BIRTH TRAUMA

Introduction
The majority of birth injuries are minor and often unreported.
Occasionally, though, birth injuries may be so severe as to be fatal or
leave the child with a permanent disability. They may occur because
of inappropriate or deficient medical skills or attention, but they also
can occur despite skilled and competent obstetrical care. Birth injuries
are mostly iatrogenic, and the legal implications of these should
be noted. Most of these injuries can be managed nonoperatively, but
prompt identification of those that will need surgical intervention
is essential.
DEFINITION
Injuries to the infant that result from mechanical forces (i.e., compression,
traction) during the birth process are categorized as birth trauma.

Demographics
The incidence of significant birth injuries in the United Sates is 68
per 1,000 live births, accounting for less than 2% of perinatal mortality.
1 In Africa, statistics on birth injuries are lacking. However, a survey
of rural Egyptian birth attendants in different regions revealed an
overall prevalence of birth injuries at 7%, and up to 17% in the Aswan
region.2 Autopsy studies on stillbirths from Accra, Ghana, also estimate
the incidence of perinatal deaths due to birth trauma as 5.4%.

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Birth Trauma
Updated: Feb 2, 2015

Overview

Etiology
Prognosis
Soft Tissue Injury
Brachial Plexus Injury
Cranial Nerve Injury
Laryngeal Nerve Injury
Spinal Cord Injury
Bone Injury
Intra-Abdominal Injury

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Multimedia Library
References

Overview
Injuries to the infant that result from mechanical forces (ie, compression,
traction) during the birth process are categorized as birth trauma. Factors
responsible for mechanical injury may coexist with hypoxic-ischemic insult;
one may predispose the infant to the other. Lesions that are predominantly
hypoxic in origin are not discussed in this article.
Significant birth injury accounts for fewer than 2% of neonatal deaths and
stillbirths in the United States; it still occurs occasionally and unavoidably,
with an average of 6-8 injuries per 1000 live births. In general, larger
infants are more susceptible to birth trauma. Higher rates are reported for
infants who weigh more than 4500g.
Most birth traumas are self-limiting and have a favorable outcome. Nearly
one half are potentially avoidable with recognition and anticipation of
obstetric risk factors. Infant outcome is the product of multiple factors.
Separating the effects of a hypoxic-ischemic insult from those of traumatic
birth injury is difficult.
Risk factors for birth trauma include the following [1] :
Large-for-date infants, especially infants who weigh more than 4500

Instrumental deliveries, especially forceps (midcavity) or vacuum [2]

Vaginal breech delivery
Abnormal or excessive traction during delivery
Occasionally, injury may result from resuscitation. Recognition of trauma
necessitates a careful physical and neurologic evaluation of the infant to
establish whether additional injuries are present. Symmetry of structure
and function should be assessed, the cranial nerves should be examined,
and specifics such as individual joint range of motion and scalp/skull
integrity should be evaluated.

Etiology
The birth process is a blend of compression, contractions, torques, and
traction. When fetal size, presentation, or neurologic immaturity
complicates this event, such intrapartum forces may lead to tissue
damage, edema, hemorrhage, or fracture in the neonate. The use of
obstetric instrumentation may further amplify the effects of such forces or
may induce injury alone. Under certain conditions, cesarean delivery can
be an acceptable alternative but does not guarantee an injury-free birth.
Factors predisposing to injury include the following:

Prima gravida

Cephalopelvic disproportion, small maternal stature, maternal pelvic

anomalies
Prolonged or rapid labor
Deep, transverse arrest of descent of presenting part of the fetus
Oligohydramnios
Abnormal presentation (breech)
Use of midcavity forceps or vacuum extraction
Versions and extractions
Very low-birth-weight infant or extreme prematurity
Fetal macrosomia
Large fetal head
Fetal anomalies

CLASSIFICATION OF BIRTH INJURIES

Soft tissue injuries

Erythema petechia
Ecchymosis
Lacerations
Subcutaneous fat necrosis
Skull injuries

Caput succedaneum
Cephalhematoma
Linear fractures

Facial injuries

Subconjunctival hemorrhage
Retinal hemorrhage

Musculoskeletal injuries

Clavicular fractures
Fractures of long bones
Sternocleidomastoid injury
Intra-abdominal injuries

Liver hematoma
Splenic hematoma
Adrenal hemorrhage
Renal hemorrhage
Peripheral nerve injuries

Facial palsy
Unilateral vocal cord paralysis
Radial nerve palsy
Lumbosacral plexus injury

Soft Tissue Injury

Soft tissue injury is associated with fetal monitoring, particularly with fetal
scalp blood sampling for pH or fetal scalp electrode for fetal heart
monitoring, which has a low incidence of hemorrhage, infection, or
abscess at the site of sampling.

Cephalhematoma
Cephalhematoma is a subperiosteal collection of blood secondary to
rupture of blood vessels between the skull and the periosteum; suture lines
delineate its extent. Most commonly parietal, cephalhematoma may
occasionally be observed over the occipital bone.
The extent of hemorrhage may be severe enough to cause anemia and
hypotension, although this is uncommon. The resolving hematoma
predisposes to hyperbilirubinemia. Rarely, cephalhematoma may be a
focus of infection that leads to meningitis or osteomyelitis. Linear skull
fractures may underlie a cephalhematoma (5-20% of cephalhematomas).
Resolution occurs over weeks, occasionally with residual calcification.
No laboratory studies are usually necessary. Skull radiography or
computed tomography (CT) scanning is performed if neurologic symptoms
are present. Usually, management solely consists of observation.
Transfusion for anemia, hypovolemia, or both is necessary if blood
accumulation is significant. Aspiration is not required for resolution and is
likely to increase the risk of infection.
Hyperbilirubinemia occurs following the breakdown of the red blood cells
(RBCs) within the hematoma. This type of hyperbilirubinemia occurs later
than classic physiologic hyperbilirubinemia. The presence of a bleeding
disorder should be considered. Skull radiography or CT scanning is also
performed if a concomitant depressed skull fracture is a possibility.

Subgaleal hematoma
Subgaleal hematoma is bleeding in the potential space between the skull
periosteum and the scalp galea aponeurosis. Ninety percent of cases
result from a vacuum applied to the head at delivery. Subgaleal hematoma
has a high frequency of occurrence of associated head trauma (40%),

such as intracranial hemorrhage or skull fracture. [4] The occurrence of these

features does not significantly correlate with the severity of subgaleal
hemorrhage.[5]
The diagnosis is generally a clinical one, with a fluctuant, boggy mass
developing over the scalp (especially over the occiput). The swelling
develops gradually 12-72 hours after delivery, although it may be noted
immediately after delivery in severe cases. The hematoma spreads across
the whole calvaria; its growth is insidious, and subgaleal hematoma may
not be recognized for hours.
Patients with subgaleal hematoma may present with hemorrhagic shock.
The swelling may obscure the fontanelle and cross suture lines
(distinguishing it from cephalhematoma). Watch for significant
hyperbilirubinemia. In the absence of shock or intracranial injury, the longterm prognosis is generally good.
Laboratory studies consist of a hematocrit evaluation. Management
consists of vigilant observation over days to detect progression and
provide therapy for such problems as shock and anemia. Transfusion and
phototherapy may be necessary. Investigation for coagulopathy may be
indicated.

