BIRTH INJURIESINTRODUCTION:

As a result of the birth process, some injuries occur that may be minor, where as others may be more serious. Parental reaction to any injury sustained by their newborn infant at birth may be out of proportion to the harm that has occurred.

BIRTH INJURIES:Birth injuries is an impairment of the infants body function or structure due to adverse influence that occurred at birth. Injury commonly occurs during labour or delivery.

It is defined as those sustained during labor and delivery. Birth injuries may be severe enough to cause neonatal death, still birth or number of morbidities.

RISK FACTORS:Maternal

Primiparity

Short stature

Maternal pelvic anomalies

Prolonged or extremely rapid labor Oligohydramnios

Deep transverse arrest of descent of presenting part of the fetus

Foetal

Abnormal presentation Very low birth weight infant or extremely prematurity

Foetal macrosomia Large fetal head Foetal anomalies

Interventional/ inorganic

Use of mid forceps Inappropriate vacuum application Versions& extractionsSITE OF INJURY AND TYPE OF INJURYSITE OF INJURYTYPE OF INJURY

Soft tissuesSkin lacerations, abrasions, fat necrosis

MusclesSternocleidomastoid

NerveFacial

Brachial plexus

Duchenne Erb(C5,C6)

Klumpke

Spinal Cord

Phrenic n

Horners SyndromeRecurrent laryngeal nerve

ScalpLacerations,abscess, hemorrhage

SkullCephalo hematoma

Subgaleal hematoma

Fracture

Intra cranialHemorrhage Intraventricular

Subdural

Subarachnoid

Bones Fracture clavicle Hemerus

Femur

Skull

Nasal bones

EyeHemorrhage Subconjunctiva

Vitreous

Retina

Viscera Rupture of liver, adrenal gland, spleen testicular injury

SOFT TISSUE INJURIES:

Abrasions, laceration, Subcutaneous fat necrosis

Clinical features:

Appear in first two weeks of life

Irregularly shaped , hard , non pitting, subcutaneous plaque with overlying dusky, red purple discoloration

Sites:

Cheeks, arms, back , buttocks, thighs

MUSCLE INJURY

Sternocledomastoid (SCM )muscle injury

Sternocleidomastoid (SCM) injury (congenital torticollis) is characterized by a well circumscribed immobile mass in the mid point of the SCM. The head tilts towards the involved side. The patient cannot move the head normally. Sternomastoid hematoma usually appears about 7-10 days after birth and is usually situated at the mid position of the muscle. It is caused by rupture of the muscle fibers and blood vessels, followed by a hematoma and cicatrical contraction. It may be associated with difficult breech delivery or attempted delivery following shoulder dystocia or excessive lateral flexion of the neck even during normal delivery. There is transient torticollis and it is wise not to massage.

Pathology:

Injury to the SCM muscle/ fascia disruption during delivery

haematoma formation

Affection of surrounding musculoskeletal structures(fibrosis

Torticollis

Management:

Treatment is conservative.

Stretching of the involved muscle should be done several times a day.

Recovery is rapid in majority of cases. Surgery is needed if it persists after 6 months of physical therapy.

Nursing Management:

Stretching exercises to the affected SCM . It include,

Tilting the head away from the affected side so that the ear can be brought into contact with the opposite shoulder

Rotating the chin towards the tight SCM muscle. When head is in the stretched position , it should be held there for about 10 seconds

The exercise should be done 4-6 times in a day with about 20 repetitions of each exercise at each time. The infant is positioned in the crib so that the head is supported by sandbags in the corrected positions. This is done to prevent the flattening of the occiput or the development of facial asymmetry The head should be rotated so that it tilts away from the involved side and so that the face looks towards the side of the tight muscle. Crib toys should be placed so that the neck is stretched when the infant reaches for them.

