BIRTH TRAUMA

BIRTH TRAUMA

Introduction

The majority of birth injuries are minor and often unreported.

Occasionally, though, birth injuries may be so severe as to be fatal or

leave the child with a permanent disability. They may occur because

of inappropriate or deficient medical skills or attention, but they also

can occur despite skilled and competent obstetrical care. Birth injuries

are mostly iatrogenic, and the legal implications of these should

be noted. Most of these injuries can be managed nonoperatively, but

prompt identification of those that will need surgical intervention

is essential.

DEFINITION

Injuries to the infant that result from mechanical forces (i.e., compression, traction) during the birth process are categorized as birth trauma.

DemographicsThe incidence of significant birth injuries in the United Sates is 68

per 1,000 live births, accounting for less than 2% of perinatal mortality.

1 In Africa, statistics on birth injuries are lacking. However, a survey

of rural Egyptian birth attendants in different regions revealed an

overall prevalence of birth injuries at 7%, and up to 17% in the Aswan

region.2 Autopsy studies on stillbirths from Accra, Ghana, also estimate

the incidence of perinatal deaths due to birth trauma as 5.4%.

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Birth Trauma

Updated: Feb 2, 2015

Overview Etiology Prognosis Soft Tissue Injury Brachial Plexus Injury Cranial Nerve Injury Laryngeal Nerve Injury Spinal Cord Injury Bone Injury Intra-Abdominal Injury Show AllMultimedia LibraryReferencesOverview

Injuries to the infant that result from mechanical forces (ie, compression, traction) during the birth process are categorized as birth trauma. Factors responsible for mechanical injury may coexist with hypoxic-ischemic insult; one may predispose the infant to the other. Lesions that are predominantly hypoxic in origin are not discussed in this article.

Significant birth injury accounts for fewer than 2% of neonatal deaths and stillbirths in the United States; it still occurs occasionally and unavoidably, with an average of 6-8 injuries per 1000 live births. In general, larger infants are more susceptible to birth trauma. Higher rates are reported for infants who weigh more than 4500g.

Most birth traumas are self-limiting and have a favorable outcome. Nearly one half are potentially avoidable with recognition and anticipation of obstetric risk factors. Infant outcome is the product of multiple factors. Separating the effects of a hypoxic-ischemic insult from those of traumatic birth injury is difficult.

Risk factors for birth trauma include the following[1]:

Large-for-date infants, especially infants who weigh more than 4500 g

Instrumental deliveries, especially forceps (midcavity) or vacuum[2] Vaginal breech delivery

Abnormal or excessive traction during delivery

Occasionally, injury may result from resuscitation. Recognition of trauma necessitates a careful physical and neurologic evaluation of the infant to establish whether additional injuries are present. Symmetry of structure and function should be assessed, the cranial nerves should be examined, and specifics such as individual joint range of motion and scalp/skull integrity should be evaluated.

Etiology

The birth process is a blend of compression, contractions, torques, and traction. When fetal size, presentation, or neurologic immaturity complicates this event, such intrapartum forces may lead to tissue damage, edema, hemorrhage, or fracture in the neonate. The use of obstetric instrumentation may further amplify the effects of such forces or may induce injury alone. Under certain conditions, cesarean delivery can be an acceptable alternative but does not guarantee an injury-free birth. Factors predisposing to injury include the following:

Prima gravida

Cephalopelvic disproportion, small maternal stature, maternal pelvic anomalies

Prolonged or rapid labor

Deep, transverse arrest of descent of presenting part of the fetus

Oligohydramnios

Abnormal presentation (breech)

Use of midcavity forceps or vacuum extraction

Versions and extractions

Very low-birth-weight infant or extreme prematurity

Fetal macrosomia

Large fetal head

Fetal anomalies

CLASSIFICATION OF BIRTH INJURIES

Soft tissue injuries

Erythema petechia

Ecchymosis

Lacerations

Subcutaneous fat necrosis

Skull injuries

Caput succedaneum

Cephalhematoma

Linear fractures

Facial injuries

Subconjunctival hemorrhage

Retinal hemorrhage

Musculoskeletal injuries

Clavicular fractures

Fractures of long bones

Sternocleidomastoid injury

Intra-abdominal injuries

Liver hematoma

Splenic hematoma

Adrenal hemorrhage

Renal hemorrhage

Peripheral nerve injuries

Facial palsy

Unilateral vocal cord paralysis

Radial nerve palsy

Lumbosacral plexus injury

Soft Tissue Injury

Soft tissue injury is associated with fetal monitoring, particularly with fetal scalp blood sampling for pH or fetal scalp electrode for fetal heart monitoring, which has a low incidence of hemorrhage, infection, or abscess at the site of sampling.

Cephalhematoma

Cephalhematoma is a subperiosteal collection of blood secondary to rupture of blood vessels between the skull and the periosteum; suture lines delineate its extent. Most commonly parietal, cephalhematoma may occasionally be observed over the occipital bone.

The extent of hemorrhage may be severe enough to cause anemia and hypotension, although this is uncommon. The resolving hematoma predisposes to hyperbilirubinemia. Rarely, cephalhematoma may be a focus of infection that leads to meningitis or osteomyelitis. Linear skull fractures may underlie a cephalhematoma (5-20% of cephalhematomas). Resolution occurs over weeks, occasionally with residual calcification.

No laboratory studies are usually necessary. Skull radiography or computed tomography (CT) scanning is performed if neurologic symptoms are present. Usually, management solely consists of observation. Transfusion for anemia, hypovolemia, or both is necessary if blood accumulation is significant. Aspiration is not required for resolution and is likely to increase the risk of infection.

Hyperbilirubinemia occurs following the breakdown of the red blood cells (RBCs) within the hematoma. This type of hyperbilirubinemia occurs later than classic physiologic hyperbilirubinemia. The presence of a bleeding disorder should be considered. Skull radiography or CT scanning is also performed if a concomitant depressed skull fracture is a possibility.

