COLLEGE OF HEALTH SCIENCE
DEPARTMENT OF MIDWIFERY
COURSE NEWBORN CARE
FOR POSTBASIC
1
28-03-2023 BY SHambel N.

Learning Objectives
At end on this lesson student able to :-
• Know what is birth injury
• Know the causes of birth injury
• Differentiate different types of birth injury
• Know the difference between Caput succedaneum and
Cephalhaematoma
• Understand facial nerve injury and Neck, shoulder, and chest
injuries
• Classic triad Horner syndrome

Birth injury
 “A physical injury sustained by an infant in the process of
birth.”
It estimates ranging from approximately 6 to 8 per 1000
live births.
 The highest percentage of birth injuries occurs in mothers
who were subjected to birthing instruments (eg, vacuum
extraction, forceps)

Birth injury
 Injuries can also occur as a result of inappropriate use of
excessive force.
Sometimes, bony injury may be an unintended consequence
of saving the baby’s life when there is severe shoulder
dystocia.
Preterm babies are particularly susceptible to injury, either at
delivery or after admission to the neonatal intensive care unit
(NICU) where they are vulnerable to preventable iatrogenic
injuries.

Birth injury
The most common birth injuries are
– Injuries to the scalp, skull and brain e.g cephalohematoma,
caput succedaneum
– Facial nerve injury e,g facial paralysis,
– Neck, shoulder, and chest injuries e.g fracture of the clavicle
– Extremities injury

Birth injury
commoner types of birth injury and their incidence
Cephalhaematoma 1:100
Brachial plexus injury 0.5–1:1000
Facial nerve palsy 0.5–1:1000
bony (non-skull) fracture 1–2:1000
Skull fractures Rare
Subaponeurotic haemorrhage 1:1250
Major subdural haemorrhage 1:50 000
Spinalcord injuries Very rare
Overall incidence 6–8:1000 births

Risk factors
 Fetal condition
– Prematurity
– Small for gestational age
– Multiple pregnancy
– Fetal distress
 Malpresentation
– Breech presentation
– Brow
– face
– compound
 Maternal factors
– Nulliparity
– Short stature
– Obesity
 Malposition
– Unengaged head
– Occipitoposterior arrest
– Deep transverse arrest
 Cephalopelvic disproportion
– Macrosomia, e.g. infant of diabetic mother,
hydrops fetalis
– Macrocephaly, e.g. hydrocephalus
– Previous pelvic fracture
 Shoulder dystocia
 Prolonged labour
 Precipitate labour
 Inexperienced obstetrician or midwife

Injuries to the scalp, skull and brain
Swelling or bleeding can occur at various levels in the scalp
 The Swelling or bleeding is deep or superficial
Figure of Anatomic location of injuries to the head

Caput succedaneum
Relatively common
this accumulation of blood and serum, causes an edematous
swelling at birth over the presenting part of the scalp during a
vertex delivery.
Resulted from increased pressure of the uterine and vaginal
walls during labor on the fetal head
Associated with overlying erythema, bruising, and petechiae.
This swelling is subcutaneous but exterior to the periosteum.
It crosses the midline of the skull and suture lines.

Caput succedaneum…
It is usually associated with molding.
 Hyperbilirubinemia rarely develops.
 It typically has well-defined margins of the vacuum cup.
resolves within a few days, occasionally with bruising.

Cephalhaematoma
 It is subperiosteal accumulation of blood that is caused by rupture of
superficial veins between the skull and periosteum.
 Occurs in about 1-2% of live birth
 It is more common in instrumental deliveries (4–5 times higher in forceps
deliveries, 8–9 times higher in vacuum deliveries,)
 The bleed is below the periosteum overlying 1 cranial bone, usually the
parietal bone
 The extent of the swelling is limited by the underlying skull bone and does not
cross suture lines

Cephalhaematoma…
Subperiosteal bleeding is slow and may not appear until
the second day of life
 Enlargement may occur during the first week, and the
swelling may persist for several weeks
 May be associated with skull fracture
May calcify Exacerbates jaundice
Resolves in days to months

Cephalhaematoma…
• Cephalhaematoma. Note the swelling over the right parietal bone. This child
also has hypotonia with a characteristic drooping appearance to the mouth.