Proper demonstration of the exercise to the parents

NERVE INJURIES:

Commonly associated with breech delivery

Cause- Hyper extension , traction,& over stretching with simultaneous rotation

Types- Facial palsy, Brachial Palsy, Erbs palsy, Klumpkes Palsy, Brachial plexus injury, phrenic nerve injury (C3,4 and 5)

Facial palsyCause:Compression by the forceps blades. It is involved by direct pressure of the forceps blades or by hemorrhage and edema around the nerve.Clinical features:

Assymmetrical crying facies, the eye of the affected side which remains open and eyelids are immobile. On crying , the angle of the mouth is drawn over to the unaffected side. No nasolabial fold is present. Sucking remains unaffected.Mangement:

Protection of the eye, which remains open even during sleep, with synthetic tears (1% methyl cellulose drops).

The condition usually disappears within weeks unless complicated by intracranial damage

Neurological and surgical consultation

Nursing management:

Feeding is first given by NG tube in order to prevent aspiration

When possible the infant should be feed orally using a soft nipple having a large hole

Eye shield to prevent drying of the conjunctiva and cornea

Gentle restraining of the hands

Brachial palsyEither the nerve roots or the trunk of the brachial plexus are involved. The damage of the nerve is due to stretching (common) or effusion or hemorrhage inside the sheath.

Causes :

Undue traction on the neck during attempted delivery of the shoulder.

hyperextension of neck to one side with forcible digital extension and abduction of the arm in an attempt to deliver the shouldersErb paralysis(C5-6):

Affected arm in adducted and internally rotated with elbow extended (Waiters tip position)

Forearm is prone and wrist is flexed

The limb falls limply to the side of the body when passively adducted

Moros, biceps, radial reflexes absent on affected side

Grasp reflex intact

Klumpkes paralysis (C7& T1)

intrinsic muscles of the hand are affected & grasp is absent( claw Hand)

Biceps and radial reflex are present

Horners syndrome, if cervical sympathetic fibres of T1 are involved

injury to the entire brachial plexus the entire arm is flaccid , all reflexes are absent

Complications

Contractures

Management:

X ray studies to rule out bony injury, chest examination to rule out diagphragmatic involvement

Passive movements started after 7-10 days( After resolution of the nerve edema)

Splints to prevent wrist and digit contractures

Recovery:

improvement in 1-2 wks normal function

no improvement is 6 months permanent deficit

Nursing Management:

The goal of the care is to prevent the contractures of the paralysed muscle

The arm should be partially immobilisd in a position of maximum relaxation so that the nonparalysed muscles cannot exert pull on the affected muscles

By the use of splint or brace when the upper arm is paralysed, the arm is abducted 90 degrees and rotate internally at the shoulder with the elbow flexed so that the palm of the hand is turned towards the head

When the lower arms and hand areparalysed , the lower arm and the wrist are kept in a neutral position and the hand is placed over a small pad

The infant is immobilized for 6months during part of the day and night

A longer period of immobilization may be necessary for some infants.

After 7-10 days , complete ROM exercises may be given gently several times each day inorder to maintain muscle tone and prevent contraction deformity

Before or splint or brace is obtained , the nurse can pin the infants long shirt sleeve to the mattress covering

When any form of immobilization is used , the fingers and hands must be observed for any coldness or discolouration and the skin for signs of irritation

When a splint is used the parents must be taught how to apply it properly and how to provide the skin care

They should be taught the proper dressing technique- affected hand first and on removing the unaffected hand first

More physical contact and affection than normal child

Brachial plexus injury

The incidence is about .1 to 0.2% of shoulder dystocia, even in normal delivery, macrosomia, malpresentation and instrumental delivery.

phrenic nerve palsy(C3, 4, & 5)

Unilateral and associated with brachial plexus injuries

Clinical features:

Respiratory distress ipsilaterally diminished breath sounds

Management:

USG/Fluroscopic studies- Paradoxical movements of the diaphragm

Pulmonary toilet

Refractory cases- diagphramatic placation, phrenic nerve pacing

Nursing management:

