Birth injuryBirth injury

Amy J. Gagnon, M.D.Amy J. Gagnon, M.D.Maternal-Fetal MedicineMaternal-Fetal Medicine

Colorado Perinatal Care CouncilColorado Perinatal Care CouncilNovember 18, 2011November 18, 2011

Birth injury: overviewBirth injury: overview

• CephalohematomaCephalohematoma• Subgaleal hemorrhageSubgaleal hemorrhage• Retinal hemorrhageRetinal hemorrhage• Facial nerve palsyFacial nerve palsy• FractureFracture• Hypoxic injuryHypoxic injury

Operative vaginal deliveryOperative vaginal delivery

• 1997 U.S. rate operative vaginal delivery: 9.4%1997 U.S. rate operative vaginal delivery: 9.4%• 2007 U.S. rate operative vaginal delivery: 4.3%2007 U.S. rate operative vaginal delivery: 4.3%• IndicationsIndications

– Prolonged second stage: Prolonged second stage: • Nulliparous women: lack of continuing progress for 3 hours with Nulliparous women: lack of continuing progress for 3 hours with

regional anesthesia, or 2 hours without regional anesthesia regional anesthesia, or 2 hours without regional anesthesia • Multiparous women: lack of continuing progress for 2 hours with Multiparous women: lack of continuing progress for 2 hours with

regional anesthesia, or 1 hour without regional anesthesiaregional anesthesia, or 1 hour without regional anesthesia

– Suspicion of immediate or potential fetal compromise. Suspicion of immediate or potential fetal compromise. – Shortening of the second stage for maternal benefit.Shortening of the second stage for maternal benefit.

ACOG Practice Bulletin. Number 18, June 2000.Martin et al. National Center for Health Statistics; 2010.

Operative vaginal Operative vaginal deliverydelivery

• Cochrane review (Issue 2, 1999)Cochrane review (Issue 2, 1999)– Use of vacuum associated with much less maternal Use of vacuum associated with much less maternal

traumatrauma– Vacuum associated with an increase in neonatal Vacuum associated with an increase in neonatal

retinal hemorrhages and cephalohematomaretinal hemorrhages and cephalohematoma• Retinal hemorrhages: twofold higher risk with vacuum Retinal hemorrhages: twofold higher risk with vacuum

versus forceps; data on the long-term consequences of versus forceps; data on the long-term consequences of these hemorrhages fails to demonstrate any significant these hemorrhages fails to demonstrate any significant effecteffect

• Some studies reveal neonates delivered by Some studies reveal neonates delivered by VAVD more likely to be readmitted with VAVD more likely to be readmitted with jaundicejaundice

Carmody F, et al. Acta Obstet Gynecol Scand 1986;65:763-766

Vacuum versus ForcepsVacuum versus Forceps

Gei & Pacheco. Obstet Gynecol Clin N Am. 2011; 38:323-49.Williams. Clin Perinatol. 1995;22:933-52.Schaal et al. J Gynecol Obstet Biol Reprod. 2008;37:S231-43Lurie et al. Arch Gynecol Obtet. 2006;274(1):34-6.

Vacuum versus ForcepsVacuum versus Forceps

• Particular indication for procedureParticular indication for procedure• AnesthesiaAnesthesia• Availability of instrumentsAvailability of instruments• Training/experience of physicianTraining/experience of physician• Patient preferencePatient preference

Vacuum-assisted vaginal Vacuum-assisted vaginal deliverydelivery

• Prospective observational study of 134 Prospective observational study of 134 VAVD.VAVD.– 28 infants (21%) with scalp trauma.28 infants (21%) with scalp trauma.

• 17 superficial lacerations; none required sutures.17 superficial lacerations; none required sutures.• 6 with large caput succedaneum.6 with large caput succedaneum.• 12 cephalohematomas.12 cephalohematomas.• 1 infant with subgaleal, subdural, and 1 infant with subgaleal, subdural, and

subarachnoid hemorrhage. (This infant did not subarachnoid hemorrhage. (This infant did not

become anemic or hypotensive.)become anemic or hypotensive.)

