Journal of Neonatology
2008
REVIEW ARTICLE
Birth injuries: Strategies for prevention
Manju Puri, Pooja Diwedi
Department of Obstetrics & Gynecology, Lady Hardinge Medical College & Smt. SK Hospital, New Delhi 110 001
purimanju@rediffmail.com
Introduction
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The incidence of major birth trauma has decreased
remarkably over the past 2-3 decades due to improved
obstetrical care and liberal use of caesarean sections.
However, birth injuries still contribute significantly to
neonatal morbidity and mortality. In United States birth
injuries account for less than 2% of all neonatal deaths and
stillbirths with an average of 6-8 cases of birth injuries per
1000 live births.1 For every neonatal death due to birth trauma
about 20 surviving neonates suffer from major birth injuries2.
Prevention of birth injuries is currently gaining importance
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due to increased medical malpractice litigations related to
these injuries. Research is being conducted in the field of
birth injuries with the aim of better understanding of the
etiopathogenesis of these injuries and formulation of
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preventive strategies for the same.
Etiopathogenesis of birth injuries
The birth injuries can be broadly classified into two
categories – Hypoxic injuries and mechanical injuries.
Hypoxic injuries result from hypoxic ischemic insult. Injuries
resulting from mechanical forces during birth process are
categorized as birth trauma. In this article, only injuries
resulting from mechanical factors are being discussed.
Birth process involves interplay of various forces like
compression, propulsion, torque and traction. In normal labor
all these forces act on the baby in moderation without any
harmful effects. However, when these forces are complicated
by factors like cephalopelvic or fetopelvic disproportion, big
sized baby, fetal malposition or malpresentation, prolonged
or precipitate labor, instrumentation, prematurity, obstetric
procedures etc. they can result in birth injuries3.
Birth injuries can be sustained either during antepartum
or intrapartum period. Majority of these injuries are sustained
during the intrapartum period. The various modes of
sustaining birth injuries are as shown in Table 1.
Table 1: Etiopathogenesis of birth injuries.
Antepartum
Secondary to trauma to
pregnant women
• Motor vehicle accident
• Assault
- Intentional (domestic
violence, suicide, homicide) • Breech vaginal delivery
- Unintentional (falls, burns etc.) • During C.S.
Vol. 22, No. 1, Jan. - Mar.
Birth injuries associated with operative
vaginal delivery
The association of birth injuries and operative vaginal
delivery can be traced back to WJ Little4 (1861) and later to
other workers5,6. The various types of injuries associated with
operative vaginal delivery are soft tissue injuries to face and
scalp, intracranial injuries and injury to brachial plexus. The
frequency of occurrence of soft tissue injuries with forceps
and ventouse is 17% and 16% respectively7. Ever since
vacuum extraction was introduced, it was perceived as a
safer option than forceps delivery as regard to birth injuries.
The scenario changed in 1998 when FDA released a warning
regarding life threatening fetal risks like subgaleal
hemorrhage associated with vacuum extraction. However,
this issue is still debatable.
The most common major soft tissue injuries are
cephalhaematoma and subgaleal hemorrhage. In addition
there are other minor injuries like abrasions, bruises,
subconjunctival hemorrhage and facial nerve injury.
Cephalhaematoma is due to damage to blood vessels in
between the periosteum and skull and is self limiting. On
the contrary, subgaleal hemorrhage results from tearing of
blood vessels between the periosteum and galea
aponeurotica. It tends to spread because of the potential
subgaleal space which can accommodate the entire blood
volume of the neonate. Cephalhaematoma resolves
spontaneously whereas subgaleal hemorrhage can be life
threatening and results in hypovolemic shock, DIC and
neonatal mortality(25%)8. According to Cochrane review
vacuum extraction has a stronger association with
cephalhaematomas compared to forceps (10% vs. 4% OR
2.38)7. Likewise subgaleal hemorrhage is 4 times more
common with vacuum delivery. It is important to note that
the occurrence of these complications is usually associated
with difficult vacuum extraction or failed vacuum extraction
evident by prolonged extraction time, multiple pulls, or
repeated detachment9.
Intracranial injury and hemorrhage are relatively
uncommon but important birth injuries associated with
operative vaginal delivery. The overall frequency of
Intrapartum occurrence is < 0.4%10. It is usually in the form of subdural
hemorrhage or subarachnoid hemorrhage. Subdural
hemorrhage is the commonest. This is usually small in size
located in the occipital region near the junction of fax and
•Operative vaginal delivery tentorium and results from excessive molding and tearing
• Shoulder dystocia of the dura. It is rarely massive and resolves spontaneously.
