mechanical birth injuries

1. Dr.N.Vinay kumar
Under the guidance of
Dr.J.M Pawar sir
BIRTH INJURIES

2. Birth Injuries
 The term birth injury is used to
denote: avoidable and
unavoidable mechanical, hypoxic
ischemic injury affecting the infant
during labor and delivery
 0.7% (Seven of every 1,000) births
result in birth injuries. though
most women give birth in modern
hospitals surrounded by medical
professionals.
 Birth injuries account for fewer
than 2% of neonatal deaths.

3. predisposing factors
 Primiparity
 maternal short stature
 Maternal pelvic anomalies
 Prolonged or unusually rapid
labor
 Oligohydramnios
 Malpresentation of the fetus
(breech)
 Cephalopelvic disproportion
 Deep transverse arrest of
presenting part of the fetus

4.  Use of forceps or vaccum extraction
 Versions and extractions
 Very low birth weight or extreme prematurity
 Fetal macrosomia birth weight over about 4,000 grams
 Fetal macrocephaly (Large head)
 Fetus anomalies

5. CLASSIFICATION OF BIRTH INJURIES
 Soft tissue injuries
 Head and neck injuries
 Facial injuries
 Cranial nerve injuries
 Spinal cord injuries
 Peripheral Nerve injury
 Fractures
 Intra-abdominal injury

6. Soft tissue
 Abrasions
 Erythema petechia
 Ecchymosis
 Lacerations
 Subcutaneous fat necrosis
Skull
 Caput succedaneum
 Cephalohematoma
 Subgaleal hemorrhage
 fractures
 Intracranial hemorrhages
Face
 Subconjunctival hemorrhage
 Retinal hemorrhage
Cranial nerve & spinal cord injuries
 Facial palsy
Peripheral nerve
 Brachial plexus palsy
 Unilateral vocal cord
paralysis
 Radial nerve palsy
 Lumbosacral plexus injury
Musculoskeletal injuries
 Clavicular fractures
 Fractures of long bones
 Sternocleido-mastoid injury
Intra-abdominal injuries
 Liver hematoma
 Splenic hematoma
 Adrenal hemorrhage
 Renal hemorrhage

7. SOFT TISSUE INJURIES
 Abrasions
 Erythema petechia
 Ecchymosis
 Lacerations
 Subcutaneous fat necrosis

8. Abrasions and lacerations
 May occur as scalpel cuts during
Cesarean delivery or during instrumental
delivery (i.e, vacuum, forceps)
 Infection remains a risk, but most
uneventfully heal
Management
 Careful cleaning, application of antibiotic
ointment, and observation
 Lacerations occasionally require suturing

9. Subcutaneous fat necrosis
 Irregular, hard, nonpitting, subcutaneous
induration with overlying dusky red-purple
discoloration on the extremities, face, trunk, or
buttocks
 May be caused by pressure during delivery.
 No treatment is necessary
 Subcutaneous fat necrosis sometimes calcifies

10. SKULL INJURIES
 Caput succedaneum
 Cephalohematoma
 Subgaleal hemorrhage
 Skull fractures (Linear-Depressed)
 Intracranial hemorrhages

14. Caput succedaneum
 Oedema of the presenting part
caused by pressure during a
vaginal delivery.
 This is a serosanguineous,
subcutaneous, extraperiosteal
fluid collection with poorly
defined margins and non
fluctuating.

15. Cephalhematoma
 Subperiosteal collection of
blood between the skull and
the periosteum.
 It may be unilateral or
bilateral, and appears within
hours of delivery as a soft,
fluctuant swelling on the side
of the head.
 A cephalhaematoma never
extends beyond the edges of
the bone or crosses suture
lines.

18. Subgaleal hematoma
 Bleeding in the potential space between skull periosteum
& scalp galea aponeurosis Crossing the suture lines.due to
rupture of emmisar veins
(і) Diffuse swelling of the head. Sutures usually are not
palpable. The amount of blood under the scalp is far more
than is estimated. Within 48 hours the blood tracks
between the fibres of the occipital and frontal muscles
causing bruising behind the ears, along the posterior hair
line and around the eyes.
(ii) Shock and pallor: tachycardia, a low blood pressure,
within 30 minutes of the haemorrhage the haemoglobin
and packed cell volume start to fall rapidly.

19. Management
Cephalhematoma
 Supportive.
 hyperbilirubinemia – photo therapy
Subgaleal hematoma
 Transfusions may be required if blood loss is
significant.
 In severe cases, surgery may be required to cauterize
the bleeding vessels.

20. Skull fractures
May occur as a result of pressure from :
 1. Forceps
 2. The maternal symphysis pubis.
 3. Sacral promontory, or
 4. Ischial spines.
Linear skull fractures
 Usually the parietal bones.
 Compression forceps, or skull against
symphysis or ischealspines.
 Rarely, dural tear occurs.

