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Birth injuries.P

  2. DEFINE BIRTH INJURIES Birth injuries are an impairment of the infant’s body function or structure due to adverse influences that occurred at birth. Birth injuries may be severe enough to cause neonatal deaths, still births or number of morbidities.
  3. RISK FACTORS FOR BIRTH INJURIES Prim parity Small maternal stature Maternal pelvic anomalies Prolonged or unusually rapid labor Oligohydramnios Malpresentation of the fetus 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
  4. Skull injuries are those injuries that impairs the structure of the skull and functions of the underlying organs in the skull. The most common site of birth injury is head, because 96% babies are delivered by cephalic presentation. I. Caput succedaneum II. Cephalohematoma III. Skull Fractures IV. Scalp injuries
  5. 1.Caput Succedaneum A caput succedaneum is an edematous swelling which forms normally in the soft tissues over the presenting part of the scalp due to infiltration of serosanguinous fluid by the pressure of girdle of contact. 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
  6. Clinical feature It is present at or shortly after birth and doesn't tend to enlarge. The swelling is diffuse , boggy, pits on pressure and may cross suture line. Management No specific treatment is needed Advice the woman and family to avoid applying pressure on caput But if extensive ecchymoses are present, hyperbilirubinemia may develop Shock – Blood transfusion
  7. 2. CEPHALHEMATOMA A Cephalohematoma is a sub periosteal blood collection caused by rupture of vessels beneath the periosteum. Causes It is due to rupture of a small vein from the skull that may be from : • Friction between bones of maternal pelvis and fetal skull as in cephalopelvic disproportion or precipitate labour.
  8. Clinical Features The swelling is usually never at birth, gradually develops a few hours after birth and may persist for weeks. It is incompressible and never crosses the suture line. The overlying scalp may show discoloration. The condition may be confused with caput succedaneum or meningocele. Meningocele lies over a suture line or fontanels and there is impulse on crying.  Rarely suppuration occurs.
  9. Management No active treatment is necessary unless it becomes infected or complicated. A head CT should be obtained if neurological symptoms are present. Vitamin K 1-2 mg IM should be given to correct any coagulation defect. In case of infected hematoma, the condition is treated with incision and drainage, systematic antibiotics and monitoring of hematocrit and bilirubin level. Advice the woman and family to avoid hot compress by using oil.
  10. 3. Scalp Injuries  Scalp injuries are those injuries that are characterized by impairment in integrity of the scalp tissue. Causes • Forceps delivery (tip of the blades) • Incised wound inflicted during cesarean section • Scalp-electrode placement • Episiotomy Management  The wound should be dressed with an antiseptic solution like 2% mercurochrome. On occasion, the incised wound may cause risk hemorrhage and requires stitches.
  11. 4. Skull Fracture Fracture of the vault of the skull (frontal bone or anterior part of the parietal bone) is defined as distortion in the continuity of skull bone which may be of fissure/linear or depressed type. Causes Effect of difficult forceps delivery or due to wrong application of forceps.  Projected sacral promontory of the flat pelvis.
  12. Clinical Features Fissure fracture if uncomplicated is usually symptomless. Depressed fracture may be associated with neurological manifestations. Signs of associated complications such as intracranial hemorrhage, raised intracranial pressure, leakage of CSF. Diagnosis History of type of delivery, other injuries to head during birth. • Physical examination X-ray can confirm diagnosis.
  13. Management  Linear or fissure fracture requires no treatment.  Depressed fracture may require surgical elevation. If there is leakage of cerebral fluid through nose, antibiotic therapy is indicated.
  14. Intracranial injuries are the injuries to the structures inside the cranium during the process of the birth that is characterized by abnormal neurological manifestations within first 48 hours of life.
  15. Traumatic Intracranial Hemorrhage It is defined as hemorrhage inside cranium due to trauma and it can be extradural or subdural hemorrhage. Extradural hemorrhage: It is defined as hemorrhage in space between cranial bones and outer layer of duramater. It is usually associated with fractured skull bone. Subdural hemorrhage: It is defined as hemorrhage in the space between arachnoid mater and inner layer of duramater.
  16. Causes of Traumatic ICH  Excessive moulding in deflexed vertex.  Rapid compression of the head during delivery of the after-coming head of breech or in precipitate labor.  Forcible forceps traction following wrong application of the blades. Clinical Features of Traumatic ICH The hemorrhage may be fatal and the baby is delivered stillborn or with severe respiratory depression(APGAR score:0-3). Gradually, the features of cerebral irritation appear. Hydrocephalus and mental retardation may be a late sequelae.