Subgaleal haemorrhage
 Also called Subaponeurotic haemorrhage
 haemorrhage may occur beneath the aponeurotic sheet joining the
two portions of the occipitofrontalis muscle of the scalp
 It may be the consequence of trauma during delivery, especially
with vacuum extraction, or may indicate the presence of a
coagulation defect.
 The scalp becomes fluctuant (‘hot water bottle’ sign) and enlarges
rapidly, with a marked drop in haemoglobin.
 Affected babies require rapid diagnosis and appropriate transfusion
with volume expanders or blood.

Subgaleal haemorrhage…
 The “classic triad” is tachycardia, decreasing hematocrit, and an
increasing occipital frontal circumference (OFC).
 The OFC can increase 1 cm for every 30 to 40 mL of blood.
 Associated signs include
– hemorrhagic shock
– severe blood loss (potential to hold >40% of the total blood volume)
– anemia
– hypotonia
– Seizures
– pallor
 This can be a fatal complication (mortality rate up to 14 %) of a traumatic
birth.

Diagnosis scalp and head inury
Physical examination
Head
– Carefully examine the head for any evidence of a caput
succedaneum, cephalhematoma, subgaleal hemorrhage, or
fracture
– Check to see whether the suture lines are crossed (differentiates
between the caput succedaneum and cephalhematoma).
– Depressed skull fractures are obvious; others may require
radiologic studies

Diagnosis scalp and head inury ..
Laboratory studies based on site of trauma
• Hematocrit. Blood loss can occur, sometimes requiring
transfusions, especially in subgaleal hemorrhage.
• Serum bilirubin. Significant hyperbilirubinemia may
result from cephalohematoma or other traumatic bleeding
event
• Coagulation studies are required to detect the
consumption coagulopathy associated with subgaleal
hemorrhage

Diagnosis scalp and head inury
• Imaging and other studies of Head injury
• Skull radiographs should be obtained to rule out the possibility of
skull fractures
• Head ultrasonography to detect an intracranial hemorrhage
• CT scan for diagnosis of an intracranial hemorrhage (epidural,
subarachnoid).
• MRI should be obtained if neurologic symptoms occur or if an
intracranial injury occurs with a cephalhematoma or a skull fracture.
• Imaging should be considered in any infant with a large caput
succedaneum that does not decrease in 72 hours, if the swelling
increases >24 hours after delivery, or if there are neurologic deficits

Management of head injury
Caput succedaneum
• No specific treatment is necessary because it resolves within
the first several days after birth but can be present for up to 4
to 6 days. It rarely causes jaundice or significant blood loss.
Rarely, scalp necrosis can occur.
• Consider imaging if there is a
– large caput succedaneum that does not go away in 48 to 72 hours
after birth or
– increase in swelling 24 hours after birth
– presence of neurologic deficits, or hemodynamic instability.

Management of head injury…
Cephalhematoma
 Observation is usually all that is needed
 Incision and aspiration are not recommended
 The cephalohematoma usually resolves in 3 to 4 weeks
 leaving a palpable subcutaneous nodule that is reabsorbed after 3 to
4 months
 CT or skull radiography may be necessary
– if neurologic symptoms occur or
– underlying skull fracture needs to be ruled out
 blood loss and hyperbilirubinemia can occur and should be treated.

Management of head injury …
Subgaleal hemorrhage
• Recommended treatment is close observation and aggressive management of
hypovolemia and severe blood loss with shock
• Measure serial hematocrit and occipital frontal circumference.
• provide adequate oxygenation and assisted ventilation, monitor serial hematocrits
• Monitor fluid intake and urinary output.
• Phototherapy may be needed for indirect hyperbilirubinemia
• Observe any skin lesions for infection and treat appropriately
• Surgical evacuation of the hematoma may be required if there are signs of brain
compression

Facial nerve injury
• This is the most common peripheral nerve (cranial nerve VII)
injury secondary to birth trauma and is seen in up to 1% of
live births.
• Most cases implicate forceps use, but approximately 33%
occur in deliveries without instruments.
• The injury is secondary to the pressure of the forceps or the
face lying on the maternal sacral promontory
• The nerve is injured at the point where it emerges from the
stylomastoid foramen.