Subgaleal hematoma

Subgaleal hematoma is bleeding in the potential space between the skull periosteum and the scalp galea aponeurosis. Ninety percent of cases result from a vacuum applied to the head at delivery. Subgaleal hematoma has a high frequency of occurrence of associated head trauma (40%), such as intracranial hemorrhage or skull fracture.[4]The occurrence of these features does not significantly correlate with the severity of subgaleal hemorrhage.[5]The diagnosis is generally a clinical one, with a fluctuant, boggy mass developing over the scalp (especially over the occiput). The swelling develops gradually 12-72 hours after delivery, although it may be noted immediately after delivery in severe cases. The hematoma spreads across the whole calvaria; its growth is insidious, and subgaleal hematoma may not be recognized for hours.

Patients with subgaleal hematoma may present with hemorrhagic shock. The swelling may obscure the fontanelle and cross suture lines (distinguishing it from cephalhematoma). Watch for significant hyperbilirubinemia. In the absence of shock or intracranial injury, the long-term prognosis is generally good.

Laboratory studies consist of a hematocrit evaluation. Management consists of vigilant observation over days to detect progression and provide therapy for such problems as shock and anemia. Transfusion and phototherapy may be necessary. Investigation for coagulopathy may be indicated.

Caput succedaneum

Caput succedaneum is a serosanguineous, subcutaneous, extraperiosteal fluid collection with poorly defined margins; it is caused by the pressure of the presenting part against the dilating cervix. Caput succedaneum extends across the midline and over suture lines and is associated with head molding. Caput succedaneum does not usually cause complications and usually resolves over the first few days. Management consists of observation only.

Abrasions and lacerations

Abrasions and lacerations sometimes may occur as scalpel cuts during cesarean delivery or during instrumental delivery (ie, vacuum, forceps). Infection remains a risk, but most of these lesions uneventfully heal.

Management consists of careful cleaning, application of antibiotic ointment, and observation. Bring edges together using Steri-Strips. Lacerations occasionally require suturing.

Subcutaneous fat necrosis

Subcutaneous fat necrosis is not usually detected at birth. Irregular, hard, nonpitting, subcutaneous plaques 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.

Brachial Plexus Injury

Peripheral nerve damage in the form ofbrachial plexus injuryoccurs most commonly in large babies, frequently with shoulder dystocia or breech delivery. Incidence forbrachial plexus injuryis 0.5-2 per 1000 live births. Most cases are Erb palsy; entire brachial plexus involvement occurs in 10% of cases.

Traumatic lesions associated withbrachial plexus injuryinclude the following:

Fractured clavicle (10%)

Fractured humerus (10%)

Subluxation of cervical spine (5%)

Cervical cord injury (5-10%)

Facial palsy (10-20%)

Erb palsy (C5-C6) is most common and is associated with lack of shoulder motion. The involved extremity lies adducted, prone, and internally rotated. Moro, biceps, and radial reflexes are absent on the affected side. The grasp reflex is usually present. Five percent of patients have an accompanying (ipsilateral) phrenic nerve paresis.

Klumpke paralysis (C7-8, T1) is rare and results in weakness of the intrinsic muscles of the hand; the grasp reflex is absent. If cervical sympathetic fibers of the first thoracic spinal nerve are involved, Horner syndrome is present.

A study by Iffy et al indicated that an approximately four-fold rise in the incidence of shoulder dystocia has occurred in the United States since the mid-20th century, with a review of 11 other countries revealing no comparable increase in most other nations. The investigators considered the rise in dystocia to be primarily related to a trend in the United States, starting in the 1980s, toward active management of the birthing process, in place of a more conservative approach.[6]Prognosis

No uniformly accepted guidelines for determining prognosis are available. Narakas developed a classification system (types I-V) based on the severity and extent of the lesion, providing clues to the prognosis in the first 2 months of life.[7]According to the collaborative perinatal study (59 infants), 88% of cases resolved in the first 4 months, 92% resolved by 12 months, and 93% resolved by 48 months.[8]In another study, which examined 28 patients with upper plexus involvement and 38 with total plexus palsy, 92% spontaneously recovered.[9]Residual long-term deficits may include progressive bony deformities, muscle atrophy, joint contractures, possible impaired growth of the limb, weakness of the shoulder girdle, and/or Erb engram flexion of the elbow accompanied by adduction of shoulder.

Workup

Workup consists of radiographic studies of the shoulder and upper arm to rule out bony injury. The chest should be examined to rule out associated phrenic nerve injury. Electromyography (EMG) and nerve conduction studies are occasionally useful.

Fast spin-echo magnetic resonance imaging (MRI) can be used to evaluate plexus injuries noninvasively in a relatively short time, minimizing the need for general anesthesia. MRI can define meningoceles and may distinguish between intact nerve roots and pseudomeningoceles (indicative of complete avulsion).

Carefully performed, intrathecally enhanced CT myelography may show preganglionic disruption, pseudomeningoceles, and partial nerve root avulsion. CT myelography is more invasive and offers few advantages over MRI.

Immobilization, physical therapy, and surgery

Management consists of prevention of contractures. Immobilize the limb gently across the abdomen for the first week and then start passive range-of-motion exercises at all joints of the limb. Use supportive wrist splints.

The best results from surgical repair appear to be obtained in the first year of life.[10]Several investigators have recommended surgical exploration and grafting if no function is present in the upper roots at age 3 months, although the recommendation for early explorations is far from universal.[11]Complications of brachial plexus exploration include infection, poor outcome, and burns from the operating microscope. Patients with root avulsion do not do well.