21. Depressed skull fractures
 Depressed fractures are usually indentations similar
to a dent in a Ping-Pong ball; occurs due to
complication of forceps delivery or fetalcompression.

22. Indications for surgery
•radiographic evidence of bone
fragments in the cerebrum
•presence of neurologic deficits
•signs of increased intracranial pressure
•failure to respond to closed manipulation.
Indications for nonsurgical management
•Depressions less than 2 cm in width.
•Without neurologic symptoms.

23. Intracranial hemorrhages
Causes:
1. Sudden compression and decompression of the head as in
breech and precipitate labour.
2. Marked compression by forceps or in cephalopelvic
disproportion.
3. Fracture skull.
 Bleeding can occur
– External to the brain into the epidural, subdural or
subarachnoid space.
– In to the parenchyma of the cerebrum or cerebellum.
– Into the ventricles from the subependymal germinal matrix
or choroid plexus.

24. Intracranial hemorrhages
TYPES
Intracranial haemorrhage
Epidural hemorrhage
Subdural hemorrhage
Subarachnoid hemorrhage
Intraparenchymal haemorrhage
Germinal matrix hemorrhage /
intraventricular haemorrhage

25. Intracranial Haemorrhage Sites:
Subdural : results from damage to the superficial veins
where the vein of Galen and inferior sagittal sinus
combine to form the straight sinus.
Subarachnoid: injury to bridgin veins or leptomeningeal
anastomosis injury or AV malformation.
Intraventricular :into the brain ventricles.
Intracerebral : into the brain tissues .

29. Intracranial Haemorrhage:
Clinical picture:
 Flaccidity or rigidity
 Breathing is irregular and periodic or gasping.
 Eyes: no movement, pupils may be fixed and dilated.
 Opisthotonus, twitches and convulsions.
 Vomiting .
 High pitched cry.
 Anterior fontanelle is tense and bulging.
 Lumbar puncture reveals bloody C.S.F.

30. Subarachnoid hemorrhages (SAH)
(i) Attacks of apnoe, irregular breathing, bradycardia.
(ii) Hyperesthesia, tremor, seizures, bulging of
fontanella,“Sunset” sign positive.
(iii) Changes of spinal fluid in lumbar puncture: it becomes
xanthochromic or/and contains blood.

31. Intraventricular (IVH) hemorrhages
 Intracranial hemorrhage that originates in periventricular
subependymal germinal matrix with subsequent
entrance of blood into the ventricular system.
 EARLY IVH: IVH develop within 72hrs after birth.
 LATE IVH: IVH develop after 72hrs of life.
 Incidence and severity is inversely proportional to
gestation age and birth weight.

32. Clinical features
1) Apnea
2) Bradycardia
3) Acidosis
4) Cutaneous mottling
5) A bulging fontanel
6) High pitched cry
7) Absent Moro reflex
8) Seizures
9) A sudden drop in hematocrit
10) Failure to suck well
11) Change in muscle tone

33. diagnosis
 Intraventricular hemorrhage is diagnosed on the
basis of :
 History
 Clinical manifestations
 cranial ultrasonography or
 CT scan

34. Grading of IVH

36. Management
 No specific treatment is available for IVH, it may be
associated with other complications that require
therapy.
 Maintain ABC.
 Seizures are aggressively treated with anticonvulsant
drugs.
 Anemia and coagulopathies requires transfusion
with packed red blood cells or fresh frozen plasma.
 Shock and acidosis are treated with slow
administration of sodium bicarbonate and fluid
resuscitation.

37. FACIAL INJURIES
 Subconjunctival hemorrhage
 Retinal hemorrhage
 Other ocular injuries
 Nasal septal dislocation

38. Subconjunctival hemorrhage
 Breakage of small blood vessels in
the eyes of a baby. One or both of
the eyes may have a bright red
band around the iris.
 This is very common and does not
cause damage to the eyes.
 The redness is usually absorbed in a
week to ten days

39. Other Ocular injuries
 Rupture of Descemet’s membrane of the cornea
 lid lacerations
 hyphema (blood in anterior chamber)
 vitreous hemorrhage
 corneal edema,
 corneal abrasion

40. Nasal Septal dislocation
 Involves dislocation of the triangular cartilaginous portion of
the septum from the vomerine groove.
Clinical features
 airway obstruction.
 deviation of the nose to one side.
The nares are asymmetric, with flattening of the side of the
dislocation (Metzenbaum sign). 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
 Definitive diagnosis can be made by rhinoscopy
 manual reduction

41. PERIPHERAL NERVEINJURIES
 Brachial plexus palsy
 Phrenic nerve injury
 Laryngeal nerve injury
 Radial nerve palsy
 Lumbosacral plexus injury