Logistic regression analysis showed duration of Logistic regression analysis showed duration of vacuum application to be the best predictor of vacuum application to be the best predictor of scalp injury (duration 0.5 to 26 minutes, with a scalp injury (duration 0.5 to 26 minutes, with a median length of 3 minutes)median length of 3 minutes)

Teng & Sayre. Obstet Gynecol. 1997 Feb;89(2):281-5

CephalohematomaCephalohematoma

• Bridging vein ruptures between the Bridging vein ruptures between the outer skull table and the periosteum outer skull table and the periosteum of the parietal boneof the parietal bone

• The periosteum is circumferentially The periosteum is circumferentially anchored to the edges of the parietal anchored to the edges of the parietal bone. Usually a self-limited lesion.bone. Usually a self-limited lesion.

• Rates:Rates:– Vacuum: 112/1,000Vacuum: 112/1,000– Forceps: 63/1,000Forceps: 63/1,000– SVD: 17/1,000 SVD: 17/1,000

CephalohematomaCephalohematoma

• Secondary analysis of 322 infants Secondary analysis of 322 infants randomized to be delivered by vacuum.randomized to be delivered by vacuum.

• Logistic regression identified three Logistic regression identified three factors associated with clinically factors associated with clinically diagnosed cephalohematoma.diagnosed cephalohematoma.– Time required for delivery.Time required for delivery.– Increasing asynclitism.Increasing asynclitism.– Station at applicationStation at application

•Bofill et al., J Repro Med 1997;42:565-9.Bofill et al., J Repro Med 1997;42:565-9.

Vacuum time and Vacuum time and cephalohematomacephalohematoma

6 68

15

21

33

25

0

5

10

15

20

25

30

35

1 min 2 min 3 min 4 min 5 min 6 min 7 min

% Cephalohematoma

Bofill et al., J Repro Med 1997;42:565-9.Bofill et al., J Repro Med 1997;42:565-9.

Subgaleal hemorrhageSubgaleal hemorrhage• Blood collects in the loose areolar tissue in Blood collects in the loose areolar tissue in

space between the galea aponeurotica and space between the galea aponeurotica and periosteum.periosteum.

• The subgaleal space has potential area of The subgaleal space has potential area of several hundred milliliters (can contain the several hundred milliliters (can contain the entire blood volume of the neonate.) entire blood volume of the neonate.) Bounded laterally by the zygomatic arches, Bounded laterally by the zygomatic arches, anteriorly by the orbital ridges, and anteriorly by the orbital ridges, and posteriorly by the nape of the neck.posteriorly by the nape of the neck.

Subgaleal hemorrhageSubgaleal hemorrhage

• Incidence:Incidence:– 4/10,000 SVD4/10,000 SVD– 26-45/1,000 VAVD26-45/1,000 VAVD

** Occurs almost exclusively ** Occurs almost exclusively with the vacuum device.with the vacuum device.

• Led to FDA issuing a “public health Led to FDA issuing a “public health advisory” regarding the use of vacuum-advisory” regarding the use of vacuum-assisted delivery devices in May 1998assisted delivery devices in May 1998– Cited fivefold increase in rate of deaths and Cited fivefold increase in rate of deaths and

serious morbidity during previous 4 years serious morbidity during previous 4 years when compared to previous 11 yearswhen compared to previous 11 years

FDA Public health advisory FDA Public health advisory regarding vacuum-assisted regarding vacuum-assisted

delivery devicesdelivery devices• Persons should be versed in their use Persons should be versed in their use

and aware of indications, and aware of indications, contraindications, precautions as contraindications, precautions as supported in accepted literature & supported in accepted literature & current device labelingcurrent device labeling

• Apply steady traction in line of birth Apply steady traction in line of birth canal. No rocking or applying torque.canal. No rocking or applying torque.

• Notify pediatriciansNotify pediatricians• Educate neonatal care staff re: Educate neonatal care staff re:

complications of VAVDcomplications of VAVD• Report reactions associated with use to Report reactions associated with use to

FDAFDA

Forceps-assisted deliveryForceps-assisted delivery• Nationally, decrease in experienced Nationally, decrease in experienced

teachers/trainingteachers/training

• Facial nerve palsy:Facial nerve palsy:– 5-year period at Brigham and Women's Hospital5-year period at Brigham and Women's Hospital

• 81 cases of acquired facial-nerve palsy (44,292 81 cases of acquired facial-nerve palsy (44,292 deliveries) deliveries) incidence of 1.8 per 1000 incidence of 1.8 per 1000

• 74 of the 81 (91 percent) associated with forceps 74 of the 81 (91 percent) associated with forceps delivery delivery