  17. Anoxic Intracranial Hemorrhage It is defined as hemorrhage inside the cranium due to perinatal asphyxia, trauma and ischemia. It can be intraventricular, subarachnoid and intracerebral. Causes : Perinatal asphyxia, trauma and ischemia Clinical features: Altered level of consciousness Focal neurological defecits Seizures
  18. Diagnosis of ICH Doppler ultrasonography can detect any change in cerebral circulation. CT scan is useful to detect cortical neuronal injury. Magnetic resonance imaging (MRI) is used to evaluate any hypoxic ischemic brain injury. CSF analysis: Elevated RBCs, WBCs and protein.
  19. MANAGEMENT OF ICH The baby should be nursed in quiet ,warm and well ventilated environment. Maintain cleanliness of the air passage, suction immediately after birth to remove the secretion that occludes the pharynx. And supply oxygen as necessary. Frequently monitor the baby for skin color, vital signs and neurological manifestations. Feeding by nasogastric tube is advisable, fluid balance is to be maintained, if necessary by parenteral route. .
  20. Administer Vitamin K 1mg IM to prevent further bleeding due to hypoprothrombinaemia. Prophylactic antibiotics are to be administered. Anticonvulsants like phenobarbitone, phenytoin and diazepam can be given for seizures Open surgical evacuation -Rarely ventricular- peritoneal shunt and subdural-peritoneal shunt is required.
  21. Soft tissue injuries are the injuries to skin, subcutaneous tissues, muscles and visceral organs due to some degree of disproportion between the presenting part and the maternal pelvis during the birth process and also from forcep blades, vacuum extractor cups, scalp electrodes and scalpels.
  22. A. Injury to Skin and Subcutaneous Tissue Erythema and abrasions: Erythema and abrasion during birth are superficial reddening of the skin with impaired integrity that usually are the result of the application of forceps, discoloration is same configuration as the instrument. Ecchymosis: Ecchymosis are small hemorrhagic areas( greater than 10 mm in diameter) that may occur after traumatic or breech delivery. Lacerations or scalpel cut: it is injury may occur during cesarean section. They usually occur on the buttocks, scalp or thigh. Small cut heal spontaneously. Some time it may need repair by stitches with 0-7 nylon. Healing is usually rapid.
  23. B. Muscles injuries: Injury to muscle are those trauma to muscle that can occur when it is torn or when its blood supply is disrupted. Torticollis and sternomastoid hematoma are common muscle trauma during birth. Sternomastoid hematoma Torticollis
  24. Torticollis Torticollis or twisted neck is defined as damage and spasm of sternomastoid muscle during the birth of the anterior shoulder when the fetus presents by the vertex or during rotation of the shoulders when the fetus is being born by breech.  Clinical features: The head tilts towards the affected side constantly and the chin points towards one shoulder. One shoulder may be higher in the body than the other shoulder. Neck muscle swelling right after the birth.
  25. Management: Muscle stretching exercises and neck braces. The uncomplicated swelling will resolve within 7-10 days. If it doesn't resolve even after 6 months of muscle stretching exercise then muscle release surgery is required.
  26. Sternomastoid hematoma: It is sternomastoid muscle injury caused by rupture of the muscle fibers and blood vessels, followed by a hematoma and cicatrical contraction and may be associated with difficult breech delivery or attempted delivery following shoulder dystocia or excessive lateral flexion of the neck even during normal delivery. Clinical Features: It usually appears few days after birth and is usually situated at the mid position of the muscle. Small moderately dense or rather small consistency of mass of with the size of walnut appears. There is transient torticollis. Management: Muscle stretching exercises. Surgery is indicated if hematoma fails to get reabsorbed.
  27. Visceral Injuries Injuries to organs like liver, spleen ,kidney, adrenals or lungs are called visceral injuries . Visceral organs are commonly injured during breech delivery. The most common result of the injury is hemorrhage. The hemorrhage may remain concealed as subcapsular hematoma or capsule may rupture with the blood flowing into peritoneal cavity. Prognosis is usually poor. Clinical Features: Pallor , tachycardia, shock and symptoms according to the organs being injured. Management:  Correction of hypovolemia, anemia and coagulation disorders. Management may be needed to repair injured viscera surgically.
  28. FACIAL NERVE INJURIES Erb’s palsy: • It is an injury to C5,6, there is failure of abduction of the arm from the shoulder inability for external rotation of the arm and to supinate the forearm. The characteristic position is adduction and internal rotation of the arm and pronation of the forearm. • The biceps and Moro reflex is absent on the affected side. Klumpke’s paralysis: • This type of plexus involving 7th and 8th cervical and the 1st thoracic nerve roots. There is paralysis of muscles of the forearm. The arm is flexed at the elbow and wrist is extended.
  29. Phrenic nerve paralysis: • C3, C4, & C5 injury result paralysis of the ipsilateral diaphragm. This is due to excessive stretching of neck at birth. with dyspnoea, cyanosis and irregular breathing. FACIAL NERVE PALSY (BELL’S PALSY) • forceps delivery – prolonged second stage of labor may caused • 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.