SNO TIME OBJECTIVES CONTENT TEACHING METHOD AV AIDS EVALUATION

1 2mints To explain about BIRTH INJURIES Lecture OHP

birth injuries INTRODUCTION:
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 infant’s 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.

To explain about RISK FACTORS:

2 5mnts
the risk factors Maternal
 Primiparity
 Short stature Lecture cum OHP-
 Maternal pelvic anomalies discussion
 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& extractions

SITE OF INJURY AND TYPE OF INJURY

3 Evplain about the
site and type of
SITE OF INJURY TYPE OF INJURY
injury Soft tissues Skin – lacerations, abrasions, fat
necrosis
Muscles Sternocleidomastoid
Nerve Facial
Brachial plexus
Duchenne Erb(C5,C6)
Klumpke
Spinal Cord
Phrenic n
Horner’s Syndrome
Recurrent laryngeal nerve
Scalp Lacerations,abscess, hemorrhage
Skull Cephalo hematoma
Subgaleal hematoma
Fracture
Intra cranial Hemorrhage – Intraventricular
 Subdural
Subarachnoid
Bones Fracture – clavicle
Hemerus
Femur
Skull
Nasal bones
Eye Hemorrhage
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
4 Describe the
NERVE INJURIES:
nerve injuries
Commonly associated with breech delivery
Cause- Hyper extension , traction,& over stretching with
simultaneous rotation
Types- Facial palsy, Brachial Palsy, Erb’s palsy, Klumpke’s Palsy,
Brachial plexus injury, phrenic nerve injury (C3,4 and 5)
 Explain about the Facial palsy
facial palsy Cause: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
Describe the Brachial palsy
5
brachial palsy
Either 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 shoulders
Erb paralysis(C5-6):
6 Explain about erb
 Affected arm in adducted and internally rotated with elbow
paralysis
extended (Waiter’s tip position)
 Forearm is prone and wrist is flexed
 The limb falls limply to the side of the body when passively
adducted
 Moro’s, biceps, radial reflexes absent on affected side
 Grasp reflex intact
Explain about Klumpke’s paralysis (C7& T1)
7
klumpkes  intrinsic muscles of the hand are affected & grasp is absent(
claw Hand)
 Biceps and radial reflex are present
 Horner’s 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
8 Explain about
Brachial plexus injury
brachial plexes
The incidence is about .1 to 0.2% of shoulder dystocia, even in
injury
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 infant’s condition

9 Describw the scalp SCALP INJURIES

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
fractures

3) Subgaleal hematoma
Definition: 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:
10 Explain about the
intracranial Intracranial hemorrhage (ICH) may be—
haemorrhage (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:
o fracture of skull bone
o rupture of the inferior sagittal sinus or
o rupture of small veins leaving the cortex.
Massive hemorrhage may occur following
o Tear of the tentorium cerebelli thereby opening up the
straight sinus or rupture of the vein of Galen or its Faix
cerebri tributaries
o Injury to the superior sagittal sinus.
Clinical presentation:
 Nuchal rigidity
  Coma
 apnea
 bulging fontanelle (increased intracranial pressure)
nonreactive pupils
 seizures may be present.

12 Illustrate
Pathophysiology:
pathophysiology
Normally, the faix cerebri is attached to the tentorium cerebelli and
of intra cranial
haemorrhage
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
cerebelli—called 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:
13 List out the 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
Describe Intraventricular Hemorrhage-The pathogenesis of IVH in the
intraventricular term infant is more likely due to trauma (difficult delivery) or
haemorrhage
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.
14 Explain sub
Subarachnoid—This may be due to tear of some tributary veins
arachnoid
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 evacuation—Serial 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
15 Explain the FRACTURES
fractures skull
Bones involved- Frontal, parital, occipital
complications:
 Brain contusions
 Disruption of blood vessels
 seizures
 hypotension & death
 dural laceration
Management:
 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 septum
Complications:
 unrecognized and untreated facial fractures- craniofacial
malformations, ocular, respiratory & mastication problems
 Management:
 protection of airway
 plastic surgeon; ENT reference
 Cranial CT scan
 Treatment of fractures
Nursing considerations:
 Maintain proper body alignment
 Gentle handling
 Careful during dressing
 Immobilization
 Relief of pain

16 Describe spinal SPINAL CORD INJURIES

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 function

17 Describe eye EYE INJURIES

injury Ocular 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 cases

NURSING MANAGEMENT IN BIRTH INJURIES

Nursing Diagnoses
(a) Injury related to birth trauma
(b) Impaired physical mobility related to brachial plexus injury
(c) Impaired gas exchange related to diaphragmatic paralysis
(d) Acute pain related to injury
Nursing Interventions
 Nursing interventions for birth injuries include:
  Administering treatment to the new born based on the injury
and according to the primary care provider’s prescriptions.
 Preventing further trauma by decreasing stimuli and
movement.
 Educating the infant’s parents and family regarding the
injury and the management of the injury. 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:
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2. Meharban Singh . Care of Newborn . 6th edition. Published
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3. Lowdermilk ,Perry, Cashion. Maternity Nursing.8th edition.
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4. Wong D.L etal . Essentials Of Paediatric Nursing. 6th
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5. Marlow D.R. Redding B. Textbook of Paediatric nursing. 1st
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