Caput succedaneum
Caput succedaneum is a serosanguineous, subcutaneous, extraperiosteal
fluid collection with poorly defined margins; it is caused by the pressure of
the presenting part against the dilating cervix. Caput succedaneum
extends across the midline and over suture lines and is associated with
head molding. Caput succedaneum does not usually cause complications
and usually resolves over the first few days. Management consists of
observation only.

Abrasions and lacerations

Abrasions and lacerations sometimes may occur as scalpel cuts during
cesarean delivery or during instrumental delivery (ie, vacuum, forceps).
Infection remains a risk, but most of these lesions uneventfully heal.
Management consists of careful cleaning, application of antibiotic ointment,
and observation. Bring edges together using Steri-Strips. Lacerations
occasionally require suturing.

Subcutaneous fat necrosis

Subcutaneous fat necrosis is not usually detected at birth. Irregular, hard,
nonpitting, subcutaneous plaques with overlying dusky, red-purple
discoloration on the extremities, face, trunk, or buttocks may be caused by
pressure during delivery. No treatment is necessary. Subcutaneous fat
necrosis sometimes calcifies.

Brachial Plexus Injury

Peripheral nerve damage in the form of brachial plexus injury occurs most
commonly in large babies, frequently with shoulder dystocia or breech
delivery. Incidence for brachial plexus injury is 0.5-2 per 1000 live births.
Most cases are Erb palsy; entire brachial plexus involvement occurs in
10% of cases.
Traumatic lesions associated with brachial plexus injury include the
following:

Fractured clavicle (10%)

Fractured humerus (10%)
Subluxation of cervical spine (5%)
Cervical cord injury (5-10%)
Facial palsy (10-20%)
Erb palsy (C5-C6) is most common and is associated with lack of shoulder
motion. The involved extremity lies adducted, prone, and internally rotated.
Moro, biceps, and radial reflexes are absent on the affected side. The
grasp reflex is usually present. Five percent of patients have an
accompanying (ipsilateral) phrenic nerve paresis.
Klumpke paralysis (C7-8, T1) is rare and results in weakness of the
intrinsic muscles of the hand; the grasp reflex is absent. If cervical
sympathetic fibers of the first thoracic spinal nerve are involved, Horner
syndrome is present.
A study by Iffy et al indicated that an approximately four-fold rise in the
incidence of shoulder dystocia has occurred in the United States since the
mid-20th century, with a review of 11 other countries revealing no
comparable increase in most other nations. The investigators considered
the rise in dystocia to be primarily related to a trend in the United States,
starting in the 1980s, toward active management of the birthing process, in
place of a more conservative approach.[6]

Prognosis
No uniformly accepted guidelines for determining prognosis are available.
Narakas developed a classification system (types I-V) based on the
severity and extent of the lesion, providing clues to the prognosis in the
first 2 months of life.[7]
According to the collaborative perinatal study (59 infants), 88% of cases
resolved in the first 4 months, 92% resolved by 12 months, and 93%
resolved by 48 months.[8]In another study, which examined 28 patients with
upper plexus involvement and 38 with total plexus palsy, 92%
spontaneously recovered.[9]
Residual long-term deficits may include progressive bony deformities,
muscle atrophy, joint contractures, possible impaired growth of the limb,
weakness of the shoulder girdle, and/or Erb engram flexion of the elbow
accompanied by adduction of shoulder.

Workup
Workup consists of radiographic studies of the shoulder and upper arm to
rule out bony injury. The chest should be examined to rule out associated
phrenic nerve injury. Electromyography (EMG) and nerve conduction
studies are occasionally useful.
Fast spin-echo magnetic resonance imaging (MRI) can be used to
evaluate plexus injuries noninvasively in a relatively short time, minimizing
the need for general anesthesia. MRI can define meningoceles and may
distinguish between intact nerve roots and pseudomeningoceles (indicative
of complete avulsion).
Carefully performed, intrathecally enhanced CT myelography may show
preganglionic disruption, pseudomeningoceles, and partial nerve root
avulsion. CT myelography is more invasive and offers few advantages over
MRI.

Immobilization, physical therapy, and surgery

Management consists of prevention of contractures. Immobilize the limb
gently across the abdomen for the first week and then start passive rangeof-motion exercises at all joints of the limb. Use supportive wrist splints.
The best results from surgical repair appear to be obtained in the first year
of life.[10] Several investigators have recommended surgical exploration and
grafting if no function is present in the upper roots at age 3 months,
although the recommendation for early explorations is far from universal. [11]
Complications of brachial plexus exploration include infection, poor
outcome, and burns from the operating microscope. Patients with root
avulsion do not do well.
Palliative procedures involving tendon transfers have been of some use.
Results from a study by Ruchelsman et al of 21 children who suffered
brachial plexus birth injury indicated that patients who have no active wrist
extension following the trauma can be successfully treated with a tendon
transfer but that surgical outcomes tend to be worse in patients with global
palsy.[12]
Latissimus dorsi and teres major transfers to the rotator cuff have been
advocated for improved shoulder function in Erb palsy. One permanent and
3 transitory axillary nerve palsies have been reported from the procedure.

Cranial Nerve Injury

Cranial nerve and spinal cord injuries result from hyperextension, traction,
and overstretching with simultaneous rotation; they may range from
localized neurapraxia to complete nerve or cord transection.
Unilateral branches of the facial nerve and vagus nerve, in the form of
recurrent laryngeal nerve, are most commonly involved in cranial nerve
injuries and result in temporary or permanent paralysis.

Compression by the forceps blade has been implicated in some facial

nerve injury, but most facial nerve palsy is unrelated to trauma from
obstetric instrumentation (eg, forceps). The compression appears to occur
as the head passes by the sacrum.
Physical findings for central nerve injuries are asymmetrical facies with
crying. The mouth is drawn towards the normal side, wrinkles are deeper
on the normal side, and movement of the forehead and eyelid is
unaffected. The paralyzed side is smooth with a swollen appearance, the
nasolabial fold is absent, and the corner of the mouth droops. No evidence
of trauma is present on the face.
Physical findings for peripheral nerve injuries are asymmetrical facies with
crying. Sometimes evidence of forceps marks is present. With peripheral
nerve branch injury, the paralysis is limited to the forehead, eye, or mouth.
The differential diagnosis includes nuclear genesis (Mbius syndrome),
congenital absence of the facial muscles, unilateral absence of the
orbicularis oris muscle, and intracranial hemorrhage.