Palliative procedures involving tendon transfers have been of some use. Results from a study by Ruchelsman et al of 21 children who suffered brachial plexus birth injury indicated that patients who have no active wrist extension following the trauma can be successfully treated with a tendon transfer but that surgical outcomes tend to be worse in patients with global palsy.[12]Latissimus dorsi and teres major transfers to the rotator cuff have been advocated for improved shoulder function in Erb palsy. One permanent and 3 transitory axillary nerve palsies have been reported from the procedure.

Cranial Nerve Injury

Cranial nerve and spinal cord injuries result from hyperextension, traction, and overstretching with simultaneous rotation; they may range from localized neurapraxia to complete nerve or cord transection.

Unilateral branches of thefacial nerveandvagus nerve, in the form of recurrent laryngeal nerve, are most commonly involved in cranial nerve injuries and result in temporary or permanent paralysis.

Compression by the forceps blade has been implicated in some facial nerve injury, but most facial nerve palsy is unrelated to trauma from obstetric instrumentation (eg, forceps). The compression appears to occur as the head passes by the sacrum.

Physical findings for central nerve injuries are asymmetrical facies with crying. The mouth is drawn towards the normal side, wrinkles are deeper on the normal side, and movement of the forehead and eyelid is unaffected. The paralyzed side is smooth with a swollen appearance, the nasolabial fold is absent, and the corner of the mouth droops. No evidence of trauma is present on the face.

Physical findings for peripheral nerve injuries are asymmetrical facies with crying. Sometimes evidence of forceps marks is present. With peripheral nerve branch injury, the paralysis is limited to the forehead, eye, or mouth.

The differential diagnosis includes nuclear genesis (Mbius syndrome), congenital absence of the facial muscles, unilateral absence of the orbicularis oris muscle, and intracranial hemorrhage.

Management and recovery

Most infants begin to recover in the first week, but full resolution may take several months. Palsy that is due to trauma usually resolves or improves, whereas palsy that persists is often due to absence of the nerve.

Management consists of protecting the open eye with patches and synthetic tears (methylcellulose drops) every 4 hours. Consultation with a neurologist and a surgeon should be sought if no improvement is observed in 7-10 days.

Diaphragmatic paralysis

Diaphragmatic paralysis secondary to traumatic injury to the cervical nerve roots that supply the phrenic nerve can occur as an isolated finding or in association with brachial plexus injury. The clinical syndrome is variable. The course is biphasic; initially the infant experiences respiratory distress with tachypnea and blood gases suggestive of hypoventilation (ie, hypoxemia, hypercapnia, acidosis). Over the next several days, the infant may improve with oxygen and varying degrees of ventilatory support. Elevated hemidiaphragm may not be observed in the early stages. Approximately 80% of lesions involve the right side and about 10% are bilateral.

The diagnosis is established by ultrasonography or fluoroscopy of the chest, which reveals the elevated hemidiaphragm with paradoxic movement of the affected side with breathing.

Prognosis

The mortality rate for unilateral lesions is approximately 10-15%. Most patients recover in the first 6-12 months. An outcome for bilateral lesions is poorer. The mortality rate approaches 50%, and prolonged ventilatory support may be necessary.

Management consists of careful surveillance of respiratory status, and intervention, when appropriate, is critical.

Laryngeal Nerve Injury

Disturbance oflaryngeal nervefunction may affect swallowing and breathing. Laryngeal nerve injury appears to result from an intrauterine posture in which the head is rotated and flexed laterally. During delivery, similar head movement (when marked) may injure the laryngeal nerve, accounting for approximately 10% of cases of vocal cord paralysis attributed to birth trauma.

The infant presents with a hoarse cry or respiratory stridor, caused most often by unilateral laryngeal nerve paralysis. Swallowing may be affected if the superior branch is involved. Bilateral paralysis may be caused by trauma to both laryngeal nerves or, more commonly, by a central nervous system (CNS) injury, such as hypoxia or hemorrhage, that involves the brain stem. Patients with bilateral paralysis often present with severe respiratory distress or asphyxia.

Direct laryngoscopic examination is necessary to make the diagnosis and to distinguish vocal cord paralysis from other causes of respiratory distress and stridor in the newborn. Differentiate from other rare etiologies such as cardiovascular or CNS malformations or a mediastinal tumor.

Paralysis often resolves in 4-6 weeks, although recovery may take as long as 6-12 months in severe cases. Treatment is symptomatic. Once the neonate is stable, providing small, frequent feeds minimizes the risk of aspiration. Infants with bilateral involvement may require gavage feeding and tracheotomy.

Spinal Cord Injury

Spinal cord injury incurred during delivery results from excessive traction or rotation. Traction is more important in breech deliveries (the minority of cases), and torsion is more significant in vertex deliveries. The true incidence of spinal cord injuries is difficult to determine. The lower cervical and upper thoracic region for breech delivery and the upper and midcervical region for vertex delivery are the major sites of injury.

Major neuropathologic changes consist of acute lesions, which are hemorrhages, especially epidural lesions, intraspinal lesions, and edema. Hemorrhagic lesions are associated with varying degrees of stretching, laceration, and disruption or total transaction. Occasionally, the dura may be torn, and rarely, vertebral fractures or dislocations may be observed.

The clinical presentation is stillbirth or rapid neonatal death with failure to establish adequate respiratory function, especially in cases involving the upper cervical cord or lower brainstem. Severe respiratory failure may be obscured by mechanical ventilation and may cause ethical issues later. The infant may survive with weakness and hypotonia, and the true etiology may not be recognized. A neuromuscular disorder or transient hypoxic ischemic encephalopathy may be considered. Most infants later develop spasticity that may be mistaken for cerebral palsy.

The diagnosis is made using MRI or CT myelography. Little evidence indicates that laminectomy or decompression has anything to offer. A potential role for methylprednisolone is recognized. Supportive therapy is important.

Prevention is the most important aspect of medical care. Obstetric management of breech deliveries, instrumental deliveries, and pharmacologic augmentation of labor must be appropriate. Occasionally, injury may be sustained in utero.

