B.

Sc DEGREE COURSE IN NURSING

MIDWIFERY AND OBSTETRICAL NURSING
Unit X- Assessment and management of
High risk new born
TOPIC - BIRTH INJURIES

Prof. Sheeba. R, HOD

DATE – 15/4/20,
AFTERNOON SESSION
 OBJECTIVES
The student will be able to
•define birth injuries
•identify the risk factors
•enlist the types of birth injuries
•name the common clinical features
•describe the investigations
•explain the management
•draw the nursing process
 OVERVIEW

• Definition
• Risk factors
• Types
• Clinical features
• Investigations
• Management
• Midwifery role in prevention and treatment of
BIRTH INJURIES
 INTRODUCTION

Birth injuries are the structural destruction or

functional deterioration of the neonates body due
to traumatic event at birth. Some of these injuries
are avoidable when appropriate care is available
and others are part of delivery process that can
occur even when extreme caution is practiced.
 DEFINITION

• An impairment of the infants body function or

structure due to adverse influences that occur at
birth
• Injuries to the infant that result from
mechanical forces (i.e., compression, traction)
during the birth process are categorized as birth
trauma.
 INCIDENCE

• Has been estimated at 2-7/1,000 live births

• 5-8/100,000 infants die of birth trauma, and
• 25/100,000 die of anoxic injuries
• Such injuries represent 2-3% of infant deaths.
 RISK FACTORS

• Primiparity
• Small maternal stature
• Maternal pelvic anomalies
• Prolonged or unusually rapid labor
• Oligohydramnios
• Malpresentation of the fetus
cont

• Use of mid forceps or vaccum extraction

• Versions and extractions
• Very low birth weight or extreme prematurity
• Fetal macrosomia or large fetal head
• Fetal anomalies
TYPES
HEAD AND NECK INJURIES
 EXTRACRANIAL INJURIES

• Caput succedaneum

• Cephalhematoma

• Subgaleal hemorrhage
 CAPUT SUCCEDANEUM

• A caput succedaneum is a serosanguinous fluid

collection above the periosteum. It presents as a
soft tissue swelling with purpura and ecchymosis
over the presenting portion of the scalp. It may
extend across the midline and across suture
lines.
 CLINICAL FEATURES

• The edema disappears within the 1st few days

of life.
• Molding of the head and overriding of the
parietal bones disappear during the 1st weeks of
life.
• Rarely, a hemorrhagic caput may result in
shock and require blood transfusion.
 MANAGEMENT

• No specific treatment is needed

• But if extensive ecchymoses are present,

hyperbilirubinemia may develop

• Shock – Blood transfusion

 CEPHALHEMATOMA

• A cephalhematoma is a subperiosteal blood

collection caused by rupture of vessels beneath
the periosteum.
 CLINICAL FEATURES

• Swelling, usually over a parietal or occipital bone

• Swelling does not cross a suture line and is
often not associated with discoloration of the
overlying scalp.
• Limited to the surface of one cranial bone.
 DIAGNOSIS TREATMENT

• Physical examination • If infection is

• Skull radiograph suspected, aspiration
• cranial computed of the mass
tomography • If sepsis, antibiotics
• hyperbilirubinemia –
photo therapy
 SUBGALEAL HEMORRHAGE

• A subgaleal hemorrhage is bleeding between

the galea aponeurosis of the scalp and the
periosteum.
• A subgaleal hemorrhage
presents as a firm-to-
fluctuant mass that crosses
suture lines.
• The mass is typically noted
within 4 hours of birth.
 LABORATORY FINDINGS

• Serial hemoglobin and hematocrit monitoring,

• Coagulation profile to investigate for the
presence of a coagulopathy.
• Bilirubin levels also need to be monitored
 TREATMENT

• Supportive
• Transfusions may be required if blood loss is
significant.
• In severe cases, surgery may be required to
cauterize the bleeding vessels.
• These lesions typically resolve over a 2–3 week
period
 CRANIAL INJURIES