Regarding brachial plexus injury with operative vaginal
delivery, its association is stronger with forceps delivery than
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 Journal of Neonatology
with vacuum extraction10. The frequency of occurrence of
brachial plexus injury with vacuum extraction alone is 1.7 –
3.7/ 1000 live births, with forceps delivery 2.5 – 5.3/ 1000
and with both vacuum and forceps 4.6 – 7.2/ 1000 live births.
This can be explained by the fact that in the presence of
cephalopelvic disproportion, head of the baby moulds and
delivers with the help of vacuum or forceps but shoulders
are held above the pelvic inlet with resultant stretching of
brachial plexus. As the force applied with forceps is more,
the obstruction to the shoulders at the pelvic inlet can be
overcome but with higher chances of brachial plexus injury.
The vacuum extraction in such cases usually fails.
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Strategies for prevention of birth injuries with
operative vaginal delivery
1. Use of good clinical judgment in selecting patients for
operative vaginal delivery.
2. Use of more than one method to deliver a baby should be
avoided. In cases of doubt, it is better to resort to caesarean
section than try another method.
3. Proper training to conduct operative vaginal delivery
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should be imparted.
4. Emphasis should be laid on correct application of forceps
or vacuum cup. The vacuum cup should be placed in the
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midline and towards the occiput to aid in flexion so that
smaller diameters of fetal skull cross the perineum.
5. While applying traction, prolonged extraction time, more
number of pulls (>3) and detachment of vacuum cup or
slipping of forceps blades should be avoided.
6. The traction force should be applied constantly at right
angles to the head during the uterine contraction coupled
with mother’s bearing down efforts.
7. All babies born by operative vaginal delivery should be
closely observed for birth injuries for early diagnosis and
timely management.
Birth injuries associated with shoulder
dystocia
Shoulder dystocia is one of the most dreaded obstetric
emergencies and often results in birth injuries. The incidence
of shoulder dystocia varies from 0.2% - 3% and 21-42% of
cases are associated with neonatal morbidity11. The various
injuries associated with shoulder dystocia are neonatal
fractures, brachial plexus injury (8.4%-22.7%) and rarely
hypoxic encephalopathy and neonatal death12,13,14. This high
incidence of neonatal morbidity is probably due to the fact
that not many obstetricians feel confident in performing
direct fetal maneuvers for atraumatic resolution of this
condition. McRobert’s positioning is invariably used as the
first line maneuver as this is simple and easy to execute. This
maneuver is useful in resolving only about 40% of cases15.
Although shoulder dystocia can be prevented by doing
an elective caesarean section in women at high risk but nearly
50% of cases are in nonmacrosomic infants of low risk
mothers, hence the condition can neither be predicted and
nor be prevented in totality.
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Vol. 22, No. 1, Jan. - Mar. 2008
To reduce the neonatal morbidity associated with shoulder
dystocia it is important to understand the mechanics of this
condition and various maneuvers used for its resolution.
Shoulder dystocia can either be due to foetopelvic
disproportion or soft tissue dystocia resulting mostly from
positional misalignment consequent to insufficient time
given for normal rotation of shoulders as in hasty vaginal
delivery e.g. operative vaginal delivery and precipitate
delivery. It is important to understand that the usually
accepted safe head to body delivery time is 4 min. It may be
extended up to 6-8 min except in certain circumstances
where blood flow to the fetus is compromised as in placental
separation or when the umbilical cord has been clamped
and cut before the delivery of the body16.
Strategies for preventing birth injuries
associated with shoulder dystocia
1. Follow a “Hands off” approach after the delivery of the
fetal head. It means waiting for the next uterine
contraction before applying traction on the head. This
allows for restitution and external rotation of fetal head
and averts shoulder dystocia in most women with average
sized babies.
2. Diagnose the cause of shoulder dystocia and plan the
management strategy accordingly. It may be a safer option
to carry out fetal maneuvers in patients with suspected
foetopelvic disproportion.
3. Avoid excessive and jerky traction especially lateral
(upwards or downwards) to avoid injury to the brachial
plexus. Repeated unsuccessful attempts to traction
increase the risk of brachial plexus injury.
4. Proper execution of all the maneuvers e.g. in McRobert’s
positioning it is important that hips should be flexed
without abduction and that suprapubic pressure should
be applied firmly on to the posterior shoulder. If left shoulder
is anterior, pressure should be applied by someone standing
on the mother’s right.
5. Counteractive maneuvers should be avoided as it results
in worsening of the impaction and impede rotation e.g.
fundal pressure should be avoided till the impaction is
cleared.
6. An understanding that management of shoulder dystocia
is time sensitive so that if one maneuver fails to resolve
the condition within 30 sec, next maneuver preferably
foetal maneuver should be done.