Bone Injury

Fractures are most often observed following breech delivery, shoulder dystopia, or both in infants with excessive birth weights.

Clavicular fracture

The clavicle is the most frequently fractured bone in the neonate during birth; this is most often an unpredictable, unavoidable complication of normal birth.[13]Some correlation with birth weight, midforceps delivery, and shoulder dystocia is recognized.[14]The infant may present with pseudoparalysis. Examination may reveal crepitus, palpable bony irregularity, and sternocleidomastoid muscle spasm. Radiographic studies confirm the fracture.

Healing usually occurs in 7-10 days. In order to decrease pain, arm motion may be limited by pinning the infant's sleeve to the shirt. Assess other associated injury to the spine, brachial plexus, or humerus.

Long bone fracture

Loss of spontaneous arm or leg movement is an early sign of long bone fracture, followed by swelling and pain on passive movement. The obstetrician may feel or hear a snap at the time of delivery. Radiographic studies of the limb confirm the diagnosis and distinguish this condition from septic arthritis.

Femoral and humeral shaft fractures are treated with splinting. Closed reduction and casting is necessary only when displaced. Watch for evidence of radial nerve injury with humeral fracture. Callus formation occurs, and complete recovery is expected in 2-4 weeks. In 8-10 days, the callus formation is sufficient to discontinue immobilization. Orthopedic consultation is recommended.

Epiphysial displacement

Separation of the humeral or femoral epiphysis occurs through the hypertrophied layer of cartilage cells in the epiphysis. The diagnosis is clinically based on swelling around the shoulder, crepitus, and pain when the shoulder is moved. Motion is painful, and the arm lies limp by the side. Because the proximal humeral epiphysis is not ossified at birth, it is not visible on radiography. Callus appears in 8-10 days and is visible on radiography.

Management consists of immobilizing the arm for 8-10 days. Fracture of the distal epiphysis is more likely to have a significant residual deformity than is fracture of the proximal humeral epiphysis.

Intra-Abdominal Injury

Intra-abdominal injury is relatively uncommon and can sometimes be overlooked as a cause of death in the newborn. Hemorrhage is the most serious acute complication, and the liver is the most commonly damaged internal organ.

Signs and symptoms of intraperitoneal bleed

Bleeding may be fulminant or insidious, but patients ultimately present with circulatory collapse. Intra-abdominal bleeding should be considered for every infant who presents with shock, pallor, unexplained anemia, and abdominal distension. Overlying abdominal skin may have a bluish discoloration. Radiographic findings are not diagnostic but may suggest free peritoneal fluid. Paracentesis is the procedure of choice.

Hepatic rupture

The most common lesion is subcapsular hematoma, which increases to 4-5 cm before rupturing. Symptoms of shock may be delayed. Lacerations are less common; they are often caused by an abnormal pull on the peritoneal support ligaments or by the effect of excessive pressure by the costal margin. Infants with hepatomegaly may be at higher risk. Other predisposing factors include prematurity, postmaturity, coagulation disorders, and asphyxia. In cases associated with asphyxia, a vigorous resuscitative effort (often by unusual methods) is the culprit.

Splenic rupture is at least a fifth as common as liver laceration. Predisposing factors and mechanisms of injury are similar.

Rapid identification and stabilization of the infant are the keys to management, along with assessment of coagulation defect. Blood transfusion is the most urgent initial step. Persistent coagulopathy may be treated with fresh frozen plasma, the transfusion of platelets, and other measures.

Patients with hepatic rupture usually present immediately following birth, or the rupture becomes obvious within the first few hours or days after delivery.

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Birth Injuries to the Baby

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Epidemiology Skull injuries Brachial plexus injury Cranial nerve injury Laryngeal nerve injury Spinal cord injury Fractures Abdominal bleeding Hypoxia Prevention ReferencesPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than thecondition leaflets.

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The passage from the safety of the uterus to the outside world is made hazardous by the following:

The skull has to mould to facilitate passage through the pelvis and there may becephalopelvic disproportion(CPD) - a mismatch between the size of the fetal head and the capacity of the maternal pelvis. It may represent a large head in a normal pelvis or a normal head in a restricted pelvis.

Malposition increases risk, whilst malpresentation necessitatesCaesarean section.

Contractions tax the reserve of the placenta.

The lungs and circulation undergo great changes.

Difficulties in delivery may compound the situation. Delivery may need to be expedited because offetal distress. This may present as fetal hypoxia (shown onelectronic fetal monitoring) and as acidosis on fetal blood sampling.

Injuries may be caused by a combination of mechanical trauma and hypoxia. Birth injuries may be minor and transient but they can produce serious and permanent effect as well as being fatal.[1] Previously it was assumed that most cases ofcerebral palsywere due to obstetric mismanagement, but now the figure for those caused by obstetric trauma is put at around 5%.[2]Epidemiology

Figures for major (but not fatal) birth trauma in the UK are not routinely collected. For fatal outcomes a national intrapartum-related confidential enquiry reported and reviewed 37 cases in which birthweight was in excess of 2,500 grams for the year 1994-1995.[3]

American and Canadian papers found that birth trauma occurred in 2% deliveries andbrachial plexus injuryin 0.5 to 2.0 per 1,000 live births.[4][5]NEW - log your activity Add notes to any clinical page and create a reflective diary

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Click to find out more Risk factors

Risk factors for birth trauma include:

A large infant (especially if weighing more than 4,500 g).

Cephalopelvic disproportion (CPD).

Instrumental delivery (especially mid-cavityforcepsorventouse deliveryfor deep transverse arrest).

Breech delivery (vaginal delivery, or emergency caesarean section during labour are associated with small, but significant risk of short-term increase in morbidity and mortality).[6] A premature baby (small head and incompletely formed skull - precipitate delivery can cause "champagne cork popping" - risking intracranial haemorrhage).