Management and recovery

Most infants begin to recover in the first week, but full resolution may take
several months. Palsy that is due to trauma usually resolves or improves,
whereas palsy that persists is often due to absence of the nerve.
Management consists of protecting the open eye with patches and
synthetic tears (methylcellulose drops) every 4 hours. Consultation with a
neurologist and a surgeon should be sought if no improvement is observed
in 7-10 days.

Diaphragmatic paralysis
Diaphragmatic paralysis secondary to traumatic injury to the cervical nerve
roots that supply the phrenic nerve can occur as an isolated finding or in
association with brachial plexus injury. The clinical syndrome is variable.
The course is biphasic; initially the infant experiences respiratory distress
with tachypnea and blood gases suggestive of hypoventilation (ie,
hypoxemia, hypercapnia, acidosis). Over the next several days, the infant
may improve with oxygen and varying degrees of ventilatory support.
Elevated hemidiaphragm may not be observed in the early stages.
Approximately 80% of lesions involve the right side and about 10% are
bilateral.
The diagnosis is established by ultrasonography or fluoroscopy of the
chest, which reveals the elevated hemidiaphragm with paradoxic
movement of the affected side with breathing.

Prognosis
The mortality rate for unilateral lesions is approximately 10-15%. Most
patients recover in the first 6-12 months. An outcome for bilateral lesions is

poorer. The mortality rate approaches 50%, and prolonged ventilatory

support may be necessary.
Management consists of careful surveillance of respiratory status, and
intervention, when appropriate, is critical.

Laryngeal Nerve Injury

Disturbance of laryngeal nerve function may affect swallowing and
breathing. Laryngeal nerve injury appears to result from an intrauterine
posture in which the head is rotated and flexed laterally. During delivery,
similar head movement (when marked) may injure the laryngeal nerve,
accounting for approximately 10% of cases of vocal cord paralysis
attributed to birth trauma.
The infant presents with a hoarse cry or respiratory stridor, caused most
often by unilateral laryngeal nerve paralysis. Swallowing may be affected if
the superior branch is involved. Bilateral paralysis may be caused by
trauma to both laryngeal nerves or, more commonly, by a central nervous
system (CNS) injury, such as hypoxia or hemorrhage, that involves the
brain stem. Patients with bilateral paralysis often present with severe
respiratory distress or asphyxia.
Direct laryngoscopic examination is necessary to make the diagnosis and
to distinguish vocal cord paralysis from other causes of respiratory distress
and stridor in the newborn. Differentiate from other rare etiologies such as
cardiovascular or CNS malformations or a mediastinal tumor.
Paralysis often resolves in 4-6 weeks, although recovery may take as long
as 6-12 months in severe cases. Treatment is symptomatic. Once the
neonate is stable, providing small, frequent feeds minimizes the risk of
aspiration. Infants with bilateral involvement may require gavage feeding
and tracheotomy.

Spinal Cord Injury

Spinal cord injury incurred during delivery results from excessive traction
or rotation. Traction is more important in breech deliveries (the minority of
cases), and torsion is more significant in vertex deliveries. The true
incidence of spinal cord injuries is difficult to determine. The lower cervical
and upper thoracic region for breech delivery and the upper and
midcervical region for vertex delivery are the major sites of injury.
Major neuropathologic changes consist of acute lesions, which are
hemorrhages, especially epidural lesions, intraspinal lesions, and edema.
Hemorrhagic lesions are associated with varying degrees of stretching,
laceration, and disruption or total transaction. Occasionally, the dura may
be torn, and rarely, vertebral fractures or dislocations may be observed.
The clinical presentation is stillbirth or rapid neonatal death with failure to
establish adequate respiratory function, especially in cases involving the
upper cervical cord or lower brainstem. Severe respiratory failure may be

obscured by mechanical ventilation and may cause ethical issues later.

The infant may survive with weakness and hypotonia, and the true etiology
may not be recognized. A neuromuscular disorder or transient hypoxic
ischemic encephalopathy may be considered. Most infants later develop
spasticity that may be mistaken for cerebral palsy.
The diagnosis is made using MRI or CT myelography. Little evidence
indicates that laminectomy or decompression has anything to offer. A
potential role for methylprednisolone is recognized. Supportive therapy is
important.
Prevention is the most important aspect of medical care. Obstetric
management of breech deliveries, instrumental deliveries, and
pharmacologic augmentation of labor must be appropriate. Occasionally,
injury may be sustained in utero.

Bone Injury
Fractures are most often observed following breech delivery, shoulder
dystopia, or both in infants with excessive birth weights.

Clavicular fracture
The clavicle is the most frequently fractured bone in the neonate during
birth; this is most often an unpredictable, unavoidable complication of
normal birth.[13] Some correlation with birth weight, midforceps delivery, and
shoulder dystocia is recognized.[14] The infant may present with
pseudoparalysis. Examination may reveal crepitus, palpable bony
irregularity, and sternocleidomastoid muscle spasm. Radiographic studies
confirm the fracture.
Healing usually occurs in 7-10 days. In order to decrease pain, arm motion
may be limited by pinning the infant's sleeve to the shirt. Assess other
associated injury to the spine, brachial plexus, or humerus.

Long bone fracture

Loss of spontaneous arm or leg movement is an early sign of long bone
fracture, followed by swelling and pain on passive movement. The
obstetrician may feel or hear a snap at the time of delivery. Radiographic
studies of the limb confirm the diagnosis and distinguish this condition from
septic arthritis.
Femoral and humeral shaft fractures are treated with splinting. Closed
reduction and casting is necessary only when displaced. Watch for
evidence of radial nerve injury with humeral fracture. Callus formation
occurs, and complete recovery is expected in 2-4 weeks. In 8-10 days, the
callus formation is sufficient to discontinue immobilization. Orthopedic
consultation is recommended.

Epiphysial displacement

Separation of the humeral or femoral epiphysis occurs through the

hypertrophied layer of cartilage cells in the epiphysis. The diagnosis is
clinically based on swelling around the shoulder, crepitus, and pain when
the shoulder is moved. Motion is painful, and the arm lies limp by the side.
Because the proximal humeral epiphysis is not ossified at birth, it is not
visible on radiography. Callus appears in 8-10 days and is visible on
radiography.
Management consists of immobilizing the arm for 8-10 days. Fracture of
the distal epiphysis is more likely to have a significant residual deformity
than is fracture of the proximal humeral epiphysis.