• LINEAR SKULL FRACTURES

• DEPRESSED SKULL FRACTURES

 LINEAR SKULL FRACTURES

• Usually affect the parietal

bones.
• Usually due to compression
from the application of forceps,
or from the skull pushing
against the maternal
symphysis or ischeal spines.
• Rarely, a linear fracture may
be associated with a dural
tear, with subsequent
development of a
leptomeningeal cyst.
 DEPRESSED SKULL FRACTURES

Indications for surgery include

• radiographic evidence of bone
fragments in the cerebrum
• presence of neurologic deficits
• signs of increased intracranial pressure
• signs of cerebrospinal fluid beneath the galea
• failure to respond to closed manipulation.
Indications for nonsurgical management
include
• Depressions less than 2 cm in width and
depressions over a major venous sinus
• Without neurologic symptoms
 INTRACRANIAL INJURY

• Intracranial haemorrhage
• Epidural hemorrhage
• Subdural hemorrhage
• Subarachnoid hemorrhage
• Intraparenchymal haemorrhage
• Germinal matrix hemorrhage / intraventricular
haemorrhage
 INTRACRANIAL HAEMORRHAGE
Causes
• Sudden compression and decompression of the head as
in breech and precipitate labour.
• Marked compression by forceps or in cephalopelvic
disproportion.
• Fracture skull.
Predisposing factors:
• Prematurity due to physiological hypoprothrombinaemia,
fragile blood vessels and liability to trauma.
• Asphyxia due to anoxia of the vascular wall .
• Blood diseases.
INTRACRANIAL HAEMORRHAGE SITES
 CLINICAL PICTURE

1. Altered consciousness.
2. Flaccidity.
3. Breathing is absent, irregular and periodic or gasping.
4.Eyes: no movement, pupils may be fixed and dilated.
5.Opisthotonus, rigidity, twitches and convulsions.
6. Vomiting .
7. High pitched cry.   
8. Anterior fontanelle is tense and bulging.
9. Lumbar puncture reveals bloody C.S.F.
 INVESTIGATIONS PROPHYLAXIS

• Ultrasound is of value. • Vitamin K: 10 mg IM to

– CT scan is the most the mother in late
reliable. pregnancy or early in
– MRI labour.
• Episiotomy: especially in
prematures and breech
delivery.
• Forceps delivery: carried
out by an experienced
obstetrician respecting
the instructions for its
use.
 EPIDURAL HEMORRHAGE

Epidural hemorrhage primarily arises from injury

to the middle meningeal artery, and is frequently
associated with a cephalhematoma or skull
fracture.
 CLINICAL MANIFESTATIONS

• Diffuse neurologic symptoms

• Increased intracranial pressure
• Bulging fontanels
• Localized symptoms,
• Lateralizing seizures
• Eye deviation.
 DIAGNOSIS

 Cranial computed tomography showing a high-density

lentiform lesion in the temporoparietal region
 Skull radiographs

MANAGEMENT

• Surgical management
• Aspiration of blood from the accompanying
cephalhaematoma
 SUBDURAL HEMORRHAGE

Most frequent intracranial hemorrhage related to birth

trauma
 LOCATION

• Laceration of the • Laceration of the

superficial cerebral vein,
causing bleeding over
the cerebral convexity
• Occipital osteodiastasis,
with rupture of the
occipital sinus, resulting
in a posterior fossa
clot • Laceration of the falx,
tentorium, with rupture of
the straight sinus, vein of
Galen transverse sinus,
or infratentorial veins
causing a posterior
fossa clot and brainstem
compression
with rupture of the inferior
sagittal sinus resulting in
a clot in the longitudinal
cerebral fissure
 CLINICAL FEATURES

• Respiratory symptoms such as apnea

• Seizures
• Focal neurologic deficits
• Lethargy
• Hypotonia
• Other neurologic symptoms
 DIAGNOSIS

• Cranial computed tomography

• Cranial ultrasonography
• MRI.
• Coagulation profile

MANAGMENT

• Antiepileptic drug if having seizures

• If the babys ICP is increased surgical removal of blood

 SUBARACHNOID HEMORRHAGE

• Subarachnoid hemorrhage is caused by rupture of the

bridging veins of the subarachnoid space or small
leptomeningeal vessels
INTRAPARENCHYMAL HAEMORRHAGE

