require treatment. Intraocular hemorrhage
usually also goes away without medical intervention, but in severe cases it
requires the supervision of an ophthalmologist.

8. INTRACRANIAL HEMORRHAGE
There are the following variants of intracranial hemorrhage (ICH): subdural, epidural,
subarachnoid, periventricular, intraventricular,parenchymal and cerebellar. In addition,
hemorrhagic cerebral infarctions are isolated, when hemorrhage occurs in the layers of the
white matter of the brain after ischemic (a consequence of thrombosis or embolism)
softening of the brain.
Intraventricular (IVH) and paraventricular hemorrhages (PVH) are typical for premature
babies weighing less than 1500 g (or those born before the 35th week of gestation), in
which the frequency of their diagnosis reaches 50% (in children weighing less than 1000 g
at birth IVH are diagnosed in 65-75% of cases), while among full-term ones – 1: 1000.

9. CAUSES
The main causative factors of ICH are birth traumatism; may be:
1. perinatal hypoxia and hemodynamic (especially pronounced arterial hypotension) and metabolic
disorders (pathological acidosis, excessive activation of lipid peroxidation against the background of
reoxygenation, etc.) caused by its severe forms;
2. perinatal disorders of coagulation (deficiency of vitamin K-dependent factors) platelet hemostasis
(hereditary and acquired thrombocytopenia);
3. lack of the ability to autoregulate cerebral blood flow in children with small gestational age, especially
those who have undergone combined hypoxia and asphyxia;
4. Intrauterine viral and mycoplasma infections that cause damage to the vascular wall, as well as the
liver, brain;
5. irrational care and iatrogenic interventions (mechanical ventilation with rigid parameters, rapid
intravenous infusions, especially hyperosmolar solutions such as sodium bicarbonate, uncontrolled
excessive oxygen therapy, lack of anesthesia during painful procedures, negligent care and performance
of manipulations that traumatize the child, drug polypharmacy using many platelet inhibitors).

10. The immediate cause of the birth brain injury is the discrepancy
between the size of the bone pelvis of the mother and the head of the
fetus (various anomalies of the bone pelvis, large fetus), rapid (less than
2 hours) or protracted (more than 12 hours) childbirth; incorrectly
performed obstetric benefits when applying forceps, breech
presentation and fetal rotation, caesarean section, extraction of the
fetus by the pelvic end, traction behind the head; vacuum extractor;
excessive attention to «protection of the perineum» with disregard for
the interests of the fetus.
However, for a child who has undergone chronic intrauterine hypoxia or
has another antenatal pathology, normal childbirth can be traumatic.
Birth trauma to the brain and hypoxia are combined, and in some cases,
damage to brain tissue and ICH are the result of severe hypoxia, in
others - its cause.

11. PATHOGENESIS
Subdural and epidural hemorrhages in the brain substance, cerebellum are
usually of traumatic origin. Traumatic genesis of any intracranial hemorrhage is
very likely if at the same time there are other manifestations of birth trauma,
cephalohematoma, hemorrhage under the aponeurosis, traces of the imposition
of obstetric forceps, fractures of the clavicle, etc.
Intraventricular, paraventricular, punctate hemorrhages into the brain substance
are usually associated with hypoxia. Subarachnoid hemorrhages can be of both
hypoxic and traumatic genesis.

12. There are 4 groups of factors that directly lead to intraventricular hemorrhages
(IVH):
1) arterial hypertension and increased cerebral blood flow – rupture of capillaries;
2) arterial hypotension and decreased cerebral blood flow – ischemic
capillary damage;
3) increased cerebral venous pressure – venous stasis, thrombosis;
4) changes in the hemostatic system.

13. In some children, especially premature babies, the deficiency of procoagulants (vitamin
K-dependent blood coagulation factors) with an increase on the 24th day of life has a
pathogenetic significance in case of ICH. That is why prophylactic or therapeutic
prescription of vitamin K in the first days of life is so important.
Children with very low birth weight may have a deeper and wider spectrum of
deficiency of various factors of the coagulation, anticoagulant and fibrinolytic systems,
which predisposes not only to IVH, but also to ischemic-thrombotic brain lesions –
periventricular leukomalacia with possible subsequent IVH.
A significant proportion of children with IVH have hereditary thrombocytopathy: a
defect in release reactions or type 1 von Willebrand disease.