The neonate is placed on the affected side , and oxygen is given as necessary

The neonate is treated like any infant having respiratory difficulty

The infant should be feed intravenously , by gavage , and then orally as the condition improves

Observe for the symptoms of pulmonary infection, which may complicate the infants condition

SCALP INJURIES

1) Associated with foetal monitoring

Fetal scalp blood sampling for the estimation of PH- heomorrhage and infection Foetal scalp electrode for FHR monitoring

2) Cephal hematoma

Definition: it is the collection of blood between the pericranium and the flat bones of the skull,usually unilateral and over a parital bone.it is due to the rupture of a small emissary vein from the skull and may be associated with fracture of the skull bone. This may be caused by forceps delivery but also may be met with following normal labour. It is never present at birth but gradually develops after 12-24 hours. Prognosis:

Prognosis is good.

Rarely suppuration occurs.

Complication: Hypotension

Infection

Associated skull fractures

Resolution:

Slow resolution occurs over 1-2 months , occasionally with residual calcification

Management:

Observation

No active reatment is required

Prevention of infection is necessary

A head CT should be taken if neurological symptoms are suspected

Transfusion and photo therapy(extensive haematomas) Rule out bleeding disorders Aspiration for smear & culture if infection is suspected

Skull X -rays and CT scan to diagnose depressed skull fractures3) Subgaleal hematomaDefinition: Blood that has invaded the potential space between the skull periosteum and scalp galea aponeurosis , and the area that extend posterior from the orbital ridges to the occipital and laterally to the ears

Complication:

Spread of hematoma leading to hemorrhage , shock and death, periorbital and auricular ecchymosis

Infection

Resolution: Very slow resorption

Management:

Observation

Treatment for blood loss, hyperbilirubinemia and infection

Rule out bleeding disorders and antibiotics if infection occurs

INTRACRANIAL HAEMORRHAGES:Intracranial hemorrhage (ICH) may be(a) External to the brain (epidural, subdural or subarachnoid spaces); (b) in the parenchyma of brain (cerebrum or cerebellum); (c) into the ventricles from subependymal germinal matrix or choroid plexus.

TYPES:TRAUMATIC Extradural hemorrhage:

Usually associated with fracture skull bone.Subdural :

Slight hemorrhage may occur following:

fracture of skull bone

rupture of the inferior sagittal sinus or

rupture of small veins leaving the cortex.

Massive hemorrhage may occur following

Tear of the tentorium cerebelli thereby opening up the straight sinus or rupture of the vein of Galen or its Faix cerebri tributaries Injury to the superior sagittal sinus. Clinical presentation: Nuchal rigidity

Coma

apnea bulging fontanelle (increased intracranial pressure) nonreactive pupils

seizures may be present. Pathophysiology:

Normally, the faix cerebri is attached to the tentorium cerebelli and both help in anchoring the base of the skull to the vault.During excessive moulding, there is compression of the diameter of engagement (occipitofrontal In detlexed head) with elongation of the diameter at right angle to it (mentoivertical).This results in upward movement of the vault from the base. As a result, too much strain is put on the vertical fibetri of tentorium cerebellicalled stress fibers.

If the moulding is excessive or applied suddenly, these fibers are torn.As a result, it allows excessive elongation of the vault until the tear etends to involve the straight sinus or vein of Galen or its tributaries.The resulting hemorrhage may be supratentorial or bublentoriid.Excessive moulding of the head lead to elongation of the mentovertical diamtter tear of the tentorium cerebelli

Causes:

Excessive moulding in deflexed vertex with gross disproportion

Rapid compression of the head during delivery of the after-coming head of breech or in precipitate labour