Intra cerebral
Causes:
 rupture of an av malformation or aneurysm
 coagulation disturbances
 extracorporeal membrane oxygenation therapy
 secondary to a large ICH in any other compartment
• Intracerebellar :
more common in preterm than the term babies. May
be a primary haemorrhage or may result from venous
hemorrhagic infarction or from extension of GMH/ IVH
 CLINICAL FEATURES

• In the preterm infant

– IPH is often clinically silent in either intracranial fossa ,
unless the hemorrhage is quite large
• In the term infant, manifestations are
– Seizures
– Hemiparesis
– Gaze preference
– Irritability
– Depressed level of consciousness
 DIAGNOSIS

• CT Scans
• MRI
• Cranial ultrasonography

MANAGEMENT

• Symptomatic treatment and support

• Neurosurgical intervention
 BRACHIAL PLEXUS INJURY
• Erb’s palsy
• Klumpke’s palsy
• Injury to the upper plexus,
• Erb-Duchenne paralysis
 BRACHIAL PLEXUS INJURY

Risk factors
• Macrosomia
• shoulder dystocia
• instrumented deliveries
• malpresentation
 BRACHIAL PLEXUS INJURY

• C4: phrenic nerve palsy

• C5-C6 +/-C7: Erb’s or Erb-Duchenne palsy
(80% of brachial plexus injuries)
• C8-T1: Klumpke’s palsy
• C5-T1: Complete brachial plexus injury, or Erb-
Klumpke palsy
 ERB-DUCHENNE PARALYSIS

• 5th and 6th cervical nerves injury

• The infant loses the power to abduct the arm
from the shoulder, rotate the arm externally, and
supinate the forearm
• Erb’s palsy may also be associated with injury to
the phrenic nerve,
which is innervated with
fibers from C3–C5
 FEATURES

• Adduction and internal rotation of the arm with

pronation of the forearm.
• Biceps reflex is absent
• Moro reflex is absent on the affected side.
• The involved arm is held in the ‘‘waiter’s tip’’
position, with adduction and internal rotation of
the shoulder, extension of the elbow, pronation
of the forearm, and flexion of the wrist and
fingers.
 KLUMPKE’SPALSY

• Involves the C8 and T1 nerves, resulting in

weakness of the intrinsic hand muscles and long
flexors of the wrist and fingers
• The grasp reflex is absent but the biceps reflex
is present.
• Flaccid extremity with absent reflexes.
 ASSOCIATED LESIONS

• Hematomas of the sternocleidomastoid muscle,

and fractures of the clavicle and humerus.
• Ipsilateral Horner’s syndrome (ptosis, miosis,
and anhydrosis) when there is accompanying
injury to the sympathetic fibers of T1.
 TYPES

• Neuropraxia with temporary conduction block

• Axonotmesis with a severed axon, but with intact
surrounding neuronal elements
• Neurotmesis with complete postganglionic disruption of the
nerve
• Avulsion with preganglionic disconnection from the spinal
cord

DIAGNOSIS

• Physical examination.
• Radiographs of the shoulder and upper arm
 MANAGEMENT
• Initial treatment is
conservative.
• The arm is immobilized
across the upper abdomen
during the first week
• Physical therapy with passive
range-of-motion exercises at
the shoulder, elbow and wrist
should begin after the first
week.
• Infants without recovery by 3
to 6 months of age may be
considered for surgical
exploration
 FACIAL NERVE PALSY (BELL’S PALSY)

Facial paralysis can be caused by pressure on the facial

nerves during birth or by the use of forceps during birth.

The affected side of the face droops and the infant is

unable to close the eye tightly on that side.

When crying the mouth is pulled across to the normal side.

 RISK FACTORS

– forceps delivery
– prolonged second
stage of labor
 CLINICAL MANIFESTATIONS
• weakness of both upper and lower facial muscles.

