Birth Injuries

Julniar M Tasli Herman Bermawi Afifa Ramadanti

Purpose
To increase knowledge, competencies & skills, required to successfully detect, prevent,assess and manage Birth Injuries

Predisposing Factors
Maternal factors: Fetal factors Primigravida Abnormal presentation Cephalopelvic Breech, face disproportion, VLBW or extreme small maternal prematurity stature, Fetal macrosomia maternal pelvic Large fetal head anomalies Fetal anomalies Prolonged or rapid Obstetrical interventions labor Use of mid-cavity forceps Dystocia or vacuum extraction Oligohydramnios Versions and extractions

Types of Injury
Extracranial Cranial Intracranial Nerve Face Bones Intra-abdominal

1?

2?

3?

4?
5?

6?
7?

Caput Succedaneum

Extracranial injury
Cephalhematoma Subgaleal hemorrhage with skull fracture

Caput Succedaneum
most frequent pressure on the scalp against cervix subcutaneous, extraperiosteal accumulation of blood/serum crosses suture lines resolves within days NO treatment is needed

Complications rare hemorrhagic caput infection jaundice anemia DDX-Cephalhematoma

Epicranial aponeuroses

Skin

Caput succedaneum

Periosteum Skull

Cephalhematoma
sub-periosteal hemorrhage from rupture of blood vessels between the skull and the periosteum buffeting of fetal head against the pelvis no extension across suture lines most commonly parietal, may occasionally be observed over the occipital bone Increases in size with time 5-18% associated skull fracture X-ray Forceps or Vacuum

Complications Jaundice, anemia Infection: diagnostic aspiration resolution within 2-8 wks calcification may persist for > 1 year

Only if ? infection

Epicranial aponeuroses

Skin

Caput succedaneum Cephalhematoma

Periosteum Skull

Subgaleal Hemorrhage

Blood under galea aponeurosis Mid-forceps and vacuum scalp swelling, ecchymoses May extend to periorbital region and neck Frequently associated with head trauma (40%)
intracranial hemorrhage or skull fracture occurrence of these features does not correlate with the severity of hemorrhage

Anemia/hypovolemia/shock

Diagnosis is generally clinical: Fluctuant boggy mass developing over the scalp Develops gradually in 12-72 hours Hematoma spreads across the whole calvarium Subgaleal Swelling cross suture lines Management: supportive Hemorrhage Close observation to detect progression Monitor hematocrit Monitor for hyperbilirubinemia Investigation for coagulopathy may be indicated

Epicranial aponeuroses Periosteum Skull Dura

Lesion

Skin

Caput Cephalhematoma Subgaleal hemorrhage extradural hemorrhage

External swelling

after birth No Yes

Caput succedaneum Soft, pitting Cephalhematoma Firm, tense

Crosses suture lines Yes No

acute blood loss No No

Subgaleal hematoma Firm, fluctuant

Yes

Yes

Yes

Skull Fractures
Uncommon because of compressible skull & open sutures Forceps/Prolonged labor Linear/Depressed Usually asymptomatic Associated intracranial hemorrhage may produce symptoms

Skull Fractures
Linear Skull Fracture
fracture on convexity of skull associated cephalhematoma

Depressed Skull Fractures

ping-pong indentation usually asymptomatic

Management:
Conservative: elevation of depressed fracture by vacuum Surgical elevation

Prognosis: healing in a few

months

Intracranial hemorrhage
Epidural Subdural Subarachnoid

Epidural hemorrhage
Rare :2.2% of all intracranial bleed Injury to the middle meningeal artery Clinical symptoms:
Non-specific: bulging fontanelle Specific: lateralizing seizures, eye deviation

Diagnosis:
Head CT X-ray: associated skull fracture

Treatment: majority needs surgical evacuation

Subdural hemorrhage
Most frequent: 73% of all intracranial bleed Injury to veins and venous sinuses and laceration:
Tentorium Falx Superficial cerebral vein Occipital osteodiastasis

Diagnosis:
Head CT MRI: to deliniate posterior fossa hematomas X-ray: associated skull fracture

Clinical symptoms (within 24 hour):

Respiratory: apnea, cyanosis CNS: seizures, focal deficits, lethargy, hypotonia Posterior fossa: ICP:apnea, unequal pupils, eye deviation, coma

Treatment:
conservative (support) or surgical evacuation

Subarachnoid hemorrhage
Incidence: 0.1 per 1000 birth Injury to bridging veins of the subarachnoid space Clinical symptoms : Could be asymptomatic CNS: seizures usually 2nd day, otherwise normal during interictal
Diagnosis: Head CT CSF: bloody Treatment: conservative (support) Monitor for posthemorrhagic hydrocephalus