Forcible forceps traction following wrong application of blades Clinical features: The hemorrhage may be fatal and the baby is delivered stillborn or with severe respiratory depression. In lesser affection, the baby recovers from the respiratory depression. Gradually, the feature of cerebral irritation appears such as, frequent high pitch cry, neck retraction, incoordinate ocular movements, convulsion, vomiting and bulging of anterior fontanelle. ANOXIC Intraventricular Hemorrhage-The pathogenesis of IVH in the term infant is more likely due to trauma (difficult delivery) or perinatal asphyxia. In the preterm infant IVH is mainly due to ischemia/reperfusion. Clinical presentation: clinically silent, seizures, apnea, irritability, lethargy, vomiting or a full fontanelle. Diagnosis:

neuroimaging studies: Real time portable cranial ultrasonography is the procedure of choice in the term newborn. IVH is diagnosed by head CT or CUS. MRI is also helpful.

SubarachnoidThis may be due to tear of some tributary veins running from the brain to one of the sinuses. The symptoms may appear late (one week). Clinical presentations are: Seizures

irritability and lethargy with focal neurological signs.

Intracerebral- Small petechial hemorrhage may occur in the brain substance (parenchyma) due to anoxia. It usually occurs in mature babies following prolonged labor. Clinical features are vague

loss of weight

flaccid limbs

worried and anxious expression. Risk factors for GMHAVH: Extreme prematurity

birth asphyxia

the need for vigorous resuscitation at birth

presence of neonatal seizures

sudden elevation of blood pressure.

PREVENTION: Comprehensive antenatal and intranatal care is the key to success in the reduction of intracranial injuries-Antenatal prevention of IVH/GMH:

Tocolysis with indomethacin should be avoided.

In utero transfer of preterm labor to a center with NICU.

Cesarean delivery before active phase of labour in preterm infants.

Antenatal steroids can reduce the risk by three fold.

To prevent or to detect at the earliest, intrauterine fetal asphyxia by intensive fetal monitoring.

To avoid traumatic vaginal delivery in preference to cesarean section. Difficult forceps should be avoided.

Administration of vitamin K 1 mg intramuscularly soon after birth in susceptible babies. Postnatal prevention: Avoid birth asphyxia

fluctuation of blood pressure

correct acid base abnormalities

Surfactant therapy is found helpful

INVESTIGATIONS:

Ultrasionography is used to detect intraventricular hemorrhage;

Doppler ultrasonography can detect any change in cerebral circulation;

CT scan is useful to detect cortical neuronal injury;

Magnetic resonance imaging( MRI) is used to evaluate any hypoxic ischemic brain injury;

CSF Elevated RBCs, WBCs and protein MANAGEMENT: Supportive care: To maintain normal circulatory volume, cerebral perfusion, serum electrolytes and blood gases. Packed red blood cells transfusion may be needed where IVH is large. Thrombocytopenia and coagulation parameters should be corrected, seizures should be treated.

TREATMENT:

Follow-up with serial neuroimaging cranial ultrasound (CUS or CT) to detect any progressive hydrocephalus.

Anticonvulsant

Phenobarbitone-3-5 mg/kg/day in divided doses at 12 hourly intervals intramuscularly or orally

Phenytoin 20 mg/kg intravenously as loading dose at the rate of 1 mg/kg/min followed by maintenance dose of 5 mg/kg/day with cardiac monitoring;

Diazepam 0.1 mg/kg intravenously thrice daily. Open surgical evacuationSerial CT is indicated before surgical intervention. The infant should be monitored for any hydrocephalus. Surgical removal of the clot including the capsule may have to be done to prevent development of neurological sequelae;

Rarely subdural-peritoneal shunting may be needed. Neurosurgeon is consulted.PROGNOSIS:

Depends upon the severity, brain lesion, birth weight and gestational age of the infant

FRACTURESskull

Bones involved- Frontal, parital, occipital

complications:

Brain contusions

Disruption of blood vessels

seizures hypotension & death

dural lacerationManagement:

X ray and CT scan for diagnosis

linear fractures with no neurological manifestations- observation

depressed fractures- neurological evaluation

Repeat X- rays at 8-12 weeks to look for growing fractures

Facial mandibular fractures

Features:

Facial asymmetry

Ecchymosis

Oedema

Crepitance

Respiratory distress

Poor feeding

Dislocation of the cartilaginous nasal septumComplications:

unrecognized and untreated facial fractures- craniofacial malformations, ocular, respiratory & mastication problems

Management: protection of airway

plastic surgeon; ENT reference

Cranial CT scan

Treatment of fracturesNursing considerations:

Maintain proper body alignment

Gentle handling Careful during dressing

Immobilization

Relief of pain

SPINAL CORD INJURIES

Cause:

Hyperextented head

Vaginal breech delivery

Clinical feature:

Alert yet flaccid

Low APGAR score

Motor function absent distal to the level of injury with loss of deep tenden reflexes

Temperature instability

Constipation and urinary retension

Sensory level if cord is transected

Management:

Resuscitation and prevention of further injuries

Head to be immobilized

Neurological examinations and cervical spinal Xrays

CT scan, myelogram, MRI if required

Attention to bowel/ bladder functionEYE INJURIESOcular injuries

Types:

a. retinal and subconjunctival haemorrhages- vaginal delivery

b. ocular and periorbital injuries- forceps delivery

c. Disruption of descenets membranes of the Cornea(Scarring(Astigmatism & Amblyopia

d. HYphaema, Vittreous haemorrhage

e. local lacerations

f. palpebral oedema

g. orbital fractures with abnormal extra ocular muscle function

h. lacrimal gland / duct damage

Management:

Ophthalmic consultations

PREVENTION OF BIRTH INJURIES IN NEWBORN

A comprehensive antenatal and postnatal care is key to the success in the reduction of birth trauma.

Antenatal Period:

To screen out the at risk babies

To employ liberal use of LSCS

Intranatal period:

Normal delivery:

Continuous foetal monitoring

Attention during episiotomy

The neck should not be unduely stretched

Preterm delivery: To prevent anoxia

To avoid strong sedative

Liberal episiotomy and use of forceps to minimize intracranial compression

To administer inj. Vit K to minimize or prevent haemorrhage from the traumatized area

Forceps delivery:

Difficult cases- LSCS

Proper application of pressure

Ventouse delivery:

Avoid in preterm

Vaginal breech delivery:

Proper selection of casesNURSING MANAGEMENT IN BIRTH INJURIES

Nursing Diagnoses

(a) Injuryrelatedto birthtrauma

(b) Impaired physical mobility related tobrachial plexus injury

(c) Impaired gas exchange related to diaphragmatic paralysis

(d) Acute pain related to injury

Nursing Interventions

Nursing interventionsfor birth injuries include:

Administeringtreatment to the new born based on the injury and according to the primary care providers prescriptions. Preventing further trauma by decreasing stimuli and movement. Educating theinfants parents and family regardingthe injury and the management of theinjury. Promoting parent-newborn bonding.CONCLUSION:

Since many of the birth injuries do not require treatment , the nurse can help to clear up the misconceptions and alleviate anxieties by simple explanations.Assisting the parents to cope with the more serious injuries requires more through explanations and constant support by members of the health team.BIBLIOGRAPHY:1. D.C Dutta. Textbook Of Obstetrics including Perinatology & Contraception. 7th edition. Central Publication; Culcutta: 2013. Page no 483-487.

2. Meharban Singh . Care of Newborn . 6th edition. Published by Narinder K. Sagar; NewDelhi: 2004. Page no 325,400.

3. Lowdermilk ,Perry, Cashion. Maternity Nursing.8th edition. Mosby Publishers. Page no-775.

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8. Hatfield N.T. Broadribbs introductory Paediatric nursing. 7th edition. Wolters Kluwer: New Delhi; 2009.9. Fraser Cooper. Myles text book for midwives. 14th edition. Churchill Livinstone Publishers. .10. Lynna Y.Littileton. Maternity nursing care. 1st edition. Delmar lerning pubishers. Page no 895.