Prepared by :

Ayda khader

oct oct

20152015

Outlinetrauma during birth to skin and

superficial tissues, muscle, nerves and bones

major types of neonatal haemorrhage due to trauma

neonatal convulsionsspecific interventions with parent

Definition

The term birth injury is used to denote:

avoidable and unavoidable

mechanical, hypoxic and ischemic injury

affecting the infant

during

labor and delivery.

Injuries to the infant that result from mechanical

forces (i.e., compression, traction) during the birth

process are categorized as

birth trauma.

Birth injuries may result from :Inappropriate or deficient medical skill or attention.They may occur, despite skilled and competent obstetric care.

Incidence as been estimated at 2-7/1,000 live births5-8/100,000 infants die of birth trauma25/100,000 die of anoxic injuriesSuch injuries represent 2-3% of infant

deaths.

Predisposing factors:Macrosomia, Prematurity, Cephalopelvic disproportion,Dystocia, Prolonged or rapid delivery Breech presentation.

Predisposing factorsPrimigravidaCephalopelvic

disproportionSmall maternal staturematernal pelvic anomaliesProlonged or rapid laborArrest of descent of

presenting fetal partOligohydramniosResuscitation with CPR

Abnormal presentation (breech/face)

Use of forceps or vacuum extraction

VersionsVLBW infant or extreme

prematurityMacrosomiaLarge fetal headFetal anomaliesFetal neuromuscular disease

Trauma during birth includes:

trauma to skin and superficial tissuesmuscle traumanerve traumafractures

Birth InjuriesSoft Tissue Injuries (Abrasions, Bruising, Fat Necrosis, Lacerations)Extracranial Bleeding (Caput succedaneum, Cephalhematoma, Subgaleal Hematoma)Intracranial Bleeding (Subarachnoid, Epidural, Subdural, Cerebral, Cerebellar)Nerve Injuries (Facial and Cervical Nerve Roots, Horner Syndrome, Recurrent Laryngeal Nerve)

Fractures (Clavicle, Humerus, Femur, Skull)DislocationsTorticollis (Sternocleidomastoid injury)Eye Injuries (Subconjunctival and Retinal

Hemorrhage)Solid Organ Injury (liver, spleen, kidney, adrenal

glands)

All other skin injuries should be detected during the midwife's detailed examination of the baby immediately after birth. All trauma should be made known to the parents and reported to the baby's doctor.

Soft Tissue InjuriesBruises and Petechiae

Can be seen in the GU area in breech presentationsCan be seen around the head and neck when there is a

nuchal cord or precipitous deliveryAppearance of new bruises or petechiae after delivery

warrants further investigation to r/o sepsis/DIC or bleeding disorder

Abrasions and lacerations

Abrasions and lacerations should be kept clean and dry. If there are signs of infection, further medical consultation should be sought by the midwife or parents. Antibiotics may be required. Deeper lacerations may require closure with butterfly strips or sutures. Healing is usually rapid with no residual scarring

Fat Necrosis– Well-circumscribed firm

nodule with purplish discoloration

– Usually occurs after forceps use, but can occur at other sites of trauma

– Resolves spontaneously over weeks to months

Soft tissue trauma involves oedematous swellings and/or bruising. During labour the fetal part overlying the cervical os may be subjected to pressure, a ‘girdle of contact’, with reduced venous return and resultant congestion and oedema.

Caput succedaneum

With cephalic presentation

may be a diffuse oedematous swelling under the scalp and above the periosteum

Soft tissue swelling / edema / petechiae / ecchymoses

Crosses suture lines

A ‘false’ caput succedaneum can also occur if a vacuum extractor cup is used; because of its distinctive shape, the swelling is known as a ‘chignon

A caput succedaneum is present at birth, does not usually enlarge, can ‘pit’ on pressure

The swelling is usually self-limiting, resolving by 36 hrs of life

An abraded chignon usually heals rapidly if the area is kept clean, dry and is not irritated

Uncomplicated oedema and bruising usually resolve within days

serious complications require specific treatment, and take longer to resolve

These complications include excessive haemolysis resulting in hyperbilirubinaemia; excessive blood loss resulting in hypovolaemia, shock, anaemia and disseminated intravascular coagulation

Muscle traumaInjuries to muscle result from tearing or when the blood supply is disrupted. If the techniques for assisting at these stages of birth are correctly applied, torticollis is preventable

Lateral tilt of the neck andhead typically due to a tight

sternocleidomastoid musclHead and neck tilt toward the

involved side and chin is turned away from the involved side

The muscle length is shortened, therefore the neck is twisted to the affected side, a torticollis or wry neck

