This document discusses various types of birth injuries that can occur in newborns. It begins by defining birth injury as damage that occurs during the birthing process, usually from physical pressure during delivery. Common minor injuries include bruising, abrasions and cephalohematomas, while more serious injuries can involve bones, muscles or the brain. Risk factors for injuries include difficult or prolonged labor, large baby size and abnormal fetal positioning. The document then examines specific injuries like cephalohematomas, caput succedaneum, subgaleal hemorrhages and various types of intracranial hemorrhages. It provides details on symptoms, diagnostic methods and treatment approaches for different birth injuries.

1. BIRTH INJURIES OF NEWBORN
PRESENTED BY
LIPI MONDAL
M.SC NURSING 2ND YEAR STUDENT

2. INTRODUCTION
 Birth injury is damage that occurs as a result of physical pressure
during the birthing process, usually during transit through the birth
canal. Many newborns have minor injuries during birth.
Infrequently, nerves are damaged or bones are broken. Most
injuries resolve without treatment. A difficult delivery, with the
risk of injury to the baby, may occur with extremely large fetuses.
Injury is also more likely when the fetus is lying in an abnormal
position in the uterus before birth.

3. INCIDENCE
 India showed incidence of 3.2/1000 live birth during 2009-
2010.Significant birth injuries accounts for fewer than 2 % of
neonatal death and stillbirth. Injuries may occur during intra-
natal, antenatal, during resuscitation and may be avoidable or
unavoidable. Global neonatal mortality rate is 19 per 1000 in
2016. Incidence of birth injuries was 2.2%. in vaginal delivery it
is 3.6% and in CS 1.2%.

4. MEANING
 Birth injuries is an impairment of the infant’s body function or
structure due to adverse influences that occurred at birth.
Injuries to the newborn from the forces of labour and birth are
categorized as birth trauma. The injuries commonly occurs
during labour or delivery.

5. HIGH RISK FACTORS FOR BIRTH INJURIES
 Primigravida
 Prolonged or obstructed labor
 Fetal macrosomia
 Cephalo-pelvic disproportion
 Very low birth weight infant
 Abnormal presentation (breech)

6. CONTD…
 Instrumental delivery (forceps or ventouse)
 Difficult labor
 Shoulder dystocia
 Inadequate maternal pelvis
 Oligohydramnios
 Precipitate labor

7. TYPE OF INJURY ORGANS AFFECTED
Soft Tissue Skin - Lacerations, abrasions, fat necrosis, petechiae
Muscle Sternocleidomastoid
Nerve Facial nerve, Brachial plexus, Spinal cord, Phrenic nerve (C3, C4 or C),
Horner’s syndrome, recurrent laryngeal nerve
Eye Hemorrhages: Sub-conjunctiva, vitreous, retina
Viscera Rupture of liver, adrenal gland, spleen testicular injury
Scalp Laceration, abscess, hemorrhage, caput succedaneum
Dislocation Hip, shoulder, cervical vertebrae
Skull Cephalohematoma, subgaleal hematoma, fractures
Intracranial Hemorrhages—Intraventricular, Subdural, subarachnoid
Bones Mandible, Clavicle, Humerus, Femur, Skull and Nasal bones

8. EXTRACRANIAL INJURIES
1
•Cephalo-hematoma
2
•Caput Succedaneum
3
•Subgaleal Haemorrhage

9. FEATURES OF CEPHALO-HEMATOMA
 It is never present at birth but gradually develops after 12-
24 hrs.
 The swelling is limited by the sutures lines of the skull as the
pericranium is fixed to the margins of the bones.
 Well circumscribed, soft, fluctuant and incompressible(
irreducible fullness of cephalohematoma) does not pulsate
or bulge when the infant cries.
 There may be underlying fracture of the skull.
 A hard sharp edge can be felt surrounding the swelling due
to organization of the blood.
 A cephalohematoma is usually largest on 2nd or 3rd day.

10. MANAGEMENT OF CEPHALO-HEMATOMA
 No active treatment is needed.
 The fullness of a cephalo-hematoma
spontaneously resolves in 3 to 6 weeks.
 Only observation in most cases.
 Incision and aspiration of a cephalo-hematoma
may introduce infection so it is contraindicated.
 Symptomatic treatment of anemia and jaundice.

11. FORMATION OF CAPUT SUCCEDANEUM
 With vertex presentation the sustained pressure
of the occiput against the cervix results in
compression of local vessels, thereby slowing
venous return. The slower venous return causes
an increase in tissue fluids within the skin of the
scalp and an edematous swelling develops.