Birth injuries associated with breech vaginal
delivery
The incidence of birth injury because of breech vaginal
delivery is on decline due to increasing use of Caesarean
section for breech presentation all over the world. The various
injuries sustained by the newborn with breech vaginal
delivery are fractures, trauma to abdominal organs, nerve
injuries, spine injuries, intracranial hemorrhages etc
 Journal of Neonatology
Strategies for preventing birth injuries
associated with breech vaginal delivery
1. Proper selection of patients for vaginal delivery should be
done. Hyper extended head of fetus should be ruled out as
it can result in injury to cervical spine during delivery
2. Proper training should be imparted to the obstetricians in
the art of breech vaginal delivery so as to enable them to
carry out all the maneuvers gently and correctly.
3. The patient should be asked to actively bear down only
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once the anterior buttock starts to climb up the perineum
so as to allow for the cervix to dilate completely.
4. Nuchal arms are an important cause of neonatal trauma.
This condition can be prevented by allowing the baby to
deliver spontaneously till the umbilicus and avoiding any
traction on the body of the baby
5. The body of the baby should not be held by abdominal
grip but by pelvifemoral grip so as to prevent injuries to
the abdominal organs.
6. The body of the baby should be allowed to hang by its
own weight till the nuchal line is visible before carrying
out the Burn’s Marshall technique. This prevents injury to
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the cervical spine. Controlled delivery by forceps is also a
good option for delivery of head
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Birth injuries associated with caesarean
section
The association of birth injuries with caesarean section is
not very common. These are usually in the form of sharp
cuts on the scalp or face of the baby, fractures, nerve injuries,
trauma to abdominal organs etc. Obstetricians can prevent
these by being careful while giving incision in the uterus
especially in patients with oligoamnios, absent membranes,
occipitoposterior position, prolonged labor etc. It is important
that they do not panic if the extraction is difficult and conduct
a controlled extraction without applying undue force or
traction with in 3 min of giving uterine incision.
Birth injuries associated with trauma during
pregnancy
Trauma during pregnancy is uncommon but a significant
contributor to maternal and fetal injuries especially in
developed countries. Data from developing countries is not
available. Trauma can result in a direct fetal injury e.g.
intracranial hemorrhage, brain edema, skull fractures, injury
to spleen or liver or indirect injuries consequent to placental
abruption, uterine rupture, preterm birth, abortion etc. Late
sequelae in the form of hydrocephalus, cerebral palsy and
other neurological problems can also result17,18,19,20. In United
States various causes of trauma during pregnancy are motor
vehicle accidents (48%), assaults(17%), unintentional injuries
like falls etc (25%)17.
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Vol. 22, No. 1, Jan. - Mar. 2008
Strategies for preventing birth injuries related
to trauma during pregnancy
1. To minimize the impact of motor vehicle accident by
emphasizing proper use of seat belts. The lap belt should
be placed over the bony pelvis and shoulder belt in
between the breasts.
2. Clinicians should be sensitized to the problem of domestic
violence and should identify, counsel and help these
women by proper referral to help groups.
3. Pregnant women should be routinely supplemented with
calcium.
4. All pregnant women who sustain injuries should be
observed for delayed consequences like abruption
placentae, prematurity, IUGR etc
To summarize birth injuries sustained during pregnancy
and childbirth continue to be a significant cause of concern
both for the obstetricians and pediatricians. It is important
for the clinicians to revisit the etiopathogenesis of birth
injuries to identify the predisposing factors and device
preventive strategies so as to minimize the incidence and
adverse consequences of birth injuries. Adequate emphasis
needs to be laid on the need of good communication
between the clinicians and their patients to significantly
reduce the medico legal implications related to birth injuries.
References
1. Laroia N. Birth trauma www.emedicine.com/ped/
topic2836.htm 2008
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incidence and predisposing factors. Obstet. Gynecol.
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4. Little WJ. On the influence of abnormal parturition,
difficult labors, premature birth and asphyxia
neonatorum, on the mental and physical condition of
the child, especially in relation to deformities. Transact
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5. O’Mohony F, Settatrae R, Platt C et al. Review of singleton
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– Shoulder dystocia. Practice Bulletin 2002;100, 1045- pregnancy. Clin Obstet Gynecol. 2007; 50: 563-581.
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THILLAI NEOCON 2008

VI Annual Convention of National Neonatology Forum
Tamil Nadu Chapter

Venue : Rajah Muthiah Medical College, Annamalai Nagar, Chidambaram – 608 002 (T.N.)
Date : 4th & 5th October, 2008
till 31st Aug till 30th Sep Spot
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Rajah Muthiah Medical College & Hospital, Annamalai University, Annamalai Nagar – 608 002
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