Shoulder dystocia(a skilled midwife or obstetrician will reduce the risk).[7][8]Other risk factors include:

Primagravida (untried pelvis).

Very short labour may represent precipitate delivery of a premature baby.

Very long labour may indicate CPD

Oligohydramnios.

Congenital abnormalities(especially if there is enlarged head ormacrosomia).

Skull injuries

Cephalohaematoma

Bleeding between the periosteum and skull causes a haematoma, usually in the parietal region and sometimes the occipital region. Spread is restricted by suture lines that are adherent.

Blood loss can cause anaemia and even hypotension.

As the haematoma resolves, breakdown of haemoglobin can causehyperbilirubinaemiathat may need treatment.

An underlying skull fracture is found in up to 20% cases. If it is thought to be depressed, CT or MRI imaging is required.

Spontaneous remission may take weeks and there is sometimes residual calcification.

A haematoma may rarely become infected.

Consider the possibility of a coagulation defect.

Subgaleal haematoma

Bleeding between the periosteum and scalp is usually associated with use of ventouse extraction.

77% follow instrumental delivery and 40-50% overlie a skull fracture or brain haemorrhage.[9] It usually appears within 12-72 hours of birth as a soft, fluctuant mass within the scalp, especially over the back of the head.

It can spread slowly and be unnoticed and present as hypotension.

The spread is not restricted by suture lines.

As with cephalohaematoma, management is conservative but check for anaemia.

Caput succedaneum

This is a poorly defined, subcutaneous collection of serosanguinous fluid that spreads over suture lines and the midline.

It is very common after prolonged labour.

It does not cause significant problems and needs only to be monitored.

Cuts and abrasions

These may result from operative delivery, including cutting the baby with the scalpel blade at LSCS. Great care is needed in cutting the last layer of the uterus, even in an emergency.

Cuts need closing and dressing. Topical antibiotic may be indicated.

Subcutaneous fat necrosis

This is not usually apparent at birth.

Some time later, irregular, hard, subcutaneous plaques appear with overlying dusky red-purple discoloration.

They occur on the extremities, face, trunk or buttocks, having been caused by pressure during delivery.

There is no treatment and they should resolve but sometimes there is calcification.

Brachial plexus injury

The majority of these areErb's palsyinvolving the upper part of the brachial plexus. The underlying problem is usually injudicious traction when the anterior shoulder is trapped (shoulder dystocia).[10][11]Only 10% involve the whole brachial plexus.[12]Associated injuries include:

Fractured clavicle.

Fractured humerus.

Subluxation of cervical spine.

Cervical cord injury.

Facial palsy.

Occasionally, phrenic nerve paresis.

Erb's palsy

There is damage to the C5, C6 segments of the brachial plexus.

It produces loss of motion of the shoulder with a limp arm, adducted and internally rotated. The elbow is pronated and extended with wrist flexed.

Thegrasp reflexis normally maintained butMoro, biceps and radial reflexes are lost.

The position of the hand is said to be reminiscent of a porter who is turning away but is holding out his hand behind him for a tip.

Klumpke's paralysis

This is much less common that Erb's palsy in infants.

It is due to damage of the nerves of segmental origin C7, C8, T1 in the brachial plexus.

It causes paralysis with weakness of the hand and loss of grasp reflex.

Horner's syndromemay be seen if there is T1 damage.

Management

Most cases of brachial plexus injury resolve spontaneously within four months, but it can take up to two years.

X-rays to exclude fractures and examination for phrenic nerve paresis are required. Further investigations include MRI scan, electromyography,nerve conduction studiesand CT myography.

To prevent contractures, immobilise the arm across the upper abdomen for seven days, then start physiotherapy using wrist splints.

Consider surgery if movement is not returning after three months and electrophysiology results suggest a poor prognosis.[13]Cranial nerve injury

Cranial nerve andspinal cord injuriesresult from hyperextension, traction and overstretching with simultaneous rotation. Neurapraxia will resolve swiftly but complete nerve or cord transection is a much more serious matter.

Central damage to the facial and vagus nerves causes an asymmetrical face on crying, with swelling and smoothness of the affected side and drooping of the side of the mouth.

Peripheral damage causes paralysis to the eye, forehead or mouth only.

Most cases soon start to recover but full recovery may take months.

The eye must be protected with a covering and synthetic tears.

If there is no improvement after 7-10 days, investigation is required.

Phrenic nerve damage can cause paralysis of half of the diaphragm, leading to breathing difficulties with significant mortality. Ultrasound or X-ray shows an elevated hemidiaphragm but this may be absent in the early stages. Screening may show immobility.

Laryngeal nerve injury

Unilateral paralysis often presents with a hoarse cry orstridorand may affect swallowing.

Bilateral damage causes severe respiratory problems.

Diagnosis is by laryngoscopy to exclude other causes of the symptoms.

Recovery usually occurs after 4-6 weeks but can take up to a year.

Spinal cord injury

Damage to the spinal cord often results instillbirthor babies who die soon after delivery due to an inability to breathe.

Ventilation may be life-saving but, if the lesion is not a temporary neuropraxia, there will be later agonising decisions about turning off the ventilator.

Those who survive are weak and often develop spasticity.

Diagnosis is by MRI or CT myelography.

Treatment is supportive.

Fractures

Clavicle

Fractured clavicle is common and presents with apparent paralysis.

Palpation may show crepitus, uneven bone and muscle spasm.

It heals within 7-10 days with the arm immobilised.

Confirm the diagnosis by X-ray.

Look for other damage.

Arm and leg bones

Fracture may be heard during delivery.

It presents with absence of normal movement of the limb, with swelling becoming apparent later.

Confirm with X-ray.

Treat with 8-10 days of splinting or reduction and casting if displaced.

Check for radial nerve damage in arm fractures.