12. FEATURES
 Poorly defined margins.
 Baby’s head - swelling, puffiness, and bruising present at
birth extends across suture lines of the fetal skull and
disappears spontaneously within 3-4 days. These are hallmark
symptoms of caput succedaneum.
 Can extend over the presenting portion of the scalp and
usually associated with molding.
 Usually present after birth and resolves spontaneously
without first few days after birth.

13. SUBGALEAL HEMORRHAGE
 A Subgaleal hemorrhage is bleeding between the
galeaaponeurosis of the scalp and the periosteum.
 Causes:
 Forces that compress and then drag the head through the
pelvic outlet
 Increased use of the vacuum extractor at birth

14. FEATURES
 Presents as a firm-to-fluctuant mass that crosses suture lines.
 A boggy scalp, pallor, tachycardia, and increasing head
circumference – early signs.
 Forward and lateral positioning of the infant’s ear because
hematoma extends posteriorly.
 The mass is typically noted within 4 hours of birth.
 The bleeding extends beyond bone, often posteriorly into
neck and continues after birth.

15. DIAGNOSIS
 Serial hemoglobin and hematocrit monitoring- decrease in
hematocrit level.
 Monitor for level of consciousness.
 Coagulation profile to investigate for the presence of a
coagulopathy.
 Bilirubin levels also need to be monitored- increased as a
result of degrading blood cells.
 CT / MRI for confirming the diagnosis.

16. TREATMENT
 Supportive.
 Replacement of lost blood and clotting factors is required in
acute cases of hemorrhage.
 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.

17. SCALP INJURIES
 Minor injuries of the scalp are abrasion over the scalp.
 Causes:
 Forceps delivery
 Incised wound inflicted during cesarean section
 Scalp electrodes placement
 Episiotomy
 Signs: on occasion, the incised wound may cause brisk hemorrhage
which requires stitches.
 Care: wound may bleed require stitches and which should be dressed
with antiseptic solution.

18. SKULL FRACTURE
 Fracture of the vault of the skull (frontal or anterior part of
the parietal bone) may be linear or depressed type.
 Causes:
 Effect of difficult forceps delivery in disproportion or due to
wrong application of the forceps (blades not placed over the
bi-parietal diameter).
 Projected sacral promontory of the flat pelvis may produce
depressed fracture even though the delivery is spontaneous.

19. CONTD…
 Features:
 It may be associated with cephalo-hematoma, extradural or subdural
hemorrhage or a hematoma or brain contusion.
 Depressed fractures cases some pressure effect.
 Neurological manifestation- occur later due to compression effect.
 Treatment:
 Conservative in symptomless cases.
 Antibiotic is started.
 The depressed bone has to be elevated or subdural hematoma may have
to be aspirated or excised surgically.
 Follow-up imaging should be performed at 8-12 weeks to evaluate any
cyst formation.

20. INTRACRANIAL HEMORRHAGE
 An intracranial hemorrhage is a type of bleeding that occurs inside the
skull (cranium).
 Intracranial hemorrhage may be -
 External to the brain( epidural, subdural or subarachnoid spaces)
 In the parenchyma of brain (cerebrum or cerebellum) and
 Into the ventricles from sub-pendymal germinal matrix or choroid
plexus.
 Causes:
 Traumatic
 Anoxic
 Primary hemorrhagic disease

21. SUBDURAL HAEMORRHAGE
 Slight haemorrhage may occur following:
 Fracture of skull bone,
 Rupture of the inferior sagittal sinus ,
 Rupture of small veins leaving the cortex.
 The hemorrhage, so occurring, produces hematoma which
may remain stationary or increase in size.
 Neurological symptoms may appear acutely or may have
insidious onset, like vomiting, irritability and failure to gain
weight.
 Hydrocephalus and mental retardation may be a latesequelae.

22. MASSIVE HAEMORRHAGE
 Massive subdural haemorrhage usually results
from
 Tear of the tentorium cerebella thereby opening
up the straight sinus or rupture of the vein of
galen or its distribution.
 Injury to the superior sagittal sinus.

23. ANOXIC
 Intracerebralintraparenchymal hemorrhage( Intracerebral):
 It is also known as periventricular hemorrhagic infarction (PVHI. It was
seen following perinatal hypoxic ischemic event as small petechial
haemorrhage in the brain substance due to anoxia. It usually occurs in
mature babies following prolonged labor. The features are vague- loss of
weight, flaccid limbs and anxious expression.
 Intraventricular Hemorrhage (IVH)/Germinal Matrix Hemorrhage
(GMH)—
 The pathogenesis of IVH in the term infant is more likely due to trauma
(difficult delivery) or perinatal asphyxia. In the preterm infant GMH/IVH
is mainly due to ischemia/reperfusion. Clinical presentation is extremely
diverse: clinically silent, seizures, apnea, irritability, lethargy, vomiting
or a full fontanel.

