BIRTH INJURIES

OPIO JOEL
G COHES
 .

DEFINITION TYPES
 An impairment of 1. Head and neck injuries
the infants body
function or structure 2. Nerve injury
due to adverse 3. Facial injuries
influences that
occur at birth 4. Fractures
5. Intra-abdominal injury
6. Soft tissue injuries
 RISK FACTORS
1. Primiparity
2. Small maternal stature
3. Maternal pelvic anomalies
4. Prolonged or unusually rapid labor
5. Oligohydramnios
6. Malpresentation of the fetus
7. Use of mid forceps or vaccum extraction
8. Versions and extractions
9. Very low birth weight or extreme prematurity
10. Fetal macrosomia or large fetal head
11. Fetal anomalies
 HEAD AND NECK
INJURIES
EXTRACRANIAL INJURIES

1. Caput Succedaneum
2. Cephalhematoma
3. 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 ecchy-
mosis over the presenting portion of the scalp. It
may extend across the midline and across su-
ture lines.
• 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

 CEPHALOHEMATOMA

• A cephalhematoma is a subperiosteal
blood collection caused by rupture of
vessels beneath the periosteum.
 Clinical features
1. Swelling, usually over a parietal or
occipital bone
2. Swelling does not cross a suture line and is
often not associated with discoloration of the
overlying scalp.
3. Limited to the surface of one cranial bone.
 Diagnosis
• Physical examination
• Skull radiograph
• Cranial computed tomography
1. If infection is suspected, aspiration of the
mass
2. If sepsis, antibiotics
3. hyperbilirubinemia – photo therapy
SUBGALEAL HEMORRHAGE
• A Subgaleal hemorrhage is bleeding be-
tween the galea aponeurosis of the scalp
and the periosteum.
 Features
1. Firm-to-fluctuant mass that crosses su-
ture lines.
2. The mass is typically noted within 4
hours of birth.
 Laboratory Findings
1. Serial hemoglobin and hematocrit
monitoring,
2. Coagulation profile to investigate for the
presence of a coagulopathy.
3. Bilirubin levels also need to be monitored
 Treatment
1. Supportive
2. Transfusions may be required if blood loss is
significant.
3. In severe cases, surgery may be required to
cauterize the bleeding vessels.
4. 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.
• The pathogenesis is related to compression
from the application of forceps, or from the skull
pushing against the maternal symphysis or is-
cheal spines.
• Rarely, a linear fracture may be as-
sociated with a dural tear, with sub-
sequent development of a lep-
tomeningeal cyst.
 DEPRESSED SKULL FRACTURES
Indications for surgery include
1. Radiographic evidence of bone
fragments in the cerebrum
2. Presence of neurologic deficits
3. Signs of increased intracranial
pressure
4. Signs of cerebrospinal fluid beneath the
galea
5. 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
1. INJURY
Intracranial haemorrhage
2. Epidural hemorrhage
3. Subdural hemorrhage
4. Subarachnoid hemorrhage
5. Intraparenchymal haemorrhage
6. Germinal matrix hemorrhage / in-
traventricular haemorrhage
 INTRACRANIAL HAEMORRHAGE
• Bleeding can occur
1. External to the brain into the epidural, subdural
or subarachnoid space
2. In to the parenchyma of the cerebrum or cere-
bellum
3. Into the ventricles from the subependymal ger-
minal matrix or choroid plexus
 Risk Factors

1. Forceps delivery
2. Vacuum extraction
3. Precipitous delivery
4. Prolonged second stage of labor
5. Macrosomia

Symptoms
6. Apnea
7. Seizures
 EPIDURAL HEMORRHAGE
• Epidural hemorrhage primarily arises from in-
jury to the middle meningeal artery, and is fre-
quently associated with a cephalhematoma or
skull fracture.
Clinical Manifestations
1. Diffuse neurologic symptoms
2. Increased intracranial pressure
3. Bulging fontanels
4. Localized symptoms,
5. Lateralizing seizures
6. Eye deviation.
 Diagnosis
1. Cranial CT showing a high-density lentiform
lesion in the temporoparietal region
2. Skull radiographs
 Management
• Surgical management
• Aspiration of blood from the accompanying
cephalhaematoma
 SUBDURAL HEMORRHAGE
• Most frequent intracranial hemorrhage re-
lated to birth trauma
Clinical Features

1. Respiratory symptoms such as apnea

2. Seizures
3. Focal neurologic deficits
4. Lethargy
5. Hypotonia
6. Other neurologic symptoms
 Diagnosis
1. Cranial computed tomography
2. Cranial ultrasonography
3. MRI.
4. Coagulation profile
SUBARACHNOID HEMORRHAGE
• Subarachnoid hemorrhage is caused by rup-
ture of the bridging veins of the subarachnoid
space or small leptomeningeal vessels
 Manifestations

1. Seizures, often occurring on the second day

of life
2. Irritability
3. Depressed level of consciousness
4. Focal neurologic signs.
 Diagnosis