• FAVD, birth weight FAVD, birth weight >>3500gm, and 3500gm, and primiparity all significant risk factors for primiparity all significant risk factors for acquired facial palsy acquired facial palsy • Recovery complete for 59 patients (89%) Recovery complete for 59 patients (89%) and incomplete for the remaining 7 and incomplete for the remaining 7 (mean follow-up 34 months) (mean follow-up 34 months)

Falco NA and Eriksson E. Plast Reconstr Surg. 1990 Jan;85(1):1-4

Sequential use of vacuum & Sequential use of vacuum & forcepsforceps

Sequential use increases liklihood of Sequential use increases liklihood of adverse outcomes more than the adverse outcomes more than the sum of the relative risks of each sum of the relative risks of each

individual instrumentindividual instrument

↔↔X

Operative vaginal delivery: Operative vaginal delivery: Long term sequalae?Long term sequalae?

• 1993 Kaiser (Oakland): 1,192 FAVD vs. 1,499 1993 Kaiser (Oakland): 1,192 FAVD vs. 1,499 SVD – no difference in IQ at 5 yearsSVD – no difference in IQ at 5 years

• 10-year matched follow-up evaluation of 295 10-year matched follow-up evaluation of 295 children delivered by VAVD vs. 302 controls children delivered by VAVD vs. 302 controls (SVD) revealed no differences between the (SVD) revealed no differences between the two groups in terms of scholastic two groups in terms of scholastic performance, speech, ability of self-care, or performance, speech, ability of self-care, or neurologic abnormality neurologic abnormality

** Does not appear to be any long-term effect of ** Does not appear to be any long-term effect of operative vaginal delivery on cognitive operative vaginal delivery on cognitive developmentdevelopment

Wesley BD, et al. Am J Obstet Gynecol 1993;169:1091-1095 Ngan HY, et al. Aust N Z J Obstet Gynaecol 1990;30:111-114

““Failure”Failure”

““In cases of operative vaginal delivery, In cases of operative vaginal delivery, a true failure is not when a vaginal a true failure is not when a vaginal

delivery is not accomplished but delivery is not accomplished but when a preventable injury is when a preventable injury is

inflicted”inflicted”

Lowe B. Br J Obstet Gynaecol 1987;94:60-6.

Shoulder dystociaShoulder dystocia• Incidence 0.3 – 2% of deliveriesIncidence 0.3 – 2% of deliveries• Lack of uniform definition Lack of uniform definition

– ACOG: additional obstetric maneuvers following failure of gentle downward traction on the fetal head to effect delivery of the shoulders

– prolonged head-to-body delivery time (eg, more than 60 seconds)

• Risk factorsRisk factors– macrosomia and fetal anthropometric variations– maternal diabetes and obesity– operative vaginal delivery– precipitous delivery and prolonged second stage of labor– history of shoulder dystocia or macrosomic fetus– postterm pregnancy– advanced maternal age

Brachial plexus injuryBrachial plexus injury

• C4: phrenic nerve palsy• C5-C6 +/-C7: Erb’s or Erb-Duchenne palsy

(80% of brachial plexus injuries)• C8-T1: Klumpke’s palsy• C5-T1: Complete brachial plexus injury, or

Erb-Klumpke palsy

Erb-Duchenne palsy (C5-C6 Erb-Duchenne palsy (C5-C6 +/- C7)+/- C7)

• Classic posture result of paralysis/weakness in shoulder muscles, elbow flexors, & forearm supinators.

• Affected arm hangs & is internally rotated, extended, and pronated

• Oftentimes, C7 also involved causing loss of innervation to the forearm, wrist, and finger extensors.

• The loss of extension causes thewrist to flex and the fingers to curl up in the ‘‘waiter’s tip’’ position.

Erb-Duchenne palsy (C5-C6 Erb-Duchenne palsy (C5-C6 +/- C7)+/- C7)

• Obstetrical literature: – <10% permanent– Persistent injury more common with

BW > 4500 g and infants of diabetic mothers

• Pediatric/orthopedic literature:– permanent injury in up to 15% to 25%

of cases

Klumpke’s palsy: C8-T1

• Weakness of triceps, forearm pronators, & wrist flexors leading to a ‘‘clawlike’’ paralyzed hand with good elbow and shoulder function.

• Upper-arm function differentiates Klumpke’s palsy from Erb’s palsy.

• Only 40% of Klumpke’s palsies resolve by 1 year of life

• Associated Horner’s syndrome with sensory deficits on the affected side, contraction of the pupil, and ptosis of the eyelid is caused by cervical sympathetic nerve injury.