• At rest, the nasolabial fold is flattened and the eye

remains persistently open on the affected side.
• During crying, there is inability to wrinkle the forehead or
close the eye on the lips lateral side, and the mouth is
drawn awayfrom the affected side.
• lacerations and bruising

• neurologic findings
 TREATMENT

• Protection of the involved eye by application of

artificial tears and taping to prevent corneal
injury.
• Neurosurgical repair of the nerve should be
considered only after lack of resolution during 1
year of observation
 PHRENIC NERVE INJURY

• The phrenic nerve arises from the third through

fifth cervical nerve roots.
• Injury to the phrenic nerve leads to paralysis of
the ipsilateral diaphragm.
 CLINICAL MANIFESTATIONS

• Respiratory distress, with diminished breath

sounds on the affected side.
• Chest radiographs show elevation of the
affected diaphragm, with mediastinal shift to the
contralateral side.
• Ultrasonography or fluoroscopy can confirm the
diagnosis by showing paradoxical diaphragmatic
movement during inspiration
 TREATMENT

• Initial treatment is supportive

• Oxygen
• Respiratory failure may be treated with
continuous positive airway pressure or
mechanical ventilation.
• Gavage feedings.
• Plication of the diaphragm
 LARYNGEAL NERVE INJURY

Symptoms
•Stridor
•respiratory distress
•hoarse cry
•dysphagia,
•Aspiration
•Diagnosis :
idirect laryngoscopy
 TREATMENT

• Small frequent feedings may be required to

decrease the risk of aspiration.
• Intubation
• Tracheostomy
• Bilateral paralysis tends to produce more severe
distress, and therefore requires intubation and
tracheostomy placement more frequently
 SPINAL CORD INJURY

Clinical findings
•decreased or absent spontaneous movement
•absent deep tendon reflexes
•absent or periodic breathing
•lack of response to painful stimuli below the level
of the lesion.
• Lesions above C4 are almost always associated
with apnea
• Lesions between C4 and T4 may have
respiratory distress secondary to varying
degrees of involvement of the phrenic nerve and
innervation to the intercostal muscles
 MANAGEMENT

• If cord injury is suspected in the delivery room,

the head, neck, and spine should be
immobilized.
• Therapy is supportive.
FACIAL INJURIES
 SUBCONJUNCTIVAL HEMORRHAGE

It is the breakage of small blood vessels in the eyes of a

baby. One or both of the eyes may have a bright red
band around the iris.
This is very common and does not cause damage to the
eyes. The redness is usually absorbed in a week to ten
days.
 NASAL SEPTAL DISLOCATION

• Nasal septal dislocation involves dislocation of

the triangular cartilaginous portion of the septum
from the vomerine groove
 CLINICAL FEATURES

• airway obstruction.
• deviation of the nose to one side
• nares are asymmetric, with flattening of the side
of the dislocation (Metzenbaum sign).
• Application of pressure on the tip of the nose
(Jeppesen and Windfeld test) causes collapse of
the nostrils, and the deviated septum becomes
more apparent.
 MANAGEMENT

• Definitive diagnosis can be made by rhinoscopy

• manual reduction performed by an
otolaryngologist using a nasal elevator.
• Reduction should be performed by 3 days of age
OCCULAR INJURIES
CONGENITAL MUSCULAR TORTICOLLIS

• Atrophic muscle fibers surrounded by collagen

and fibroblasts.
• Tearing of the muscle fibers or fascial sheath
with hematoma formation and subsequent
fibrosis.
 CLINICAL FEATURES

• The head is tilted toward the

side of the lesion and rotated
to the contralateral side,
• chin is slightly elevated.
• If a mass is present, it is firm,
spindle-shaped, immobile, and
located in the midportion of the
sternocleidomastoid muscle,
without accompanying
discoloration or inflammation.
 DIAGNOSIS

• Physical examination
• Radiographs should be obtained to rule out
abnormalities of the cervical spine.
• Ultrasonography may be useful both
diagnostically and prognostically.
TREATMENT