Abdominal bleeding

This presents with shock, pallor and a distended abdomen, possibly bluish in colour.

Check for anaemia.

Diagnose with paracentesis.

Causes include hepatic laceration and rupture of spleen, so this is serious.

Hypoxia

Factors within labour are complex, but processes such as uteroplacental vascular disease, reduced uterine perfusion, fetal sepsis, reduced fetal reserves and cord compression can be involved alone or in combination producing fetal distress. Gestational and antepartum factors modify the fetal response to them.

Even though cerebral palsy is strongly associated with a low Apgar score 5 minutes after birth, the majority of babies with low scores DO NOT develop cerebral palsy.[14]The majority of cases are now thought to be a consequence of postpartum insults to the fetus.

Prevention

Good maternity care will reduce the risk of an adverse outcome to both mother and child.

Caesarean section

Fear of fetal damage and the vast cost of litigation have led to an increasing rate of Caesarean section that is now around 24% in the UK as a whole with significant geographical variation.[15]In some parts of the world the figure is higher.

There is debate as to whether the current rising rate of Caesarean section has gone too high. The World Health Organization has suggested that, in developed countries, the figure should not be above 15%. Skills in the use of Kielland's forceps and assisted breech delivery are being lost as LSCS is more readily undertaken.

PrematurityA major contributor toperinatal mortalityand morbidity is prematurity.[16]Prevention of this is important and analysis of figures for outcomes should exclude babies below a certain weight.

Weight is a more reliable parameter for risk assessment than gestational age.

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AuthorTiffany M McKee-Garrett, MDSection EditorsLeonard E Weisman, MDWilliam Phillips, MDMarc C Patterson, MD, FRACPDeputy EditorMelanie S Kim, MDINTRODUCTIONBirth injury is defined as an impairment of the neonate's body function or structure due to an adverse event that occurred at birth. The overall incidence of birth injuries has declined with improvements in obstetrical care and prenatal diagnosis. The reported incidence of birth injuries is about 2 and 1.1 percent in singleton vaginal deliveries of fetuses in a cephalic position and in cesarean deliveries, respectively [1,2]. Injury may occur during labor, delivery, or after delivery, especially in neonates who require resuscitation in the delivery room.

There is a wide spectrum of birth injuries ranging from minor and self-limited problems (eg, laceration or bruising) to severe injuries that may result in significant neonatal morbidity or mortality (ie, spinal cord injuries).

The risk factors associated with birth trauma and specific birth injuries will be reviewed here.

RISK FACTORSThe following factors that increase the risk of birth injuries may be due to the fetus (eg, fetal size and presentation), the mother (eg, maternal size and the presence of pelvic anomalies), or the use of obstetrical instrumentation during delivery:

Macrosomia When the fetal weight exceeds 4000 g, the incidence of birth injuries rises as the fetal size increases. In one study, when compared with normosmic neonates, the incidence of birth injury was twofold greater in infants weighing 4000 to 4900 g, three times greater in those with births weights between 4500 to 4999 g, and 4.5 times greater in those with a birth weight greater than 5000 g [3]. In another study, the incidence of fetal injury was 7.7 percent in infants with birth weights greater than 4500 g [4].

The diagnosis of fetal macrosomia and its impact on shoulder dystocia are discussed in greater detail separately. (See"Fetal macrosomia"and"Shoulder dystocia: Risk factors and planning delivery of at risk pregnancies", section on 'Pregnancies where high birth weight is suspected'.)

Maternal obesity Maternal obesity (defined as a body mass index greater than 40kg/m2)is associated with an increased risk of birth injuries. This may be due to the greater use of instrumentation during deliveryand/orthese mothers having an increased risk of delivering a large for gestational age infant with shoulder dystocia [5]. (See"The impact of obesity on female fertility and pregnancy"and"Cesarean delivery of the obese woman".)

Abnormal fetal presentation Fetal presentation other than a vertex position, particularly breech presentation, is associated with an increase in the risk of birth injury with vaginal delivery. Delivery by cesarean delivery reduces the morbidity associated with vaginal delivery of breech infants and is discussed separately. (See"Overview of breech presentation"and"Delivery of the fetus in breech presentation".)

Operative vaginal delivery Operative vaginal delivery refers to a delivery in which the clinician uses forceps or a vacuum device to assist the mother in delivering the fetus to extrauterine life. The instrument is applied to the fetal head, and then the clinician uses traction to extract the fetus, typically during a contraction while the mother is pushing. Both forceps and vacuum delivery are associated with an increase in birth injury when compared with nonoperative vaginal delivery (table 1). The sequential use of vacuum extraction and forceps increases the risk of birth injury greater than the use of either instrument alone (table 2). The neonatal complications of operative vaginal deliveries are discussed in detail separately. (See"Operative vaginal delivery", section on 'Neonatal complications'.)

Cesarean delivery Cesarean delivery is generally found to have a lower risk of birth trauma compared with vaginal deliveries. This finding was confirmed by an analysis of the Health Care Cost and Utilization Project Nationwide Inpatient Sample that showed cesarean delivery was associated with a decreased likelihood of all birth trauma compared with vaginal delivery (adjusted OR 0.55, 95% CI 0.53-0.58) [6]. However, when the analysis used the definition of birth trauma developed by the Agency for Healthcare Research and Quality Patient Safety Indicator (AHRQPSI), cesarean delivery was associated with an increased risk of birth trauma (adjusted OR 1.65, 95% CI 1.51-1.81). The AHRQPSI definition did not include clavicle fractures, or injuries to the brachial plexus and scalp, which were more frequently seen in vaginal deliveries. These findings suggest that risk varies between cesarean and vaginal delivery depending upon the type of birth injury.