Facial nerve injury…
 Peripheral facial nerve injury
 (more common)involves the entire side of the face.
 At rest, the infant has an open eye on the affected side.
 The nasolabial fold is flattened, and the mouth droops.
 When the infant cries, the findings are similar to those with central paralysis
 Central facial nerve injury
 Involves the lower half or two-thirds of the contralateral side of the face.
 On the paralyzed side, the nasolabial fold is obliterated, the corner of the
mouth droops, and the skin is smooth and full.
 When the infant cries, the wrinkles are deeper on the normal side, and the
mouth is drawn to the normal side

Facial nerve injury…
Eye on affected side remains open

Facial nerve injury..,
Peripheral nerve branch injury
• Only 1 group of facial muscles is involved (mouth,
eyelid, or forehead)
• injury results in paralysis of only that area

Diagnosis of Face injury
• Physical examination
• Examine the face at rest and during crying to look for any
facial asymmetry (nerve palsy or facial fractures)
• Nerve excitability or conduction tests are recommended
if there is no improvement in the facial nerve palsy after 3
to 4 days

Management for Facial nerve injury
• No specific therapy is necessary
• Full resolution usually occurs by 2 to 3 weeks
• Neurology consult should be obtained if no improvement after 3
weeks.
Complete peripheral paralysis.
• Cover the exposed eye with an eye patch and instill synthetic tears
(1% methylcellulose drops) every 4 hours. This will prevent
irritation from the dryness.
• Electrodiagnostic testing. May be beneficial in predicting recovery
• Surgery - May be necessary in severe cases

Neck, shoulder, and chest injuries
Clavicular fracture
 The most common bone fracture during delivery (∼1%–1.5% from birth trauma)
Risk factors
 Macrosomia
 increased maternal age
 shoulder dystocia
 use of instruments at delivery (forceps and vacuum)
 Most fractures are greenstick/incomplete type
 If the fracture is complete, symptoms involve
 decreased or absent movement of the arm,
 gross deformity of the clavicle
 pain response on palpation
 localized crepitus and petechiae over affected side
 an absent or asymmetric Moro reflex

Neck, shoulder, and chest injuries…
Brachial plexus injury.
 Incidence is 0.5 to 2.5 per 1000 live births
 Involves paralysis of upper arm muscles following trauma to spinal roots
C5 to T1
 Usually secondary to a prolonged delivery of a macrosomic infant with
excessive strain on the head, neck, and arm.
 The spinal roots of the fifth cervical through the first thoracic spinal
nerves (brachial plexus) are injured during birth.
 This is usually unilateral and occurs twice as often on the right as the left.
 Brachial plexus injury is diagnosed by unilateral arm weakness.
 There are 4 forms of brachial plexus injury:

Neck, shoulder, and chest injuries…
1.Erb palsy (Erb-Duchenne palsy)
• caused by injury to nerve roots C5 and C6.
• most common form of brachial plexus injury
• involves the upper arm (∼90% of cases)
• The fifth and sixth cervical roots are affected
• the arm is adducted and internally rotated and fully extended at the
elbow with pronation of the forearm and flexion of the wrist.
(“waiter’s tip” position).
• The deltoid muscle is paralyzed, which prevents the arm from being
raised.

