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         As a result of the birth process ,some injuries occur that may be minor, where as ot...
•     Observation
                 • Transfusion and photo therapy(extensive haematomas)
                 • Rule out bleed...
i.   Subependymal haemorrhage- IVH
       Clinical features: Due to blood loss- shock, pallor , respiratorty distress , DI...
                         • Hydrocephalus
                         • Surgical...
•  unrecognized and untreated facial fractures- craniofacial malformations, ocular, respiratory
                     & mas...
• Passive stretching of the muscle
Nursing Management:
  • Stretching exercises to the affected SCM . It include,
   Tilt...
         • Hyperextented head
         • Vaginal breech delivery
      Clinical feature:
         • Alert yet flacc...
• injury to the entire brachial plexus – the entire arm is flaccid , all reflexes are absent
• X- ray studies of the chest, shoulders and cervical spine
                  • Orthopaedic consultation
          2. Long...
• Proper application of pressure
Ventouse delivery:
    • Avoid in preterm
Vaginal breech delivery:
    • Proper selection...
   Ms . G. Laviga      Ms. Shesly P. Jose
   Lecturer            II...
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Birth injuries

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Birth injuries

  1. 1. BIRTH INJURIES Introduction: As a result of the birth process ,some injuries occur that may be minor, where as others may be more serious. Parental reaction to any injury sustained by their newborn infant at birth may be out of proportion to the harm that has occurred. Birth injuries: It is defined as those sustained during Labour and delivery. Birth injuries may be severe enough to cause neonatal death , still birth or number of morbidities. Risk factors: Maternal • Primiparity • Short stature • Maternal pelvic anomalies • Prolonged or extremely rapid labour • Oligohydramnios • Deep transverse arrest of descent of presenting part of the fetus Foetal • Abnormal presentation • Very low birth weight infant or extremely prematurity • Foetal macrosomia • Large fetal head • Foetal anomalies Interventional/ inorganic • Use of mid forceps • Inappropriate vacuum application • Versions& extractions Types of birth trauma and management A. HEAD & NECK INJURIES 1. Associated with foetal monitoring • Fetal scalp blood sampling for the estimation of PH- heomorrhage and infection • Foetal scalp electrode for FHR monitoring 2. Cephal hematoma Definitipon: Subsperiosteal collection of blood secondary to rupture of blood vessels between the skull and periosteum; its extent is well delineated by the suture line over few days Complication: • Anemia • Hypotension • Secondary hyper bilirubinemia • Infection • Associated skull fractures Resolution: Slow resolution occurs over 1-2 months , occasionally with residual calcification Management:
  2. 2. • Observation • Transfusion and photo therapy(extensive haematomas) • Rule out bleeding disorders • Aspiration for smear & culture if infection is suspected • Skull X -rays and CT scan to diagnose depressed skull fractures 3. Subgaleal haematoma Definition: Blood that has invaded the potential space between the skull periosteum and scalp galea aponeurosis , and the area that extend posterior from the orbital ridges to the occipital and laterally to the ears Complication: • Spread of hematoma leading to hemorrhage , shock and death, periorbital and auricular ecchymosis • Infection Resolution: Very slow resorption Management: • Observation • Treatment for blood loss, hyperbilirubinemia and infection • Rule out bleeding disorders • and antibiotics if infection occurs 4. Caput Succedaneum Definition: Serosanguinous , subcutaneous, extraperitoneal fluid collection with poorly defined margins, it may extend across the midline & over the surface line and is usually associated with head moulding. Complications: • Anemia and hyper bilirubinemia are very rare , Scalp necrosis with permanent scarring alopecia • Resolution: Over few days • Management: • observation only 5. Vacuum caput: Definition : Serosanguiness fluid collection well defined by the position of the vacuum extractor on the scalp Complications • Anemia & hyperbilirubinemia are very rare, local infection with scalp abrations and lacerations Resolution:With in few hours after birth Management: • Observation • Treatment for blood loss, hyperbilirubinemia and infection • Rule out bleeding disorders 6. Intracranial haemorrhages:
  3. 3. i. Subependymal haemorrhage- IVH Clinical features: Due to blood loss- shock, pallor , respiratorty distress , DIC, jaundice, bulging ant. frontanel, excessive somnolence,, hypotonia, weakness , seizures, temperature instability, brain stem signs( apnoea, lost extra ocular movements, facial weakness) Investigation: • Real time gray scale portable sector USG • Haemorrhagic CSF • CT scan/ MRI • Others- ABC, Haematocrit- low , thrombocytopenia, prolonged PT, PTT& hyper bilirubinemia Complications: • Post – hemorrhagic hydrocephalus Management: • The baby should be nursed in quiet environment • Incubator care- to maintain temperature, oxygen, & humidity • Avoiding extension of haemorrhage . • Slow administration of osmotically active agents, • VitK • Treatment of seizures & hyperbilirubinemia • Treatment of post – haemorrhagic hydrocephalus • Prophylatic antibiotics ii. Posterior fossa haemorrhage Clinical features: • Effects of blood loss like IVH • Bulging frontanel, increasing head circumference, lethargy, irritability • Abnormal respiration(apnoea) • Cranial nerve palsies, nystagmus, dysconjugate gaze • Hypotonia & vomiting Investigations: • USG • CT scan Management: • Treatment of blood loss & hyperbilirubinemia open surgical evacuation of the clots in the patient with neurologic symptoms iii. Ant. fossa haemorrhage Clinical features: • Signs of blood loss • Neurological manifestations- focal neurological signs, irritability , lethargy, focal seizures, hemiparesis, gaze preferences, sixth nerve dysfunction, 3rd nerve compression- dilated and poorly reactive pupil Investigation: • CSF • CT scan • USG
  4. 4. Complication: • Hydrocephalus Mangement: • Surgical intervention in case of deterioration • Treatment of hydrocephalus iv. Subarachnoid haemorrhage(SAH) Clinical features: • features of blood loss • neurological dysfunction- irritability, seizures, hemiparesis Investigations: • CSF examination • CT scan Complication: Hydrocephalus rarely Management: • Symptomatic treatment-anticonvulsants, blood loss correction • treatment of hydrocephalus & hyperbilirubinemia Nursing consideration: • Vigilant observation of the baby for possible associated complications such as infection or rarely blood loss and hypovolemia • Reassurance to the parents 7. Skull fractures Bones involved- Frontal, parital, occipital complications: • Brain contusions • Disruption of blood vessels • seizurs • hypotension & death • dural laceration Management: • X – ray and CT scan for diagnosis • linear fractures with no neurological manifestations- observation • depressed fractures- neurological evaluation • Repeat X- rays at 8-12 weeks to look for growing fractures 8. Facial mandibular fractures Features: • Facial asymmetry • Ecchymosis • Oedema • Crepitance • Respiratory distress • Poor feeding • Dislocation of the cartilaginous nasal septum Complications:
  5. 5. • unrecognized and untreated facial fractures- craniofacial malformations, ocular, respiratory & mastication problems Management: • protection of airway • plastic surgeon; ENT reference • Cranial CT scan • Treatment of fractures Nursing considerations: • Maintain proper body alignment • Gentle handling • Careful during dressing • Immobilization • Relief of pain 9. Ocular injuries Types: a. retinal and subconjunctival haemorrhages- vaginal delivery b. ocular and periorbital injuries- forceps delivery c. Disruption of descenets membranes of the Cornea→Scarring→Astigmatism & Amblyopia d. HYphaema, Vittreous haemorrhage e. local lacerations f. palpebral oedema g. orbital fractures with abnormal extra ocular muscle function h. lacrimal gland / duct damage Management: • Ophthalmic consultations 10. Ear injuries Types: • Haematoma of the external pinna- Cauliflower ear • Lacerations involving the cartilage- refractory perichondritis • Temporal bone injury- Haemotympanum & ossicular disarticulation Management: • Aspiration of pinna haematomas • Otologic consultation 11. Sternocledomastoid (SCM )muscle injury Pathology: Injury to the SCM muscle/ fascia disruption during delivery ↓ haematoma formation ↓ Affection of surrounding musculoskeletal structures←fibrosis ↓ Torticollis Management:
  6. 6. • Passive stretching of the muscle Nursing Management: • Stretching exercises to the affected SCM . It include,  Tilting the head away from the affected side so that the ear can be brought into contact with the opposite shoulder  Rotating the chin towards the tight SCM muscle. When head is in the stretched position , it should be held there for about 10 seconds  The exercise should be done 4-6 times in a day with about 20 repetitions of each exercise at each time. • The infant is positioned in the crib sothat the head is supported by sandbags in the corrected positions. This is done to prevent the flattening of the occiput or the development of facial asymmetry • The head should be rotated so that it tilts away from the involved side and so that the face looks towards the side of the tight muscle. • Crib toys should be placed so that the neck is stretched when the infant reaches for them • Proper demonstration of the exercise to the parents B. CRANIAL NERVE , SPINAL CORD & PERIPHARAL NERVE INJURIES: Commonly associated with breech delivery Cause- Hyper extension , traction,& over stretching with simultaneous rotation Types- Localized neurapraxia to complete nerve and cord transaction 1. Cranial nerve injuries i. Facial nerve injury Cause:Compression by the forceps blades Clinical features: • Central nerve injury- Assymmetrical crying facies, mouth drawn to normal side, wrinkles are more on the normal side, forehead and eyelid unaffected, nasolabial fold is absent on the affected side , corner of the mouth droops on the affected side • Peripheral nerve injury:- Asymmetrical crying facies • Peripharal nerve branch injury- asymmetrical crying facies, paralysis limited to forehead, , eye or mouth Mangement: • Protection of open eye- patches and synthetic tears 4th hourly • Neurological and surgical consultation Nursing management: • Feeding is first given by NG tube in order to prevent aspiration • When possible the infant should be feed orally using a soft nipple having a large hole • Eye shield to prevent drying of the conjunctiva and cornea • Gentle restraining of the hands ii. Recurrent laryngeal nerve injury Clinical Feature; • Unilateral abductor paralysis(hoarse cry, respiratory stridor) • Bilateral vocal cord damage- Severe respiratory distress, asphyxia Management: • Unilateral paralysis-small frequent feed to minimize risk of aspiration • Bilateral paralasis- intubation may be required • Tracheostomy if recovery doesnot occur by 6 wks 2. Spinal cord injuries
  7. 7. Cause: • Hyperextented head • Vaginal breech delivery Clinical feature: • Alert yet flaccid • Low APGAR score • Motor function absent distal to the level of injury with loss of deep tenden reflexes • Temperature instability • Constipation and urinary retension • Sensory level if cord is transected Management: • Resuscitation and prevention of further injuries • Head to be immobilized • Neurological examinations and cervical spinal Xrays • CT scan, myelogram, MRI if required • Attention to bowel/ bladder function 3. Cranial nerve root injuries i. phrenic nerve palsy(C3, 4, & 5) Unilateral and associated with brachial plexus injuries Clinical features: • Respiratory distress ipsilaterally diminished breath sounds Management: • USG/Fluroscopic studies- Paradoxical movements of the diaphragm • Pulmonary toilet • Refractory cases- diagphramatic placation, phrenic nerve pacing Nursing management: • The neonate is placed on the affected side , and oxygen is given as necessary • The neonate is treated like any infant having respiratory difficulty • The infant should be feed intravenously , by gavage , and then orally as the condition improves • Observe for the symptoms of pulmonary infection, which may complicate the infant’s condition ii. Injuries to Brachial plexus Clinical features: Duchenne – Erb paralysis(C5-6): • Affected arm in adducted and internally rotated with elbow extended (Waiter’s tip position) • Forearm is prone and wrist is flexed • The limb falls limply to the side of the body when passively adducted • Moro’s, biceps, radial reflexes absent on affected side • Grasp reflex intact Klumpke’s paralysis (C7& T1) • intrinsic muscles of the hand are affected & grasp is absent( claw Hand) • Biceps and radial reflex are present • Horner’s syndrome, if cervical sympathetic fibres of T1 are involved
  8. 8. • injury to the entire brachial plexus – the entire arm is flaccid , all reflexes are absent Complications • Contractures Management: • X –ray studies to rule out bony injury, chest examination to rule out diagphragmatic involvement • Passive movements started after 7-10 days( After resolution of the nerve edema) • Splints to prevent wrist and digit contractures Recovery: • improvement in 1-2 wks – normal function • no improvement is 6 months – permanent deficit Nursing Management: • The goal of the care is to prevent the contractures of the paralysed muscle • The arm should be partially immobilisd in a position of maximum relaxation so that the nonparalysed muscles cannot exert pull on the affected muscles • By the use of splint or brace when the upper arm is paralysed, the arm is abducted 90 degrees and rotate internally at