Nerve and spinal cord Injury

Caused by hyperextension, traction, and overstretching with simultaneous rotation They may range from localized neurapraxia to complete nerve or cord transection

Spinal cord Injury

Results from excessive traction or rotation Major sites of injury:
lower cervical and upper thoracic region for breech delivery: upper and midcervical region for vertex delivery

Clinical presentation: Absent motor function distally: respiratory function

Loss of deep tendon relfex Interruption of peripheral circulatory control temperature instability Constipation, urinary retention Diagnosis: assessment of the extend of injury: CT,MRI

Management:
Resuscitation Prevention of further injury Support of the loss of neurological function

Facial Nerve Palsy

Etiology Compression of peripheral nerve, caused by: forceps, prolonged labor, in-utero compression CNS Injury: in temporal bone fracture Clinical Manifestation Paralysis apparent early Unilateral/bilateral Affected side smooth/drooping Amplified by crying

Management Supportive :protective eye patches; corneal lubrication q 40 establish feeding Prognosis 85% recover in 1 week 90% recovery in 1 year Surgery if no resolution in 1 yr

Brachial Plexus Injury

Bilateral injury in 8-23% Etiology Traumatic lesions associated with brachial plexus injury: LGA >3500g in 50-70% of cases fractured clavicle 10% Abnormal presentation or fractured humerus 10% dysfunctional labor subluxation of cervical Signs of fetal distress in 44% spine 5% Shoulder Dystocia cervical cord injury 5-10% Breech delivery facial palsy (10-20%)

Erbs Palsy
Clinical Manifestation The involved extremity lies: in adduction in pronation and internally rotated Moro, biceps and radial reflexes are absent Grasp reflex is usually present 2-5% ipsilateral phrenic nerve paresis The "waiter's tip" posture Respiratory distress if phrenic nerve is also injured

Etiology Stretch injury to C5-C7 (Upper plexus) 90% of cases Diagnosis: Clinical examination X-ray to exclude bone injury

Klumpkes Palsy
Etiology Stretch injury to C8-T1 (lower plexus) 10% of cases Diagnosis: Clinical examination X-ray to exclude bone injury Clinical Manifestation Absent grasp reflex Clawing Associated with: Horners syndrome (ptosis, myosis, anhydrosis) : injury to sympathetic fibers T1

Brachial Plexus injury: management

Prevention of contractures To prevent discomfort: immobilize limb gently across the abdomen for first week and then Start passive range of motion exercises at all joints Supportive wrist splints Surgical exploration (???) -if no significant functional recovery by 3 months Exploration after 6 months is of little benefit

Brachial Plexus injury: Prognosis

Depends on severity and extent of lesion:
Stretch- 90-100% recovery in 1 year Rupture-needs surgical repair Avulsion-needs surgical repair

88% resolved by 4 months; 92% by 12 months; 93% by 48 months

Residual long-term deficits

Progressive bony deformities Muscle atrophy Joint contractures Impaired limb growth

Laryngeal nerve injury

Injury results from an intrauterine posture or during delivery, in which the head is rotated and flexed laterally presents with a hoarse cry or respiratory stridor Diagnosis: direct laryngoscopic Treatment :supportive
Small frequent feeds, once infant is stable Minimize the risk of aspiration Infants with bilateral involvement may require gavage feeding and tracheotomy

Prognosis: spontaneus recovery in 4-6 wk, full recovery up to 6-12 months

Fracture of the long bones

Diagnosis: X-ray Management: Uncommon: 0.1 per 1000 Splinting/immobilization in live birth adduction Risk factors: Closed reduction and casting Breech when displaced C/section Watch for evidence of radial Low birth weight nerve injury Clinical: Callus formation occurs, and complete recovery expected in decrease movement 2-4 weeks swelling and pain on passive movement In 8-10 days, the callus Obstetrician may feel or formation is sufficient to hear a snap of fracture at discontinue immobilization the time of delivery

Intra-abdominal Organ Injury

Uncommon Diagnostic work-up: History of difficult delivery Abdominal XR: not diagnostic Hemorrhage is the most may suggest free peritoneal fluid serious acute complication Ultrasound : may show Liver is the most ruptured liver, spleen or commonly damaged kidney internal organ Paracentesis in absence of urgent ultrasound/CT Clinical symptoms:
Treatment: Bleeding : fulminant (shock) Volume replacement or insidious Correct coagulopathy Overlying abdominal skin : Bleeding controlled bluish discoloration surgically