Intra-Abdominal Injury
Intra-abdominal injury is relatively uncommon and can sometimes be
overlooked as a cause of death in the newborn. Hemorrhage is the most
serious acute complication, and the liver is the most commonly damaged
internal organ.

Signs and symptoms of intraperitoneal bleed

Bleeding may be fulminant or insidious, but patients ultimately present with
circulatory collapse. Intra-abdominal bleeding should be considered for
every infant who presents with shock, pallor, unexplained anemia, and
abdominal distension. Overlying abdominal skin may have a bluish
discoloration. Radiographic findings are not diagnostic but may suggest
free peritoneal fluid. Paracentesis is the procedure of choice.

Hepatic rupture
The most common lesion is subcapsular hematoma, which increases to 45 cm before rupturing. Symptoms of shock may be delayed. Lacerations
are less common; they are often caused by an abnormal pull on the
peritoneal support ligaments or by the effect of excessive pressure by the
costal margin. Infants with hepatomegaly may be at higher risk. Other
predisposing factors include prematurity, postmaturity, coagulation
disorders, and asphyxia. In cases associated with asphyxia, a vigorous
resuscitative effort (often by unusual methods) is the culprit.
Splenic rupture is at least a fifth as common as liver laceration.
Predisposing factors and mechanisms of injury are similar.
Rapid identification and stabilization of the infant are the keys to
management, along with assessment of coagulation defect. Blood
transfusion is the most urgent initial step. Persistent coagulopathy may be
treated with fresh frozen plasma, the transfusion of platelets, and other
measures.
Patients with hepatic rupture usually present immediately following birth, or
the rupture becomes obvious within the first few hours or days after
delivery.

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Epidemiology
Skull injuries
Brachial plexus injury
Cranial nerve injury
Laryngeal nerve injury
Spinal cord injury
Fractures
Abdominal bleeding
Hypoxia
Prevention
References

PatientPlus articles are written by UK doctors and are based on research evidence, UK
and European Guidelines. They are designed for health professionals to use, so you may
find the language more technical than thecondition leaflets.

The passage from the safety of the uterus to the outside world is made hazardous by the
following:

The skull has to mould to facilitate passage through the pelvis and there may
becephalopelvic disproportion (CPD) - a mismatch between the size of the fetal
head and the capacity of the maternal pelvis. It may represent a large head in a
normal pelvis or a normal head in a restricted pelvis.

Malposition increases risk, whilst malpresentation necessitates Caesarean

section.

Contractions tax the reserve of the placenta.

The lungs and circulation undergo great changes.

Difficulties in delivery may compound the situation. Delivery may need to be expedited
because of fetal distress. This may present as fetal hypoxia (shown on electronic fetal
monitoring) and as acidosis on fetal blood sampling.
Injuries may be caused by a combination of mechanical trauma and hypoxia. Birth
injuries may be minor and transient but they can produce serious and permanent effect
as well as being fatal.[1] Previously it was assumed that most cases of cerebral
palsy were due to obstetric mismanagement, but now the figure for those caused by
obstetric trauma is put at around 5%.[2]

Epidemiology
Figures for major (but not fatal) birth trauma in the UK are not routinely collected. For
fatal outcomes a national intrapartum-related confidential enquiry reported and reviewed
37 cases in which birthweight was in excess of 2,500 grams for the year 1994-1995. [3]
American and Canadian papers found that birth trauma occurred in 2% deliveries
andbrachial plexus injury in 0.5 to 2.0 per 1,000 live births.[4][5]
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Risk factors
Risk factors for birth trauma include:

A large infant (especially if weighing more than 4,500 g).

Cephalopelvic disproportion (CPD).

Instrumental delivery (especially mid-cavity forceps orventouse delivery for deep

transverse arrest).

Breech delivery (vaginal delivery, or emergency caesarean section during labour

are associated with small, but significant risk of short-term increase in morbidity and
mortality).[6]

A premature baby (small head and incompletely formed skull - precipitate delivery
can cause "champagne cork popping" - risking intracranial haemorrhage).

Shoulder dystocia (a skilled midwife or obstetrician will reduce the risk).[7][8]

Other risk factors include:

Primagravida (untried pelvis).

Very short labour may represent precipitate delivery of a premature baby.

Very long labour may indicate CPD

Oligohydramnios.

Congenital abnormalities (especially if there is enlarged head or macrosomia).

Skull injuries
Cephalohaematoma

Bleeding between the periosteum and skull causes a haematoma, usually in the
parietal region and sometimes the occipital region. Spread is restricted by suture
lines that are adherent.

Blood loss can cause anaemia and even hypotension.

As the haematoma resolves, breakdown of haemoglobin can

causehyperbilirubinaemia that may need treatment.

An underlying skull fracture is found in up to 20% cases. If it is thought to be

depressed, CT or MRI imaging is required.

Spontaneous remission may take weeks and there is sometimes residual

calcification.

A haematoma may rarely become infected.

Consider the possibility of a coagulation defect.

Subgaleal haematoma

Bleeding between the periosteum and scalp is usually associated with use of
ventouse extraction.

77% follow instrumental delivery and 40-50% overlie a skull fracture or brain
haemorrhage.[9]

It usually appears within 12-72 hours of birth as a soft, fluctuant mass within the
scalp, especially over the back of the head.

It can spread slowly and be unnoticed and present as hypotension.

The spread is not restricted by suture lines.

As with cephalohaematoma, management is conservative but check for anaemia.

Caput succedaneum

This is a poorly defined, subcutaneous collection of serosanguinous fluid that

spreads over suture lines and the midline.

It is very common after prolonged labour.

It does not cause significant problems and needs only to be monitored.

Cuts and abrasions

These may result from operative delivery, including cutting the baby with the
scalpel blade at LSCS. Great care is needed in cutting the last layer of the uterus,
even in an emergency.

Cuts need closing and dressing. Topical antibiotic may be indicated.

Subcutaneous fat necrosis

This is not usually apparent at birth.

Some time later, irregular, hard, subcutaneous plaques appear with overlying
dusky red-purple discoloration.

They occur on the extremities, face, trunk or buttocks, having been caused by
pressure during delivery.

There is no treatment and they should resolve but sometimes there is

calcification.

Brachial plexus injury

The majority of these are Erb's palsy involving the upper part of the brachial plexus. The
underlying problem is usually injudicious traction when the anterior shoulder is trapped
(shoulder dystocia).[10][11] Only 10% involve the whole brachial plexus.[12] Associated
injuries include:

Fractured clavicle.

Fractured humerus.

Subluxation of cervical spine.

Cervical cord injury.

Facial palsy.

Occasionally, phrenic nerve paresis.

Erb's palsy

There is damage to the C5, C6 segments of the brachial plexus.