14. CLINICAL FORMS
The common manifestations of any ICH in newborns are:
1) a sudden deterioration in the general condition of the child with the development of various variants of depression
syndrome, apnea attacks, sometimes with recurrent signs of hyperexcitability;
2) changes in the nature of the cry;
3) bulging of the large fontanelle or its tension; 4) abnormal movements of the eyeballs;
5) violation of thermoregulation (hypo or hyperthermia);
6) vegetovisceral disorders (regurgitation, pathological weight loss, flatulence, unstable stools, tachypnea, tachycardia,
peripheral circulation disorder);
7) pseudobulbar («mask-like» face) and movement disorders;
8) convulsions;
9) Disorders of muscle tone;
10) Progressive post-hemorrhagic anemia;
11) metabolic disorders (acidosis, hypoglycemia, hyperbilirubinemia);
12) the addition of somatic diseases that worsen the course and prognosis of birth trauma of the brain (pneumonia,
cardiovascular failure, meningitis, sepsis, adrenal insufficiency, etc.).

15. • EPIDURAL HEMORRHAGE –Localized over the dura mater and the inner surface of the
bones of the skull and do not extend beyond the cranial sutures due to tight fusion in
these places of the dura mater. Epidural hematomas are formed with cracks and
fractures of the bones of the cranial vault with rupture of the vessels of the epidural
space, often combined with extensive external cephalohematomas.
• SUBDURAL HEMORRHAGE occurs when the skull is deformed with the displacement of
its plates. The favorite localization is the posterior cranial fossa, rarely the parietal
region, between the hard and pia mater (piazza and arachnoid).The source of
hemorrhage is the veins flowing into the superior sagittal and transverse sinuses, the
vessels of the cerebellar tentorium. Subdural hemorrhages are more often observed in
breech presentation. Subarochnoidal hemorrhage is combine. Depending on the
localization of hemorrhages, there are: 1) supratentorial (located above the cerebellar
lining) or hemispheric hematomas: 2) and subtentorial / infratentorial (located under
the cerebellar lining) in the posterior cranial fossa.

16. • SUBARACHNOIDAL HEMORRHAGE. They arise as a result of a violation of the integrity of
the meningeal vessels. The localization of hemorrhages is variable, more often in the
parietotemporal region of the cerebral hemispheres and cerebellum. With subarachnoid
hemorrhage, blood settles on the membranes of the brain, causing their aseptic
inflammation, which further leads to cicatricial and atrophic changes in the brain and its
membranes, impaired CSF dynamics. The decomposition products of blood, especially
bilirubin, have a pronounced toxic effect.
• INTRACEREBRAL HAEMORRHAGE. They occur more often when the terminal branches of
the anterior posterior cerebral arteries are damaged. Large, medium-sized arteries are
rarely damaged. With small-point hemorrhages, the clinic is mild: lethargy, regurgitation,
impaired muscle tone and physiological reflexes, unstable focal symptoms, nystagmus,
anisocoria, strabismus, focal short-term convulsions.

17. INTRAVENTRICULAR HEMORRHAGES (IVH) can be
unilateral or bilateral.Common manifestations of
severe acute IVH are the following:
1) a decrease in hematocrit for no apparent
reason and the development of anemia;
2) bulging of the large fontanelle;
3) changes in the child’s motor activity;
4) a drop in muscle tone;
5) the disappearance of the sucking and
swallowing reflexes;
6) the appearance of apnea attacks;
7) eye symptoms (immobility of the gaze,
constant horizontal or vertical nystagmus,
violation of oculocephalic reflexes, lack of
reaction of the pupil to light);
8) lowering blood pressure and tachycardia.
According to ultrasound data, four
degrees of IVH are distinguished:
I degree – hemorrhage into the germinal
matrix; synonyms: subependymal,
periventricular hemorrhage.
II degree IVH – with normal ventricular
sizes; synonyms: intraventricular,
periventricular hemorrhage.
III degree – IVH with acute dilatation of at
least one ventricle.
IV degree – IVH with the presence of
parenchymal hemorrhage (white matter).