• Active and passive stretching

• surgery
 FRACTURES

CLAVICULAR FRACTURE
Long bone fracture
 CLAVICULAR FRACTURE

• Clavicle is the most frequently fractured bone

during birth
 Risk factors

• higher birth weight

• prolonged second stage of labor
• shoulder dystocia
• instrumented deliveries
 MANAGEMENT

• Asymptomatic incomplete fractures require no

treatment.
• Complete fractures are treated with
immobilization of the arm for 7 to 10 days
 LONG BONE FRACTURES

Risk factors
• breech presentation
• cesarean delivery
• low birthweight
Clinical features
• Decreased movement of the affected extremity,
swelling, pain with passive movement, and
crepitus
• Diagnosis is made radiographically
 TREATMENT
• Immobilization and splinting
• Closed reduction and casting are required only when the bones are
displaced.
• Proximal femoral fractures
may require a spica cast
or use of a Pavlik harness
 INJURIES TO INTRA-ABDOMINAL
ORGANS
• Rupture of the liver- large infants, IDM, breech
• May appear normal from 1-3 days of life, any
infant with shock, abdominal distension, pallor,
anemia, and irritability with no evidence of blood
loss
• Abdomen is rigid, bluish discoloration of the
overlying skin.
• CT scan may help in diagnosing subcapsular
hematoma
 TREATMENT
• Prompt transfusion of PRBC and correction of
coagulation disorder
• Laparotomy with evacuation of the hematoma
and repair of any lacerations
• Any fragmented, devitalized liver tissue should
be removed
• Blood transfusion and the tamponade of intra-
abdominal pressure might be adequate therapy
in some infants
RUPTURE OF THE SPLEEN
 ADRENAL HEMORRHAGE

• Increased size and vascularity at birth

• Macrosomic, IDM, cong syphilis, neuroblastoma,
hemorrhagic disease
• Fever, tachypnea, cyanosis, mass in flank and
purpura
• Adrenal insufficiency, poor feeding, vomiting,
uremia, convulsions and shock
• US- initially solid appearance then cystic
• Blood , IVF and corticosteroids
• Laparotomy, evacuation of clots if extends to
peritoneal cavity
 INTRA-ABDOMINAL INJURY

Liver injury is the most common

• Three potential mechanisms lead to intra-
abdominal injury:
• (1) direct trauma,
• (2) compression of the chest against the surface
of the spleen or liver
• (3) chest compression leading to tearing of the
ligamentaous insertions of the liver or spleen
 CLINICAL MANIFESTATIONS

• With hepatic or splenic rupture, patients develop

sudden pallor, hemorrhagic shock, abdominal
distention, and abdominal discoloration.
• Presentation of a liver rupture with scrotal
swelling and discoloration has been described .
 Subcapsular hematomas

• Subcapsular hematomas may present more

insidiously, with anemia, poor feeding,
tachypnea, and tachycardia.
• Adrenal hemorrhage may present as a flank
mass
 DIAGNOSIS

• abdominal ultrasound
• Computed tomography
• Abdominal radiographs may show nonspecific
intraperitoneal fluid or hepatomegaly.
• Abdominal paracentesis is diagnostic if a
hemoperitoneum is present
 TREATMENT
• Volume replacement and correction of any
coagulopathy.
• If the infant is hemodynamically stable,
conservative management is indicated.
• With rupture or hemodynamic instability, a
laparotomy is required to control the bleeding.
• Patients with adrenal hemorrhage may require
hormone replacement therapy.
 SOFT TISSUE INJURY

Soft tissue injuries usually occurs when there is

some degree of disproportion between the
presenting part and the maternal pelvis

( cephalopelvic disproportion).
• Petechiae and ecchymoses
• Lacerations and abrasions
• Subcutaneous fat necrosis
 CAUSES OF SOFT TISSUE INJURIES

• Dystocia (difficult birth)

• Cephalopelvic disproportion
• Forceps delivery
• Vacuum delivery
• Enlarged fetal size
• Improper “episiotomy” technique.
• Cesarean section (rare)
 SIGNS AND SYMPTOMS