It produces loss of motion of the shoulder with a limp arm, adducted and
internally rotated. The elbow is pronated and extended with wrist flexed.

The grasp reflex is normally maintained but Moro, biceps and radial reflexes are
lost.

The position of the hand is said to be reminiscent of a porter who is turning away but is
holding out his hand behind him for a tip.

Klumpke's paralysis
This is much less common that Erb's palsy in infants.

It is due to damage of the nerves of segmental origin C7, C8, T1 in the brachial
plexus.

It causes paralysis with weakness of the hand and loss of grasp reflex.

Horner's syndrome may be seen if there is T1 damage.

Management

Most cases of brachial plexus injury resolve spontaneously within four months,
but it can take up to two years.

X-rays to exclude fractures and examination for phrenic nerve paresis are
required. Further investigations include MRI scan, electromyography, nerve
conduction studiesand CT myography.

To prevent contractures, immobilise the arm across the upper abdomen for seven
days, then start physiotherapy using wrist splints.

Consider surgery if movement is not returning after three months and

electrophysiology results suggest a poor prognosis. [13]

Cranial nerve injury

Cranial nerve and spinal cord injuries result from hyperextension, traction and
overstretching with simultaneous rotation. Neurapraxia will resolve swiftly but complete
nerve or cord transection is a much more serious matter.

Central damage to the facial and vagus nerves causes an asymmetrical face on
crying, with swelling and smoothness of the affected side and drooping of the side
of the mouth.

Peripheral damage causes paralysis to the eye, forehead or mouth only.

Most cases soon start to recover but full recovery may take months.

The eye must be protected with a covering and synthetic tears.

If there is no improvement after 7-10 days, investigation is required.

Phrenic nerve damage can cause paralysis of half of the diaphragm, leading to
breathing difficulties with significant mortality. Ultrasound or X-ray shows an
elevated hemidiaphragm but this may be absent in the early stages. Screening may
show immobility.

Laryngeal nerve injury

Unilateral paralysis often presents with a hoarse cry or stridor and may affect
swallowing.

Bilateral damage causes severe respiratory problems.

Diagnosis is by laryngoscopy to exclude other causes of the symptoms.

Recovery usually occurs after 4-6 weeks but can take up to a year.

Spinal cord injury

Damage to the spinal cord often results in stillbirth or babies who die soon after
delivery due to an inability to breathe.

Ventilation may be life-saving but, if the lesion is not a temporary neuropraxia,

there will be later agonising decisions about turning off the ventilator.

Those who survive are weak and often develop spasticity.

Diagnosis is by MRI or CT myelography.

Treatment is supportive.

Fractures
Clavicle

Fractured clavicle is common and presents with apparent paralysis.

Palpation may show crepitus, uneven bone and muscle spasm.

It heals within 7-10 days with the arm immobilised.

Confirm the diagnosis by X-ray.

Look for other damage.

Arm and leg bones

Fracture may be heard during delivery.

It presents with absence of normal movement of the limb, with swelling becoming
apparent later.

Confirm with X-ray.

Treat with 8-10 days of splinting or reduction and casting if displaced.

Check for radial nerve damage in arm fractures.

Abdominal bleeding

This presents with shock, pallor and a distended abdomen, possibly bluish in
colour.

Check for anaemia.

Diagnose with paracentesis.

Causes include hepatic laceration and rupture of spleen, so this is serious.

Hypoxia
Factors within labour are complex, but processes such as uteroplacental vascular
disease, reduced uterine perfusion, fetal sepsis, reduced fetal reserves and cord
compression can be involved alone or in combination producing fetal distress.
Gestational and antepartum factors modify the fetal response to them.
Even though cerebral palsy is strongly associated with a low Apgar score 5 minutes after
birth, the majority of babies with low scores DO NOT develop cerebral palsy.[14] The
majority of cases are now thought to be a consequence of postpartum insults to the fetus.

Prevention
Good maternity care will reduce the risk of an adverse outcome to both mother and child.

Caesarean section
Fear of fetal damage and the vast cost of litigation have led to an increasing rate of
Caesarean section that is now around 24% in the UK as a whole with significant
geographical variation.[15] In some parts of the world the figure is higher.
There is debate as to whether the current rising rate of Caesarean section has gone too
high. The World Health Organization has suggested that, in developed countries, the
figure should not be above 15%. Skills in the use of Kielland's forceps and assisted
breech delivery are being lost as LSCS is more readily undertaken.

Prematurity
A major contributor to perinatal mortality and morbidity is prematurity.[16] Prevention of this
is important and analysis of figures for outcomes should exclude babies below a certain
weight.
Weight is a more reliable parameter for risk assessment than gestational age.
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Neonatal birth injuries

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Author
Tiffany M McKee-Garrett, MD
Section Editors
Leonard E Weisman, MD
William Phillips, MD
Marc C Patterson, MD, FRACP
Deputy Editor
Melanie S Kim, MD

INTRODUCTION
Birth injury is defined as an impairment of the neonate's body function or structure due to an
adverse event that occurred at birth. The overall incidence of birth injuries has declined with
improvements in obstetrical care and prenatal diagnosis. The reported incidence of birth
injuries is about 2 and 1.1 percent in singleton vaginal deliveries of fetuses in a cephalic
position and in cesarean deliveries, respectively [1,2]. Injury may occur during labor, delivery,
or after delivery, especially in neonates who require resuscitation in the delivery room.
There is a wide spectrum of birth injuries ranging from minor and self-limited problems (eg,
laceration or bruising) to severe injuries that may result in significant neonatal morbidity or
mortality (ie, spinal cord injuries).
The risk factors associated with birth trauma and specific birth injuries will be reviewed here.

RISK FACTORS
The following factors that increase the risk of birth injuries may be due to the fetus (eg, fetal
size and presentation), the mother (eg, maternal size and the presence of pelvic anomalies),
or the use of obstetrical instrumentation during delivery:

Macrosomia When the fetal weight exceeds 4000 g, the incidence of birth injuries
rises as the fetal size increases. In one study, when compared with normosmic
neonates, the incidence of birth injury was twofold greater in infants weighing 4000 to
4900 g, three times greater in those with births weights between 4500 to 4999 g, and
4.5 times greater in those with a birth weight greater than 5000 g [3]. In another study,
the incidence of fetal injury was 7.7 percent in infants with birth weights greater than
4500 g [4].