24. CONTD…
 INVESTIGATION:
 Ultrasonography is used to detect intraventricular haemorrhage.
 Doppler Ultrasonography can detect any change in cerebral
circulation.
 CT scan is useful to detect cortical neuronal injury.
 MRI is used to evaluate any hypoxic ischemia brain injury.
 CSF- elevated RBCs, WBCs and protein.
 MANAGEMENT:
 Prevention: antenatal glucocorticoids reduce GMH/ IVH.
 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.

25. TREATMENT
 Follow up- serial neuroimaging cranial ultrasound (CT)- Detect
any progressive hydrocephalus.
 Anticonvulsant –
 Phenobarbitone- 3-5 mg/kg/day- 12 hrs interval – oral/ IM
 Phenytoin- 20mg/kg- IV (Loading dose) – rate – 1mg/ kg/ min-
followed -5mg/kg/day- cardiac monitoring.
 Diazepam- 0.1 mg/kg – IV- thrice daily.

26. CONTD…
 SUBDURAL HAEMATOMA
 Subdural tap: Aspiration of the blood through lateral angles of
the anterior fontanelle.
 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 developmental of
nuerological sequelae.
 Rarely subdural-peritoneal shunting may be needed.
 Prevention: Comprehensive antenatal and intranatal care is
the key to success in the reduction of intracranial injuries.

27.  ANTENATAL PREVENTION OF IVH/ GMH :
 Tocolysis with indomethacin should be avoided.
 In utero transfer of preterm labor to a centre with NICU.
 Caesarean delivery before active phase of labor in preterm infant.
 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 caesarean section.
difficult forceps should be avoided.
 Administration of vitamin K 1 mg IM soon after birth in susceptible
babies.
 POSTNATAL PREVENTION: Avoid birth asphyxia, fluctuation of blood
pressure, correct acid base abnormalities, surfactant therapy is found
helpful.

28. SUBARACHNOID HEMORRHAGE
 Is an accumulation of blood between the arachnoid and the pia matter.
 Causes:
 Excessive molding in deflexed vertex with gross disproportion;
 Rapid compression of the head during delivery of the after coming head
of breech or in precipitate labor and
 Forcible forceps traction following wrong application of the blades
(other than bi parietal diameter).
 Clinical features:
 Hemorrhage is fetal and baby is delivery dead.
 Baby will have respiratory depression.
 Cerebral irritation (Frequent high pitch cry, neck retraction,
incoordination ocular movements, convulsion, vomiting and bulging of
the anterior fontanel)

29. FACIAL FRACTURES
 Facial fractures can be caused by numerous forces including
natural passage through the birth canal, forceps use or
delivery of the head in breech presentation.
 Features: It is presented with facial asymmentry, ecchymosis,
edema and crepitus or respiratory distress with poor feeding.
 Treatment:
 Treatment should be started promptly because maxillary and
lacrimal fractures begins to heal within 7-10 days and
mandibular fractures starts to repair at 10-14 days.
 Airway patency should be closely monitored.
 Anti-biotic is started if sinus and middle ear is involved.

30. SKIN AND SUBCUTANEOUS INJURIES
 Bruises and lacerations on the face are usually caused by
forceps blades. These are treated with application of 1%
lotion mercurochrome.
 Buttocks in breech presentation, or eyelids, lips or nose in
face presentation, similarly become edematous and
congested. No treatment is required.
 Scalpel cut or laceration injury may occur during cesarean
section. They usually occur on the buttocks, scalp or thigh.
 Small cut heals spontaneously. Laceration injury may need
repair by stitches with 7-0 nylon. Healing is usually rapid.

31. MUSCLES INJURIES
 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 is seen in difficult breech delivery or in attempted delivery of shoulder
dystocia or excessive lateral flexion of the neck even during the normal
delivery.
 There is transient torticollis and it is wise not to massage.
 Stretching of the involved muscles should be done several times a day.
Recovery is rapid in most of the cases (3 months). Surgery is needed is it
persist after 6 months of physical therapy.
 Necrosis of the subcutaneous tissue: may occur while the superficial skin
is intact. After few days, a small hard subcutaneous nodule appears. It is
result of the fat necrosis due to pressure and takes many weeks to
disappears.No treatment is needed.