Torticollis

The right and left sternomastoid muscles run from the respective side of the top of the sternum, along the right or left side of the neck and are inserted into the mastoid process of the right or left temporal bone

A 1–3 cm, apparently painless, hard lump of blood and fibrous tissue is felt on the affected sternomastoid muscle

The swelling will usually resolve over several weeks to months with minimal sequelae

Stretching exercises are successful in 90% of the cases under the guidance of a physiotherapist

Surgical correction may be considered in resistant cases after 1 year of age

Nerve traumaThe nerves most commonly traumatized are

the facial and brachial plexus nerves. Spinal cord injury is very rare

Facial palsy can be caused by pressure on the facial nervesDue to Compression may occur in the uterus but is more likely during birth by 1) the maternal sacral promontory or2) a mis-applied forceps blade. affected side of the face droops and the infant is unable to close the eye tightly on that side. When crying the mouth is pulled across to the normal side.Spontaneous resolution is usually within 7–10 days; this may extend to months or years if the damage is severe

There is no specific treatment. If the eyelid remains open, regular instillation of eye drops lubricate the eyeball.

Feeding difficulties are usually overcome by the baby's own adaptation, although alternative feeding positions may help.

Brachial plexus

Nerve roots exiting from the spine at the fifth to eighth cervical and the first thoracic vertebrae form a matrix of nerves in the neck and shoulder; the brachial plexus.

Brachial plexus trauma usually results from excessive lateral flexion, rotation or traction of the head and neck during vaginal breech birth or when shoulder dystocia occurs.

The possible damage ranges from oedema to haemorrhage to tearing of the nerves.

There are three main injuries: Erb's palsy, Klumpke's palsy and total brachial plexus palsy.

These injuries can be unilateral or bilater

Three forms - depending on site and extent of trauma

5th and 6th cervical roots - upper arm (Erb-Duchenne) = most common form

8th cervical and 1st thoracic roots - lower arm (Klumpke) = extremely rare

Paralysis of entire arm = rare

Erb's palsy• There is paralysis of the shoulder and arm (not

the hand) due to damage to the upper brachial plexus involving the fifth and sixth cervical nerve roots

• The baby's affected arm is inwardly rotated, the elbow extended, the wrist pronated and flexed and the hand partially closed; the ‘waiter's tip position.

• PlMoro, biceps, and radial reflexes are absent on the affected side. Grasp reflex is usually man’s

Klumpke's palsy• It is less common• This is due to damage to the lower brachial

plexus involving the seventh and eighth cervical and the first thoracic nerve roots.

• The shoulder and upper arm are unaffected but the lower arm, wrist and hand are paralysed resulting in weakness of the intrinsic muscles of the hand wrist drop and grasp reflex is absent.

• Frequently with ipsilateral Horner’s syndrome (enophthalmus, ptosis, miosis, anhidrosis) - cervical sympathetic fibers from 1st thoracic root affected

Horner’s Syndrome

Total brachial plexus palsyoccur in :

1.Macrosomic infants and when lateral traction is exerted on the head and neck during delivery of the shoulder in a vertex presentation,2. When the arms are extended over the head in a breech presentation, or 3.When excessive traction is placed on the shoulders.

Total brachial plexus palsy• There is complete paralysis of the shoulder, arm

and hand, lack of sensation, and circulatory problems due to damage to all brachial plexus nerve roots.

• If there is bilateral paralysis, spinal injury should be suspected.

• All types of brachial plexus trauma will require further investigations such as X-ray and ultrasound scanning (USS) of the clavicle, arm, chest and cervical spine, and assessment of the joints.

• Passive movements of the joints and limb can be initiated under the direction of a physiotherapist.

• At 1 month of age, magnetic resonance imaging (MRI)can offer specific data on nerve damage.

• Complete recovery within 6 months is expected for 52%of babies, 2% will have no recovery and 46% will

have incomplete recovery

• Babies with no functional recovery by 6 months may require microsurgical nerve repair

Phrenic nerve palsy

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

Lateral hyperextension of neck causes overstretching or avulsion of 3rd, 4th and 5th cervical roots which supply phrenic nerve

Respiratory distress, risk of infection, elevated hemidiaphragm, paradoxical diaphragmatic movement, atelectatic areas

If no improvement within one month, recovery unlikely and plication needs to be considered

Laryngeal nerve injuryLaryngeal nerve is part of

vagus nerve - in neck behind jugular vein and carotid artery

10% of vocal cord paralysis caused by birth trauma

Hoarse cry, stridorRisk for aspiration, feeding

problemsRecovery often over 4 - 6

weeks, sometimes longer