The diagnosis of fetal macrosomia and its impact on shoulder dystocia are discussed
in greater detail separately. (See "Fetal macrosomia" and "Shoulder dystocia: Risk
factors and planning delivery of at risk pregnancies", section on 'Pregnancies where
high birth weight is suspected'.)
Maternal obesity Maternal obesity (defined as a body mass index greater than
40 kg/m2) is associated with an increased risk of birth injuries. This may be due to the
greater use of instrumentation during delivery and/or these mothers having an
increased risk of delivering a large for gestational age infant with shoulder dystocia
[5]. (See "The impact of obesity on female fertility and pregnancy" and"Cesarean
delivery of the obese woman".)

Abnormal fetal presentation Fetal presentation other than a vertex position,

particularly breech presentation, is associated with an increase in the risk of birth

injury with vaginal delivery. Delivery by cesarean delivery reduces the morbidity
associated with vaginal delivery of breech infants and is discussed separately.
(See "Overview of breech presentation" and "Delivery of the fetus in breech
presentation".)
Operative vaginal delivery Operative vaginal delivery refers to a delivery in which

the clinician uses forceps or a vacuum device to assist the mother in delivering the
fetus to extrauterine life. The instrument is applied to the fetal head, and then the
clinician uses traction to extract the fetus, typically during a contraction while the
mother is pushing. Both forceps and vacuum delivery are associated with an increase
in birth injury when compared with nonoperative vaginal delivery (table 1). The
sequential use of vacuum extraction and forceps increases the risk of birth injury
greater than the use of either instrument alone (table 2). The neonatal complications
of operative vaginal deliveries are discussed in detail separately. (See "Operative
vaginal delivery", section on 'Neonatal complications'.)
Cesarean delivery Cesarean delivery is generally found to have a lower risk of birth

trauma compared with vaginal deliveries. This finding was confirmed by an analysis
of the Health Care Cost and Utilization Project Nationwide Inpatient Sample that
showed cesarean delivery was associated with a decreased likelihood of all birth
trauma compared with vaginal delivery (adjusted OR 0.55, 95% CI 0.53-0.58) [6].
However, when the analysis used the definition of birth trauma developed by the
Agency for Healthcare Research and Quality Patient Safety Indicator (AHRQPSI),
cesarean delivery was associated with an increased risk of birth trauma (adjusted OR
1.65, 95% CI 1.51-1.81). The AHRQPSI definition did not include clavicle fractures, or
injuries to the brachial plexus and scalp, which were more frequently seen in vaginal
deliveries. These findings suggest that risk varies between cesarean and vaginal
delivery depending upon the type of birth injury.
Other factors One study reported an increased incidence of birth trauma to the
head and neck in male infants and in babies born to primiparous mothers [7].
Additionally, small maternal stature and the presence of maternal pelvic anomalies
are associated with an increased risk of birth injuries. (See"Shoulder dystocia: Risk
factors and planning delivery of at risk pregnancies", section on 'Pelvimetry and fetal
biometry'.)

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Literature review current through: Apr 2015. | This topic last updated: Aug 26, 2013.
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Topic Outline
INTRODUCTION
RISK FACTORS
SOFT TISSUE INJURIES
Bruising and petechiae
Subcutaneous fat necrosis
Lacerations

EXTRACRANIAL INJURIES
Caput succedaneum
Cephalohematoma
Subgaleal hemorrhage
Facial injuries
- Nasal septal dislocation
- Ocular injuries

INTRACRANIAL HEMORRHAGE
Subdural hemorrhage
Subarachnoid hemorrhage
Epidural hemorrhage
Intraventricular hemorrhage

FRACTURES
Clavicle
Humerus
Femur
Skull
Premature infants

DISLOCATIONS
NEUROLOGIC INJURIES
ABDOMINAL INJURIES
SUMMARY AND RECOMMENDATIONS
REFERENCES
GRAPHICS

DIAGNOSTIC IMAGES
Calcified cephalohematoma
Newborn clavicle fracture
Infant humeral fracture
Humeral fracture infant

FIGURES
Neonatal extracranial and intracranial birth injuries

PICTURES
Neonate knee dislocation

TABLES
United States birth data by delivery type
Birth outcome data New Jersey
Birth trauma by delivery type

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Birth Injury Types

Sometimes birth injuries are temporary, and other times they are permanent,
lasting a lifetime. Symptoms often vary from one infant to another. Whereas
one infant may have mild symptoms, the same injury may happen to a
different infant and cause severe symptoms.
Sometimes children arent aware of their birth injury until theyre enrolled in
school. Other times the symptoms for certain birth injuries are obvious
immediately. The severity of symptoms and signs will greatly depend upon
each childs individual circumstances as well as the type of birth injury.

Brain-Related
Injuries
Brain-related birth injuries
can manifest in several different ways. Often, brain
injuries develop from oxygen deprivation, such as anoxia, hypoxia, birth
asphyxia, and perinatal asphyxia. Hypoxic Ischemic Encephalopathy (HIE) is

a birth injury that merely describes that starvation that happens to the brain
and the sometimes-severe consequences as a result of oxygen deprivation.
When a brain has been deprived from oxygen, it can react in various ways.
For example, brain ischemia occurs when oxygen is deprived and the brain
reacts by draining the blood from the brain. A brain hemorrhage occurs when
a brain reacts to excessive blood flowing into the brain. More electrical
responses are what happens when the brain reacts to oxygen deprivation
causing general brain damage from seizures, or causing more severe
electrical disorders with cerebral palsy. Additionally, brain-related injuries can
happen from other birth injuries such as the growth of newborn jaundice into
kernicterus, flooding the brain with bilirubin, and the development of the group
B strep infection to meningitis which interferes with electrical communications
between the spine and the brain.
The leading brain-related injury in relation to birth trauma is cerebral palsy
(CP), affecting around 800,000 children. CP can develop after maternal
infections, oxygen deprivation, infant stroke, and infant infection. In many
instances, CP could have been eliminated with the corrective preventative
measures by physician. For example, if a physician fails to monitor fetal
distress and take the appropriate actions, the infant may develop CP. Other
instances include:

Failure to monitor, detect, and treat maternal infections

Failure to plan and carry out an emergency C-section
Failure to identify and treat a prolapsed umbilical cord
Failure to use birth-assisting tools correctly

Muscle-Related
or Physical
Cerebral palsy is often misinterpreted
as aInjuries
muscle-related birth injury because
in some cases, the infant has total loss of muscle control. However, cerebral
palsy is a brain-related birth injury that affects the way the brain sends
communication to the muscle groups.

Muscle-related injuries, however, are generally easy to diagnose as a clinical

evaluation can pinpoint where the limited movement or paralysis is coming
from. Some muscle-related injuries may be related to more blatant medical
malpractice such as lacerations, bruises, or broken bones. This can
also cause other physical birth injuries such as skull fractures or
cephalohematoma, the bruising of the area between the brain and the outer
layers of skin.
Common muscle-related and physical injuries include:

Brachial Plexus

Brachial plexus happens when the upper extremity of the arm is injured,
usually during delivery. Symptoms include weakness in the affected arm and
the inability to use certain muscles in the affected arm. The shoulder and
hands may also be affected. Electrical-type shocks and a burning sensation
down the affected arm is also common.