Brachial plexus injury: ? Brachial plexus injury: ? Birth injuryBirth injury

• 34%–47% brachial plexus injuries not associated with SD

• 4% occur after cesarean birth• Other causes of injury:

– normal forces of labor and delivery (symphysis against the brachial plexus)

– abnormal intrauterine pressures arising from uterine anomalies (anterior lower uterine segment leiomyoma, septum, or a bicornuate uterus)

• Performance of electromyeolography within 24–48 hours of delivery can help determine the timing of brachial plexus injury– Electromyelographic evidence of muscular denervation

normally requires 10 to 14 days to develop– Its finding in the early neonatal period strongly suggests

an insult predating delivery

Koenigsberger MR. Ann Neurol 1980;8:228.Mancias P, et al. Muscle Nerve 1994;17:1237–8.Peterson GW, et al. Muscle Nerve 1995;18:1031.

Brachial plexus injuryBrachial plexus injury

• No matter the cause, care should involve a multidisciplinary approach including pediatrics, pediatric neurology, physical therapy, and possible referral to a brachial pleuxus injury center.

FractureFracture• Majority involve clavicleMajority involve clavicle

– Often occurs in the absence of shoulder dystocia

– Incidence at the time of SD ranges from 3-9.5%

– Increasing risk with greater birth weight• Humerus most common long bone fractureHumerus most common long bone fracture• Almost invariably heal with simple supportive

therapy & do not lead to permanent disability

Hypoxic injuryHypoxic injury

• Essential criteria (must meet all four) Essential criteria (must meet all four) – Evidence of a metabolic acidosis in fetal Evidence of a metabolic acidosis in fetal

umbilical cord arterial blood obtained at umbilical cord arterial blood obtained at delivery (pH <7 and base deficit =12 mmol/L) delivery (pH <7 and base deficit =12 mmol/L)

– Early onset of severe or moderate neonatal Early onset of severe or moderate neonatal encephalopathy in infants born at 34 or more encephalopathy in infants born at 34 or more weeks of gestation weeks of gestation

– Cerebral palsy of the spastic quadriplegic or Cerebral palsy of the spastic quadriplegic or dyskinetic type dyskinetic type

– Exclusion of other identifiable etiologies such as Exclusion of other identifiable etiologies such as trauma, coagulation disorders, infectious trauma, coagulation disorders, infectious conditions, or genetic disordersconditions, or genetic disorders

Hypoxic injuryHypoxic injury

• Criteria that collectively suggest an Criteria that collectively suggest an intrapartum timing (within close proximity to intrapartum timing (within close proximity to labor and delivery, eg, 0-48 hours) but are labor and delivery, eg, 0-48 hours) but are nonspecific to asphyxial insults nonspecific to asphyxial insults – A sentinel (signal) hypoxic event occurring A sentinel (signal) hypoxic event occurring

immediately before or during labor immediately before or during labor – A sudden and sustained fetal bradycardia or the A sudden and sustained fetal bradycardia or the

absence of fetal heart rate variability in the absence of fetal heart rate variability in the presence of persistent late, or variable presence of persistent late, or variable decelerations, usually after a hypoxic sentinel event decelerations, usually after a hypoxic sentinel event when the pattern was previously normal when the pattern was previously normal

– Apgar scores of 0-3 beyond 5 minutes Apgar scores of 0-3 beyond 5 minutes – Onset of multisystem involvement within 72 hours Onset of multisystem involvement within 72 hours

of birth of birth – Early imaging study showing evidence of acute Early imaging study showing evidence of acute

nonfocal cerebral abnormalitynonfocal cerebral abnormality

Teamwork!Teamwork!

• >60% obstetric medical negligence claims relate to events alleged to occur during L&D

• >80% damages awarded• Soon after delivery, discussion with the patient

and family (complete, immediate, accurate information)

• Events of the delivery must be documented by all careteam members involved

• Communicate!***If a any sort of injury is present, the clinician

should NOT speculate regarding the cause

Additional ReferencesAdditional References

• Martin JA, Hamilton BE, Sutton PD, et al. Final data for 2007. National vital statistics reports, vol 58. Hyattsville (MD): National Center for Health Statistics; 2010.

• ACOG. Professional liability and risk management: an essential guide for obstetrician-gynecologists. 2005.

• Gabbe, 5th edition.

• Gottlieb, AG & Galan HL. Shoulder dystocia: An update. Obstet Gynecol Clin N Am. 34 (2007) 501–531

Questions/commentsQuestions/comments