Erb palsy

Neck, shoulder, and chest injuries…
1.Erb palsy (Erb-Duchenne palsy
• The paralysis of the biceps brachii and brachialis muscle
causes the arm to be limp and the forearm pronated.
• The Moro reflex is absent or weakened.
• The grasp reflex is intact, which rules out total arm paralysis.
• If the infant with brachial palsy has tachypnea and needs
oxygen, rule out phrenic nerve involvement because brachial
palsy can be associated with phrenic nerve palsy

Neck, shoulder, and chest injuries…
2.Total brachial plexus injury
 is present in almost 10% of cases, and all nerve roots are involved
 Entire arm (global or total brachial plexus) paralysis is present. Because the entire
brachial plexus is damaged
 the patient has a flaccid arm that hangs limply with no reflexes. Horner syndrome
can accompany this injury if the sympathetic fibers of T1 are damaged
3. Klumpke palsy-
 Occurs when there is damage to the C8 to T1 nerve roots
 is isolated to the lower arm because the seventh and eighth cervical and first
thoracic roots are injured
 it is rare

Neck, shoulder, and chest injuries…
4. Horner syndrome
is a preganglionic injury with damage to the sympathetic
outflow via nerve root T1
The classic triad :-
 miosis (a constricted pupil)
 partial ptosis (upper eyelid droops over the eye),
anhidrosis (loss of hemifacial sweating)

Diagnosis of Neck, shoulder, and chest injuries
 Physical examination (P/E)
 Carefully examine the neck and the shoulder
 Check Moro and grasp reflexes
 Examine the arm to see whether movement is normal.
 Investigation
• Ultrasound or radiograph of the clavicle is necessary for confirmation of the
diagnosis of fracture.
• Radiograph of the chest for phrenic nerve paralysis will show an elevated
diaphragm
• Magnetic resonance imaging of the neck and spine for nerve root avulsion.
• Electroencephalogram- Reveals the extent of the denervation weeks after the
injury

Management of Neck, shoulder, and chest injuries…
Clavicular fracture
• No specific treatment is necessary
• Immobilization (pinning the infant’s sleeve to the shirt) is sometimes done to help decrease
pain, and the prognosis is excellen
• Pain medication (acetaminophen) can be given.
• Brachial plexus injury/palsy
• physical therapy is started and continued weekly for at least 3 months
• Immobilization and physical therapy help prevent contractures until the brachial plexus
recovers. Recovery depends on the extent of the lesions and is usually good but may take
many months.
• In Erb-Duchenne paralysis, one can see improvement in 2 weeks, and recovery is usually
complete by 3 to 4 months.
• Orthopedic consultation is recommended early
• Pain management is important, and infants tend to self-splint.
• Klumpke paralysis, the prognosis is poorer, and sometimes recovery is never complete.

Extremity injuries
• Beside the clavicle, humerus and femur are the most common
fractures during the birth process.
Fractured humerus
• is seen in 0.2 per 1000 deliveries
• is the second most common fracture during birth trauma.
• The arm is immobile, and there can be swelling and localized
crepitus, with pain on movement and palpation.
• Moro reflex is absent on the affected side.

Extremity injuries…
Fractured femur
occurs in 0.13 per 1000 deliveries
 is the third most common fracture during birth trauma.
Usually occurs secondary to breech delivery with a pop or
snap sometimes heard at delivery.
Infants with congenital hypotonia are at risk.
Deformity is usually obvious; the affected leg does not move,
there is swelling, and there is pain with assisted movement

Extremity injuries…

Diagnosis of Extremity injuries
P/E
Observe for movement and deformity
 Check for pain with passive movement and palpation
A radiograph/ultrasound of the extremities usually confirms the
diagnosis of bone injury

Extremity injuries management
 Fractured humerus.
 Obtain an orthopedic consultation
 Immobilize the arm with the elbow in 90 degrees for usually 2 weeks
 Displaced fractures may require closed reduction and casting; the
prognosis is excellent.
 Fractured femur.
 orthopedic consultation
 Splinting and strict immobilization are necessary.
 Unstable fractures require Pavlik harness or a spica cast.
 Overall, the prognosis of femur humerus Fractured arexcellent

Umbilical cord rupture
• occur from trauma from an operative vaginal delivery
(forceps or vacuum device used)
• Hemorrhage with bradycardia and respiratory distress can
occur.