Erbs
Palsy
Erbs palsy
is a form of brachial plexus marked by the nerves of the upper arm
being affected, usually after a birth injury. Infants with Erbs palsy may
experience the loss of feeling and weakness in the affected. In severe cases,
infants may have total paralysis in the affected arm.
Klumpkes
Klumpkes palsy,Palsy
another form of brachial plexus, is caused by damage to the
lower nerves in the arm, affecting the arm, wrists, and fingers. Typically, an
infant with Klumpkes palsy with have total paralysis in the affected area, and
the hand usually takes on a permanent, claw-like shape.
Shoulder
Dystocia
Shoulder dystocia
is a birth injury that occurs when an infants head and
shoulders get trapped behind the mothers pelvic bone during delivery.
Although shoulder dystocia only happens in 1% of all pregnancies, the
complications that arise with this type of injury can be severe. Along with the
risk of maternal hemorrhaging and uterine rupture, the baby may experience
difficulties when breathing, a collarbone fracture, cerebral palsy, a brachial
plexus fracture, and in some instances, death.
Birth
Injuries
Related
to Infections
or Developed
Through
Pregnancy
Sometimes
the responsibility
of who
passes on the birth
injury is fuzzy. In

some instances, a birth injury is passed on from the mother, though

a physicians job is to detect and treat any maternal problems. A couple of
these injuries are attributed to infections, such as the group B strep infection
or meningitis, both infections that the mother can carry in the vagina without
even knowing it (about 1 in every 4 mothers carry these infections without any
symptoms or knowledge of these infections). Children can catch this from their
mothers just by being born, by passing through the birth canal where these
infections are stored.
Other birth injuries caught from the mother are injuries developed through
pregnancy that the physician should have tested for or found early. These
injuries include folic acid deficiency, anemia, and spina bifida. These birth
injuries could have possibly been prevented by the mother taking supplements
based on the physicians recommendations.

Additional, a birth injury that could happen at the end of pregnancy just before
delivery is meconium aspiration syndrome, which occurs when the infant is
under stress from a long and difficult delivery. The infant defecates in the
uterus and then breathes in the meconium, causing severe breathing
problems after birth.

Injuries
Delivery
Birth injuriesfrom
that arise
during delivery is a common occurrence. These types
of injuries occur from the use of vacuum extractor or forceps, tools invented to
assist in delivery. Other injuries from delivery may include administering the
wrong medication, mishandling the infant, resulting in broken bones,
lacerations, or skull fractures. Depending on how the physician handles the
delivery, an infant may also experience injuries related to stress, high blood
pressure, or hypertension.
Persistent
Pulmonary
Hypertension
of delivering
the Newborn
PPHN (PPHN)
occurs when
the pulmonary
article responsible for
oxygen to
a newborn shuts down. In turn, the infant has a difficult time breathing, which
can lead to rapid heartbeats, cyanosis, heart murmurs, and more. PPHN is
often the result of a difficult birth, yet in many instances it arises due to
medical negligence. For example, prescription-based medications such as
Zoloft, Celexa, and Paxil have been linked to an increase in blood pressure
and during pregnancy this can place stress on the infant. Other causes
include failure to treat maternal infections, failure to detect and prevent infant
asphyxia, and performing an unnecessary C-section.
Sources:
1.

http://www.stanfordchildrens.org/en/topic/default?id=birth-injury-90-P02340

2.

http://www.theguardian.com/lifeandstyle/2010/nov/14/scared-birth-trauma-midwives

3.

http://apt.rcpsych.org/content/7/4/257.full

4.

http://www.healthy.net/scr/article.aspx?Id=1058

5.

http://www.healthy.net/Health/Article/Birth_Trauma_The_Most_Common_Cause_of_Devel
opment_Delays/1058

6.

http://www.seattlechildrens.org/medical-conditions/airway/birth-asphyxia/

7.

http://www.aafp.org/afp/2004/0401/p1707.html

Birth Injury
Birth Injury Types
Birth Trauma
Caput Succedaneum
Cognitive Developmental Disabilities Due to Birth Injuries
C-Section Injuries
Epidural Birth Injuries

Fetal Lacerations
Folic Acid Deficiency Anaemia
Forceps Delivery Injury
Group B Strep Infection
Horners Syndrome
Hydrocephalus
Infant Bells Palsy
Infant Bleeding of the Brain or Hemorrhage
Infant Brain Ischemia
Infant Broken Bones
Infant Cephalohematoma
Infant Cervical Dystonia
Infant Chorioamnionitis
Infant Cystic Fibrosis
Infant Dystonia Disorder
Infant Hypoxic Ischemic Encephalopathy (HIE)
Infant Meningitis
Infant Shoulder Dystocia
Infant Skull Fractures
Infant Spina Bifida
Infant Spinal Cord Damage
Infant Subconjunctival Hemorrhage
Infant Torticollis
Intellectual Disabilities in Babies and Children
Kernicterus
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> Injury & Death > Injured Children's Justice

Center > Birth Injuries > Common Types of Birth Injuries
Sacramento Personal Injury Lawyers, Brain & Spinal

Common Types of Birth Injuries

Topics on this page:

Fetal Distress (Hypoxia)

Cerebral Palsy
Erb's Palsy
Brachial Palsy/Brachial Plexus Injury
Kernicterus (Severe Jaundice)
Brain Injuries Caused by Forceps or Vacuum Extractors Umbilical Cord Complications
The umbilical cord is the babys lifeline while it is in the womb, carrying oxygen, blood and nutrients to
the fetus right up to the point of birth.
Umbilical Prolapse occurs when the umbilical cord is "pinched in the birth canal, cutting off oxygen to
the baby.
Umbilical Cord Compression occurs when the cord gets wrapped around the babys body during
delivery, also cutting off or decreasing the flow of blood and oxygen to the baby.
Birth injuries occur when doctors and medical staff fail to quickly free the umbilical cord from
these dangerous positions.