18. TREATMENT OF CEREBRAL HEMORRHAGE
• Guard mode
• temperature control
• infusion therapy in the first 24 hours is carried out at the rate of 30-60 ml / kg.
Colloidal solutions are also administered at a dose of 10-20 ml / kg.
• Correction of potassium, calcium and magnesium in the blood.
• Correction of hemostasis – use vitamin K.
• For neonatal convulsions: Phenobarbital 10-20 mg / kg intravenously, injected very
slowly for 10-15 minutes. Diazepam at the rate of 0.1-0.3 ml / kg IV.

19. TRAUMATIC SPINAL CORD INJURY
Spinal cord injury during childbirth is more common than diagnosed because
the process of childbirth, even under optimal conditions, is potentially
traumatic for the fetus. Most often, the cervical spine is damaged, much less
often its lower parts.
Etiology. Spinal cord lesions are observed with traction for the head with
fixed shoulders, traction for the shoulders with a fixed head (with breech
presentation), with excessive rotation with facial presentation (in 25% of
newborns). At the time of childbirth, such children often used forceps, a
vacuum extractor, and various manual aids.

20. Аs a result of these factors, the following violations may occur:
1. Defects of the spine: subluxation in the joints of the I and II cervical vertebrae, blockage
of the atlanto-axial and intervertebral joints by the enclosed capsule, displacement of the
vertebral bodies (dislocation of I-II vertebrae), fracture of the cervical vertebrae and their
transverse process, anomalies in the development of the vertebrae.
2. Hemorrhages in the spinal cord and its membranes, in the epidural tissue due to vascular
tears or increased permeability.
3. Ischemia in the vertebral arteries due to stenosis, spasm or occlusion.
4. Damage to the intervertebral discs.

21. CLINIC
• The clinical picture depends on the location and type of damage.
• In case of damage to the upper cervical segments (CI-CIV), a picture of spinal shock is observed: lethargy,
weakness, diffuse muscle hypotension, a tendency to hypothermia, arterial hypotension, hypo- or
areflexia; tendon and pain reflexes are sharply reduced or absent; complete paralysis of voluntary
movements distal to the site of injury or spastic tetraparesis. There is a syndrome of respiratory
disorders up to apnea when changing the position of the patient.
• Diaphragm paresis (Kofferat’s syndrome) develops with trauma to the brachial plexus (n. Frenicus),
spinal cord at the Clll-CV level.
• Duchenne-Erb paresis and paralysis develop when the spinal cord is affected at the CV-CVI level or
brachial plexus. Clinical picture: the affected limb is brought to the body, unbent at the elbow, turned
inward. The head is often tilted and turned. The neck appears to be short with many transverse folds.
Head turn is due to the presence of spastic or traumatic torticollis. Muscle tone is reduced in the
proximal regions, as a result of which it is difficult to abduct the shoulder, turn it outward, rise to a
horizontal level, flexion in the elbow joint and supination of the forearm.

22. • Lower distal paralysis of Klumpke’s occurs when the spinal cord is injured at the level of C7-T1, or
the middle and lower bundles of the brachial plexus. There is a gross dysfunction of the hand in
the distal forearm and fingers lose the ability to move. Muscle tone in the distal parts of the arm is
reduced. On examination, the hand is pale, with a cyanotic tinge (symptom of «ischemic glove»).
Cold to the touch, muscles atrophy, the hand is flattened. The movements in the shoulder joint are
preserved.
• Injury to the thoracic spinal cord (T1-T12) is clinically manifested by respiratory disorders as a
result of dysfunction of the respiratory muscles of the chest: the intercostal spaces sink when the
diaphragm is inhibited.
•
• Injury of the lower thoracic segments of the spinal cord is manifested by the symptom of a
«flattened abdomen» due to weakness of the muscles of the abdominal wall. The cry in such
children is weak, but with pressure on the abdominal wall it becomes louder.

23. PREVENTION
• The principles of antenatal protection of the fetus and monitoring of its
condition during childbirth, the improvement of obstetric tactics are
very important. Excessive activity of the midwife is harmful: a woman
should give birth as possible independently, and the midwife should not
extract the fetus, but only support it so that it does not sag during birth.
You should not unbend, turn the child’s head, pull on it; it is necessary to
carry out an operative expansion of the vulvar ring more often. Don’t
waste time deciding whether to have a caesarean section. More
accurately remove the child.