• Facial Abrasions: a minor wound in which a

surface of the newborn’s facial skin is worn
specially with dystocia and forceps delivery
• Scleral hemorrhage: specially with vertex
presentation .
• Ecchymoses and petechiae: in the newborn’s
face with brow (face) or breech (feet)
presentation.
 Abrasions and lacerations sometimes may
occur as scalpel cuts during cesarean delivery
or during instrumental delivery (i.e, vacuum,
forceps). Infection remains a risk, but most
uneventfully heal.
Management
consists of careful cleaning, application of
antibiotic ointment, and observation.
Lacerations occasionally require suturing.
 SUBCUTANEOUS FAT NECROSIS

 Irregular, hard, non pitting, subcutaneous induration 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.
 Prevention of birth injuries
ANTENATAL PERIOD
• To screen out the at risk babies likely to be traumatized during vaginal
delivery and to employ liberal use of elective CS.
• Contracted pelvis and CPD or malpresentation like breech or
transverse lie are included in the list
INTRANATAL PERIOD
Normal delivery
- continous fetal monitoring to prevent traumatic cerebral anoxia
- episotomy should be done carefully
- the neck should not be unduly stretched while delivering the shoulder
to prevent injuries to the brachial plexus or sternomastoid.
- Special care to the preterm to prevent anoxia, avoid strong sedatives,
liberal episiotomy and to administer Vit K 1mg IM to prevent
haemorrhage from the traumatized site.
Prevention of birth injuries
 NURSING ASSESSMENT
• Review for risk factors, such as
a prolonged or abrupt labor,
abnormal or difficult
presentation, cephalopelvic
disproportion or mechanical
forces such as forceps or
vaccum used during delivery.
• Also review for multiple fetus
deliveries, large for date
infants, extreme prematurity,
large fetal head or newborns
with congenital anomalies.
• Complete a careful physical
and neurologic assessment to
establish whether injuries exist.
• Inspect the head for lumps,
bumps or bruises. Note if
swelling or bruising crosses
the suture line.
• Assess the eyes and face for
facial paralysis, observing for
asymmetry of the face with
crying or appearance of the
mouth being drawn to the
unaffected side.
 Nursing Management
• Ensure that the newborn
spontaneously moves all
extremities.
• Note any absence of or
decrease in the deep tendon
reflexes or abnormal
positioning of extremities.
• Assess and document
symmetry of structure and
function. Be prepared to assist
with scheduling diagnostic
studies to confirm trauma or
injuries,
• Nursing management is
supportive and focuses on
assessing complications
• Provide the parents with
explanations and reassurance
that these injuries resolve with
minimal or no treatment.
• Provide parents with a realistic
picture of situation to gain their
understanding and trust.
 Counselling parents with e deformed
child
• Be readily available to answer questions and teach them
how to care for their newborn, including any
modifications that might be necessary.
• Allow parents adequate time to understand the
implications of the birth trauma or injury and what
treatment modalities are needed, if any.
• Provide them with information of length of time until the
injury will resolve and when and if they need to seek
further medical attention for the condition.
• Spending time with parents and providing them with
support, information and teaching are important to allow
them to make decisions and care for their newborn.
 SUMMARY

• Caring infant patients with birth injury, involves

support of their needs, treatment and early
recognition of complications. Nurses have the
responsibility in providing support and education
to the close relatives as well. Early discharge
planning and rehabilitation should be
incorporated in the nursing plan, as care should
be provided even when the patient leaves the
hospital.
 REFERENCES
• Wong's“Nursing care of infant and children "9th
edition published by Elseiver, New Delhi.
• S parol Dutta" Pediatric nursing", 4th edition
published by Jaypee brothers , new Delhi
• *Dc Dutta, "the text book of obstetrics" 9th edition
published by Elseiver, New Delhi
• Rimple sharma "pediatric nursing" 2nd edition
published by Elseiver, new delhi
• Malik and warker," birth injuries :Review of
incidence perinatal risk factor and out come
"published by Bombay hospital on April 2012,
volume 2.