Fetal Distress (Hypoxia)

Fetal distress, or hypoxia (read more), occurs when the unborn fetus is deprived of oxygen, often
because of umbilical cord complications. The first indication of fetal distress is an abnormal heart rate.
The heart rate should be carefully monitored by doctors and medical staff using electronic fetal heart
equipment or a fetal stethoscope. If an abnormality is found, there are immediate steps that can and
should be taken to prevent birth injury, including:

Giving the mother more oxygen,

Turning the mother onto her left side, or

Delivering the child as quickly as possible using forceps or by Caesarean Section (C-Section)
back to top

Cerebral Palsy
The term "cerebral palsy (read more) refers to several different kinds of permanent brain
injuries that occur before, during, or shortly after birth. Victims of cerebral palsy can suffer a variety
of symptoms including:

Limited movement (motor skills)

Speech difficulties

Learning disabilities
In an infant, symptoms may include:

Being slow to reach development milestones like rolling over, crawling, sitting, or walking

Difficulty controlling muscles

Balance and coordination problems

Visual problems

Hearing problems

Epilepsy, seizures or spasms

Different types of cerebral palsy include spastic cerebral palsy, athetoid cerebral palsy, and ataxic
cerebral palsy.
back to top

Erbs Palsy
Erbs Palsy (read more) results from a very traumatic injury when the babys shoulder becomes
stuck behind the mothers pubic bone during delivery. Severe nerve damage affecting the neck and
arm can result.
If the baby can move one arm but not the other, or if the arm hangs down at the side of the body, Erbs
Palsy may be the problem. The condition can be temporary, with full recovery of movement and
sensation, but permanent paralysis or numbness may result in very serious cases.
back to top

Brachial Palsy/Brachial Plexus Injury

Brachial palsy occurs when the brachial plexus (the group of nerves that supplies the arms and hands)
is injured. It is most common when there is difficulty delivering the baby's shoulder, called shoulder
dystocia.
Lack of muscle control and a loss of sensation or strength in the arm, hand or wrist are common
symptoms. Intense pain is often felt from the neck down to the arm. If the injury caused bruising and
swelling around the nerves, movement should return within a few months. Tearing of the nerve may
result in permanent nerve damage.
A brachial plexus injury could be the result of medical negligence at birth where the baby's
shoulders have been injured through the use of forceps and, in turn, the brachial plexus nerves have
been stretched and torn.
back to top

Kernicterus (Severe Jaundice)

Kernicterus (read more) is a form of brain damage caused by excessive jaundice. The substance which
causes jaundice "bilirubin produced by the liver is so high that it can move out of the blood into
brain tissue.
When babies begin to have brain damage from excessive jaundice, they have difficulty staying awake
and alert, they have a high-pitched cry and seem to lack muscle tone or act "floppy (hypotonic),
followed by increased muscle tone (hypertonic), with arching of the head and back. As the damage
continues, they may develop fever, may arch their heads back into a very contorted position known
as opisthotonus or retrocollis.
When the first symptoms appear it is an emergency situation. The brain damage can be prevented
only if the treating doctor administers the right treatment quickly and without any interruption.
back to top

Brain Injuries Caused by Forceps & Vacuum Extractors

Physicians use forceps and vacuum extractors, either separately or together, to help pull the fetus
through the birth canal. Use of these devices to pull, twist, and manipulate the position of the fetus can
result intraumatic brain and spinal cord injury, as well as skull fracture.

Contact a Sacramento Birth Injury Attorney

The experienced medical malpractice attorneys at Kershaw, Cutter & Ratinoff understand that birth
injury and birth trauma cases can be complex and demanding.Our attorneys have recovered millions
of dollars in damages for injured children and their families who have been the victims
of careless doctors and medical staffs.

Our years of experience and our well-trained paralegals and administrative staff give us the advantage,
even under the most difficult circumstances. We care about our clients and treat the injured children and
their families with genuine concern, because we understand the devastating effects birth injuries can
have on them.
If your child has suffered birth injury or trauma, please fill out and submit the contact form on this
page for a free and confidential case evaluation, or call us toll-free at
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Birth injury consists of a physical injury sustained by a newborn during

labor and delivery. Most injuries are minor and resolve rapidly. Other injuries
may require some intervention. A few are serious enough to be fatal.
Types of birth injuries include:
Scalp (e.g., caput succedaneum, cephalohematoma).
Skull (e.g., linear fracture, depressed fracture).
Intracranial (e.g., epidural or subdural hematoma, cerebral contusion).
Spinal cord (e.g., spinal cord transaction or injury, vertebral artery injury).
Plexus (e.g., total brachial plexus injury, Klumpke paralysis).
Cranial and peripheral nerve (e.g., radial nerve palsy, diaphragmatic
paralysis).
Key Factors
Maternal, intrapartum, obstetric birth techniques, and newborn
factors may predispose the newborn to injuries. These include:
Fetal macrosomia.

Abnormal or difficult presentations.

Uterine dysfunction leading to precipitate or prolonged labor.
Cephalopelvic disproportion.
Multifetal gestation.
Congenital abnormalities.
Internal FHR monitoring.
Forceps or vacuum extraction.
External version.
Cesarean birth.
Diagnostic and Therapeutic Procedures and Nursing Interventions
Birth injuries are normally diagnosed by CT scan, x-ray of suspected area of
fracture, or neurological exam to determine paralysis of nerves.
Data Collection
Monitor the newborn for signs and symptoms of birth injuries, which
include:
Irritability, seizures, and depression. These are all signs of a subarachnoid
hemorrhage.
Facial flattening and unresponsiveness to grimace that accompanies crying or
stimulation, and the eye remaining open are symptoms to assess for facial
paralysis.
Weak or hoarse cry, which is characteristic of laryngeal nerve palsy from
excessive traction on the neck.
Flaccid muscle tone, which may signal joint dislocations and separation
during birth.
Flaccid muscle tone of the extremities, which is suggestive of nerve plexus
injuries or long bone fractures.
Limited motion of an arm, crepitus over a clavicle, and absence of Moro
reflex on the affected side, which are symptoms of clavicular fractures.
Flaccid arm with the elbow extended and the hand rotated inward, absence
of the Moro reflex on the affected side, sensory loss over the lateral aspect
of the arm, and intact grasp reflex, which are symptoms of Erb-Duchenne
paralysis (brachial paralysis).
Localized discoloration, ecchymosis, petechiae, and edema over the
presenting part. These are seen with soft tissue injuries.

Nursing assessments for birth injuries include:

Reviewing maternal history and looking for factors that may predispose
the newborn to injuries.
Apgar scoring that might indicate a possibility of birth injury. Neonates in
need of immediate resuscitation should be identified.
Initial head to toe physical assessment and continued assessment
upon each contact with the neonate.
Vital signs and temperature.
NANDA Nursing Diagnoses
Injury related to birth trauma
Impaired physical mobility related to brachial plexus injury
Impaired gas exchange related to diaphragmatic paralysis
Acute pain related to injury
Nursing Interventions
Nursing interventions for birth injuries include:
Administering treatment to the newborn based on the injury and
according to the primary care providers prescriptions.
Preventing further trauma by decreasing stimuli and movement.
Educating the infants parents and family regarding the injury and the
management of the injury.
Promoting parent-newborn bonding.