Other factors One study reported an increased incidence of birth trauma to the head and neck in male infants and in babies born to primiparous mothers [7]. Additionally, small maternal stature and the presence of maternal pelvic anomalies are associated with an increased risk of birth injuries. (See"Shoulder dystocia: Risk factors and planning delivery of at risk pregnancies", section on 'Pelvimetry and fetal biometry'.)

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Medical Professional or Student Hospital or Institution Group Practices Patient or CaregiverLiterature review current through:Apr 2015.|This topic last updated:Aug 26, 2013.

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References

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Arch Otolaryngol Head Neck Surg 1999; 125:193.8. Rosenberg A. Traumatic birth injury. NeoReviews 2003; 4:270.9. American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics 2004; 114:297.10. Burden AD, Krafchik BR. Subcutaneous fat necrosis of the newborn: a review of 11 cases. Pediatr Dermatol 1999; 16:384.11. Borgia F, De Pasquale L, Cacace C, et al. Subcutaneous fat necrosis of the newborn: be aware of hypercalcaemia. J Paediatr Child Health 2006; 42:316.12. Dessole S, Cosmi E, Balata A, et al. Accidental fetal lacerations during cesarean delivery: experience in an Italian level III university hospital. Am J Obstet Gynecol 2004; 191:1673.13. Siegel DH, Holland K, Phillips RJ, et al. Erosive pustular dermatosis of the scalp after perinatal scalp injury. Pediatr Dermatol 2006; 23:533.14. Anshelevich A, Osterhoudt KC, Introcaso CE, Treat JR. Picture of the month--quiz case. Halo scalp ring. Arch Pediatr Adolesc Med 2010; 164:673.15. Rawal S, Modi N, Lacey S, Keane M. Escherichia coli septicaemia arising as a result of an infected caput succedaneum. Eur J Pediatr 2006; 165:66.16. Chung HY, Chung JY, Lee DG, et al. Surgical treatment of ossified cephalhematoma. J Craniofac Surg 2004; 15:774.17. Wong CH, Foo CL, Seow WT. Calcified cephalohematoma: classification, indications for surgery and techniques. J Craniofac Surg 2006; 17:970.18. Chen MH, Yang JC, Huang JS, Chen MH. MRI features of an infected cephalhaematoma in a neonate. J Clin Neurosci 2006; 13:849.19. Chan MS, Wong YC, Lau SP, et al. MRI and CT findings of infected cephalhaematoma complicated by skull vault osteomyelitis, transverse venous sinus thrombosis and cerebellar haemorrhage. Pediatr Radiol 2002; 32:376.20. Plauch WC. Subgaleal hematoma. A complication of instrumental delivery. JAMA 1980; 244:1597.21. Uchil D, Arulkumaran S. Neonatal subgaleal hemorrhage and its relationship to delivery by vacuum extraction. Obstet Gynecol Surv 2003; 58:687.22. Gebremariam A. Subgaleal haemorrhage: risk factors and neurological and developmental outcome in survivors. Ann Trop Paediatr 1999; 19:45.23. Kilani RA, Wetmore J. Neonatal subgaleal hematoma: presentation and outcome--radiological findings and factors associated with mortality. Am J Perinatol 2006; 23:41.24. Davis DJ. Neonatal subgaleal hemorrhage: diagnosis and management. CMAJ 2001; 164:1452.25. Amar AP, Aryan HE, Meltzer HS, Levy ML. Neonatal subgaleal hematoma causing brain compression: report of two cases and review of the literature. Neurosurgery 2003; 52:1470.26. Podoshin L, Gertner R, Fradis M, Berger A. Incidence and treatment of deviation of nasal septum in newborns. Ear Nose Throat J 1991; 70:485.27. Sooknundun M, Kacker SK, Bhatia R, Deka RC. Nasal septal deviation: effective intervention and long term follow-up. Int J Pediatr Otorhinolaryngol 1986; 12:65.28. Holden R, Morsman DG, Davidek GM, et al. External ocular trauma in instrumental and normal deliveries. Br J Obstet Gynaecol 1992; 99:132.29. Looney CB, Smith JK, Merck LH, et al. Intracranial hemorrhage in asymptomatic neonates: prevalence on MR images and relationship to obstetric and neonatal risk factors. Radiology 2007; 242:535.30. Towner D, Castro MA, Eby-Wilkens E, Gilbert WM. Effect of mode of delivery in nulliparous women on neonatal intracranial injury. N Engl J Med 1999; 341:1709.31. Pollina J, Dias MS, Li V, et al. Cranial birth injuries in term newborn infants. Pediatr Neurosurg 2001; 35:113.32. Whitby EH, Griffiths PD, Rutter S, et al. Frequency and natural history of subdural haemorrhages in babies and relation to obstetric factors. Lancet 2004; 363:846.33. Chamnanvanakij S, Rollins N, Perlman JM. Subdural hematoma in term infants. Pediatr Neurol 2002; 26:301.34. Huang AH, Robertson RL. Spontaneous superficial parenchymal and leptomeningeal hemorrhage in term neonates. AJNR Am J Neuroradiol 2004; 25:469.35. Heyman R, Heckly A, Magagi J, et al. Intracranial epidural hematoma in newborn infants: clinical study of 15 cases. Neurosurgery 2005; 57:924.36. Park SH, Hwang SK. Surgical treatment of subacute epidural hematoma caused by a vacuum extraction with skull fracture and cephalohematoma in a neonate. Pediatr Neurosurg 2006; 42:270.37. Negishi H, Lee Y, Itoh K, et al. Nonsurgical management of epidural hematoma in neonates. Pediatr Neurol 1989; 5:253.38. Hayden CK Jr, Shattuck KE, Richardson CJ, et al. Subependymal germinal matrix hemorrhage in full-term neonates. Pediatrics 1985; 75:714.39. Beall MH, Ross MG. Clavicle fracture in labor: risk factors and associated morbidities. J Perinatol 2001; 21:513.40. Hsu TY, Hung FC, Lu YJ, et al. Neonatal clavicular fracture: clinical analysis of incidence, predisposing factors, diagnosis, and outcome. Am J Perinatol 2002; 19:17.41. Lam MH, Wong GY, Lao TT. Reappraisal of neonatal clavicular fracture: relationship between infant size and neonatal morbidity. Obstet Gynecol 2002; 100:115.42. Oppenheim WL, Davis A, Growdon WA, et al. Clavicle fractures in the newborn. Clin Orthop Relat Res 1990; :176.43. Bhat BV, Kumar A, Oumachigui A. Bone injuries during delivery. Indian J Pediatr 1994; 61:401.44. Caviglia H, Garrido CP, Palazzi FF, Meana NV. Pediatric fractures of the humerus. Clin Orthop Relat Res 2005; :49.45. Nadas S, Gudinchet F, Capasso P, Reinberg O. Predisposing factors in obstetrical fractures. Skeletal Radiol 1993; 22:195.46. Thompson KA, Satin AJ, Gherman RB. Spiral fracture of the radius: an unusual case of shoulder dystocia-associated morbidity. Obstet Gynecol 2003; 102:36.47. Sawant MR, Narayanan S, O'Neill K, Hudson I. Distal humeral epiphysis fracture separation in neonates -- diagnosis using MRI scan. Injury 2002; 33:179.48. Jones GP, Seguin J, Shiels WE 2nd. Salter-Harris II fracture of the proximal humerus in a preterm infant. Am J Perinatol 2003; 20:249.49. Dunkow P, Willett MJ, Bayam L. Fracture of the humeral diaphysis in the neonate. J Obstet Gynaecol 2005; 25:510.50. Morris S, Cassidy N, Stephens M, et al. Birth-associated femoral fractures: incidence and outcome. J Pediatr Orthop 2002; 22:27.51. Anglen JO, Choi L. Treatment options in pediatric femoral shaft fractures. J Orthop Trauma 2005; 19:724.52. Dupuis O, Silveira R, Dupont C, et al. Comparison of "instrument-associated" and "spontaneous" obstetric depressed skull fractures in a cohort of 68 neonates. Am J Obstet Gynecol 2005; 192:165.53. Wei C, Stevens J, Harrison S, et al. Fractures in a tertiary Neonatal Intensive Care Unit in Wales. Acta Paediatr 2012; 101:587.54. Broker FH, Burbach T. Ultrasonic diagnosis of separation of the proximal humeral epiphysis in the newborn. J Bone Joint Surg Am 1990; 72:187.55. Paige ML, Port RB. Separation of the distal humeral epiphysis in the neonate. A combined clinical and roentgenographic diagnosis. Am J Dis Child 1985; 139:1203.56. Menticoglou SM, Perlman M, Manning FA. High cervical spinal cord injury in neonates delivered with forceps: report of 15 cases. Obstet Gynecol 1995; 86:589.57. Uhing MR. Management of birth injuries. Pediatr Clin North Am 2004; 51:1169.Topic Outline