42. Brachial plexus injury

43. Erb-Duchenne palsy
 (C5-C6) common
 phrenic N (C3-5)
Klumpke palsy
 (C 7-8, T1) rare
 Horner syndrome (T1 S)
(Kerer’s paralysis) worst
 Total plexus palsy

44. Risk factors
 Macrosomia
 Shoulder dystocia
 Instrumented deliveries
 Malpresentation

45. Erb-Duchenne palsy (C5-C6)
 The most common injury.
 Lack of shoulder motion.
 The involved extremity lies adducted, pronated, and
internally rotated.
 Moro, biceps, and supinator reflexes are absent on the
affected side.
 Grasp reflex is usually present.
 Erb’s palsy may be associated with injury to the phrenic
nerve, innervated with fibers from C3–C5.

46. Klumpke paralysis (C 7-8, T1)
 Weakness of the intrinsic muscles of the hand; and long
flexors of the wrist and fingers (clawing not writing).
 Grasp reflex is absent.
 Biceps reflex is present.
 If cervical sympathetic fibers of the T 1 are involved,
Horner syndrome is present (ptosis, miosis, and
anhydrosis).
 Mainly due to Hematomas of the sternocleidomastoid
muscle, and fractures of the clavicle and humerus.

48. Diagnosis & Management
 Radiographs of the shoulder and upper arm
 Initial treatment is conservative.
 physiotherapy with passive range movements.
 Infants without recovery by 3 to 6 months of age
may be considered for surgical exploration

49. Phrenic nerve injury
 The phrenic nerve arises from the third to fifth cervical
nerve roots.(c3-c5)
 Injury to the phrenic nerve leads to paralysis of the
ipsilateral diaphragm.
 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 can confirm the diagnosis by showing
paradoxical diaphragmatic movement during inspiration

50. Treatment
 Initial treatment is supportive
 Oxygen
 Respiratory failure may be treated with continuous
positive airway pressure or mechanical ventillation.

51. Laryngeal nerve injury
Symptoms
 Stridor
 respiratory distress
 hoarse cry
 dysphagia,
 Aspiration
Diagnosis
 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

52. Facial paralysis
 It can be caused by pressure on the facial nerves during birth
or by the use of forceps during birth.
 The affected side of the face droops and the infant is unable to
close the eye tightly on that side. When crying the mouth is
pulled across to the normal side.
 involved eye is protected by application of artificial tears and
taping to prevent corneal injury.
 neurosurgical repair of the nerve should be considered only
after lack of resolution during 1 year of observation.

53. Spinal cord injury
 Occurs due to Excessive traction or rotation.
 The baby usually is posing as frog.
 “oscillation” test is positive.
(prick leg of the newborn with needle leg will flex
and extend in all joints several times)

54. 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.

55. MUSCULOSKELETALINJURIES
 Clavicular fractures
 Fractures of long bones
 Sternocleido-mastoid injury

56. The clavicle & long bonefracture
 Clavicle is the most frequently bone injured in the
neonate during birth and most often is an
unpredictable unavoidable complication of normal
delivery.
 The infant may present with pseudoparalysis.
 Examination may reveal crepitus, palpable bony
irregularity, and sternocleidomastoid muscle spasm.
 Desault's bandage should be used for 7-10 days.

58. Sternocleido-mastoid injury
 Tearing of the muscle fibers or fascial
sheath with hematoma formation and
subsequent fibrosis.
 The head is tilted toward the side of
the lesion and rotated to the
contralateral side,
 chin is slightly elevated.
 If a mass is present, it is firm, spindle-
shaped, immobile, and located in the
midportion of the
sternocleidomastoid muscle, without
accompanying discoloration or
inflammation.

59. INTRA-ABDOMINAL INJURIES
 Liver hematoma
 Splenic hematoma
 Adrenal hemorrhage
 Renal hemorrhage

60. INTRA-ABDOMINAL INJURIES
 Liver injury is the most common
 Three potential mechanisms lead to intraabdominal
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.

61. Clinical manifestations
 With hepatic or splenic rupture, patients develop sudden
pallor, hemorrhagic shock, abdominal distention, and
abdominal discoloration.
 Subcapsular hematomas may present more insidiously,
with anemia, poor feeding, tachypnea, and tachycardia.
 Adrenal hemorrhage may present as a flank mass.
Diagnosis
 abdominal ultrasound.
 Computed tomography.
 Abdominal radiographs may show nonspecific
intraperitoneal fluid or hepatomegaly.
 Abdominal paracentesis is diagnostic if a
hemoperitoneum is present

62. Treatment
 volume replacement
 Correction of coagulopathy
 Hemodynamically stable infant, conservative
management is indicated.
 With rupture or hemodynamic instability, a laparotomy
is required to control the bleeding.
 With adrenal hemorrhage hormone replacement
therapy may be required.

63. THANK YOU