the shoulder with the elbow flexed so that the palm of the hand is turned towards the head • When the lower arms and hand areparalysed , the lower arm and the wrist are kept in a neutral position and the hand is placed over a small pad • The infant is immobilized for 6months during part of the day and night • A longer period of immobilization may be necessary for some infants. • After 7-10 days , complete ROM exercises may be given gently several times each day inorder to maintain muscle tone and prevent contraction deformity • Before or splint or brace is obtained , the nurse can pin the infants long shirt sleeve to the mattress covering • When any form of immobilization is used , the fingers and hands must be observed for any coldness or discolouration and the skin for signs of irritation • When a splint is used the parents must be taught how to apply it properly and how to provide the skin care • They should be taught the proper dressing technique- affected hand first and on removing the unaffected hand first • More physical contact and affection than normal child C. BONE INJURIES Common in breech delivery & shoulder dystocia in macrosomic infants Cause: limb traction and rotation 1. Clavicular fracture Most common injury Clinical features: • Pseudoparalysis on the affected side • Crepitus • Palpable bony irregularity & sternocledomastoid muscle spasm • Greenstick fracture can be asymptomatic Management:
  9. 9. • X- ray studies of the chest, shoulders and cervical spine • Orthopaedic consultation 2. Long bone injuries Bones : Hemurus, femur Clinical features:Swelling, crepitus and pain Complication :injury to nerve in vicinity Management :Splinting ; closed reduction & casting if required 3. Epiphyseal displacement Cause :Rotation with strong traction Clinical features:swelling, crepitus, pain Management :X- ray not very useful as epiphyses are not ossified at birth Limb immobilization for 10-14 days allows callus formation D. INTRAABDOMINAL INJURIES Types : Rupture/ Subscapular haemorrhage into liver spleen or adrenal gland Clinical features:Abdominal distension, pallor, poor feeding, tachycardia, tachypnoea, shock etc Management :Clinical examination and serial determinations of the haematocrit levels -Abdominal USG - Paracentesis in case of intraperitoneal bleeding E. SOFT TISSUE INJURIES: 1) Patechiae and echymosis • Spontaneous resolution in 1 week. • Complications- Anemia; hyperbilirubinemia 2) Abrations And laceration 3) Subcutaneous fat necrosis Clinical features :Appear in first two weeks of life Irregularly shaped , hard , non pitting, subcutaneous plaque with overlying dusky, red purple discolouration Sites :Cheeks, arms, back , buttocks, thighs PREVENTION OF BIRTH INJURIES IN NEWBORN A comprehensive antenatal and postnatal care is key to the success in the reduction of birth trauma. Antenatal Period: • To screen out the at risk babies • To employ liberal use of LSCS Intranatal period: Normal delivery: • Continuous foetal monitoring • Attention during episiotomy • The neck should not be unduely stretched Preterm delivery: • To prevent anoxia • To avoid strong sedative • Liberal episiotomy and use of forceps to minimize intracranial compression • To administer inj. Vit K to minimize or prevent haemorrhage from the traumatized area Forceps delivery: • Difficult cases- LSCS
  10. 10. • Proper application of pressure Ventouse delivery: • Avoid in preterm Vaginal breech delivery: • Proper selection of cases Conclusion: Since many of the birth injuries do not require treatment , the nurse can help to clear up the misconceptions and alleviate anxieties by simple explanations.Assisting the parents to cope with the more serious injuries requires more through explanations and constant support by members of the health team. Bibliography: 1. Wong D.L etal . Essentials Of Paediatric Nursing. 6th edition. Missouri: Mosby;2001 2. Marlow D.R. Redding B. Textbook of Paediatric nursing. 1st edition.Singapore: Harwourt Brace & company; 1998 3. Judith S.A. Straight A’s in Pediatric Nursing. 2nd edition.Lippincott Williams and Wilkins:Philadelphia; 2008 4. Parthasarathy IAP textbook of Paediatrics. 2nd edition. jaypee: NewDelhi; 2002 5. Hatfield N.T. Broadribb’s introductory Paediatric nursing. 7th edition. Wolters Kluwer: New Delhi; 2009 6. D.C Dutta. Textbook Of Obstetrics including Perinatology & Contraception. 6th edition. Central Publication; Culcutta: 2004 7. Meharban Singh . Care of Newborn . 6th edition. Published by Narinder K. Sagar; NewDelhi: 2004
  11. 11. BIRTH INJURIES SUBMITTED TO SUBMITTED BY Ms . G. Laviga Ms. Shesly P. Jose Lecturer II Year MSc (N) NUINS NUINS