1. Cranial computed tomography.

2. Cranial ultrasonography
3. Lumbar puncture shows an increased
number of red blood cells
 Management

• Resolves without intervention

• Monitoring head growth

 INTRAPARENCHYMAL
HAEMORRHAGE
Types
• Intra cerebral
Causes:
1. Rupture of an av malformation or aneurysm
2. Coagulation disturbances
3. Secondary to a large ICH in any other
compartment
• Intracerebellar :
• More common in preterm than the term ba-
bies.
• 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 in-
tracranial fossa , unless the hemorrhage is
quite large
• In the term infant, manifestations are
1. Seizures
2. Hemiparesis
3. Gaze preference
4. Irritability
5. Depressed level of consciousness
 Diagnosis

1. CT Scans
2. MRI
3. Cranial ultrasonography

Management
4. Symptomatic treatment and support
5. Neurosurgical intervention
 GERMINAL MATRIX
HEMORRHAGE
(INTRAVENTRICULAR HAEMORRHAGE)
• Causes:
1. Trauma,
2. Perinatal asphyxia
3. Secondary to venous hemorrhagic in-
farction in the thalamus
Factors In The Pathogenesis
Intra vascular factors
1. Ischemia / reperfusion
2. Fluctuating cerebral blood flow
3. Increase in CBF
4. Increase in cerebral venous pressure
5. Platelet dysfunction
6. Coagulation disturbances
Vascular factors
– Tenuous involuting capillaries with large
diameter lumen
Extra vascular factors
– Deficient vascular support
– Excessive fibrinolytic activity
Clinical Features

In the preterm newborn

1. Usually clinically silent
2. Decreased levels of consciousness and
spontaneous movement
3. Hypotonia
4. Abnormal eye movement
In term newborns
1. Seizures
2. Irritability
3. Apnea
4. Lethargy
5. Vomiting with dehydration
6. Full fontanels
 Diagnosis

1. Cranial ultra sonography

2. CT or MRI
Management
3. Prevention
4. Supportive care
5. Careful monitoring
6. Surgical intervention
FACIAL INJURIES
 NASAL SEPTAL
DISLOCATION
• Nasal septal dislocation involves dislocation
of the triangular cartilaginous portion of the
septum from the vomerine groove
Clinical Features

1. airway obstruction.
2. deviation of the nose to one side
3. The nares are asymmetric, with flattening of
the side of the dislocation (Metzenbaum sign).
4. 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
1. Definitive diagnosis can be made by
rhinoscopy
2. manual reduction performed by an
otolaryngologist using a nasal elevator.
3. Reduction should be performed by 3 days of
age
 OCULAR INJURIES
1. Rupture of Descemet’s membrane of
the cornea
2. lid lacerations
3. hyphema (blood in anterior chamber)
4. vitreous hemorrhage
5. Purtscher’s retinopathy
6. corneal edema,
7. corneal abrasion
FRACTURES
 CLAVICULAR
• FRACTURE
clavicle is the most frequently
fractured bone during birth
 Risk factors
1. higher birth weight
2. prolonged second stage of labor
3. shoulder dystocia
4. 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
1. Breech presentation
2. Cesarean delivery
3. Low birthweight
Clinical features
4. Decreased movement of the affected ex-
tremity
5. Swelling
6. Pain with passive movement
7. Crepitus
 Diagnosis

Ultrasonography
Treatment
1. Immobilization and splinting
2. Closed reduction and casting are required only
when the bones are displaced.
3. Proximal femoral fractures may require a spica
cast
 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
1. Sudden pallor,
2. hemorrhagic shock,
3. abdominal distention
4. abdominal discoloration.
•
 DIAGNOSIS

1. Abdominal ultrasound
2. Computed tomography
3. Abdominal radiographs may show nonspecific
intraperitoneal fluid or hepatomegaly.
4. Abdominal paracentesis is diagnostic if a
hemoperitoneum is present
 Treatment

1. volume replacement and correction of any

coagulopathy.
2. If the infant is hemodynamically stable,
conservative management is indicated.
3. With rupture or hemodynamic instability, a
laparotomy is required to control the bleeding.
4. Patients with adrenal hemorrhage may
require hormone replacement therapy.
 SOFT TISSUE INJURIES

1. Petechiae and ecchymoses

2. Lacerations and abrasions

3. Subcutaneous fat necrosis

NERVE INJURY
 BRACHIAL PLEXUS INJURY
1. Erb’s palsy
2. Klumpke’spalsy
3. Injury to the upper plexus,
4. Erb-Duchenne paralysis
 BRACHIAL PLEXUS INJURY

• Risk factors
1. Macrosomia
2. shoulder dystocia
3. instrumented deliveries
4. malpresentation
 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
• 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
Risk factors
PALSY)
– forceps delivery
– prolonged second stage of labor
 Clinical
• weakness of both upper and lower facial
manifestations
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 ipsilateral side, and the mouth is
drawn awayfrom the affected side.
• lacerations and bruising
• neurologic findings
 TREATMENT
• protection of the involved eye by applica-
tion of artificial tears and taping to pre-
vent 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 is made by direct
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.
THANK YOU….