INTRODUCTION RISK FACTORS SOFT TISSUE INJURIES Bruising and petechiae Subcutaneous fat necrosis Lacerations EXTRACRANIAL INJURIES Caput succedaneum Cephalohematoma Subgaleal hemorrhage Facial injuries - Nasal septal dislocation - Ocular injuries INTRACRANIAL HEMORRHAGE Subdural hemorrhage Subarachnoid hemorrhage Epidural hemorrhage Intraventricular hemorrhage FRACTURES Clavicle Humerus Femur Skull Premature infants DISLOCATIONS NEUROLOGIC INJURIES ABDOMINAL INJURIES SUMMARY AND RECOMMENDATIONS REFERENCESGRAPHICS

DIAGNOSTIC IMAGES

Calcified cephalohematoma Newborn clavicle fracture Infant humeral fracture Humeral fracture infant FIGURES

Neonatal extracranial and intracranial birth injuries PICTURES

Neonate knee dislocation TABLES

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Birth Injury TypesSometimes birth injuries are temporary, and other times they arepermanent, lasting a lifetime. Symptoms often vary from one infantto another. Whereas one infantmay havemild symptoms, the same injurymay happen to a different infantand cause severe symptoms.

Sometimes children arent aware of their birth injury until theyre enrolled in school. Other times the symptoms for certain birth injuries are obvious immediately.The severity of symptoms and signs will greatly depend upon each childs individual circumstances as well as the type of birth injury.

Brain-Related Injuries

Brain-related birth injuries can manifest in several different ways. Often, brain injuries develop from oxygen deprivation, such as anoxia, hypoxia, birth asphyxia, and perinatal asphyxia. Hypoxic Ischemic Encephalopathy (HIE) is a birth injury that merely describes that starvation that happens to the brain and the sometimes-severe consequences as a result of oxygen deprivation.

When a brain has been deprived from oxygen, it can react in various ways. For example, brain ischemia occurs whenoxygen is deprived and the brain reacts by draining the blood from the brain. A brain hemorrhage occurswhen a brain reacts toexcessive blood flowinginto the brain. More electrical responses are what happens when the brain reacts to oxygen deprivation causing general brain damage from seizures, or causing more severe electrical disorders with cerebral palsy. Additionally, brain-related injuries can happen from other birth injuries such as the growth of newborn jaundice into kernicterus, flooding the brain with bilirubin, and the development of the group B strep infection to meningitis which interferes with electrical communications between the spine and the brain.

The leading brain-related injury in relation to birth trauma is cerebral palsy (CP), affecting around 800,000 children. CP can develop after maternal infections, oxygen deprivation, infant stroke, and infant infection. In many instances, CP could have been eliminated with the corrective preventative measures by physician. For example, if a physician fails to monitor fetal distress and take the appropriate actions, the infant may develop CP. Other instances include:

Failure to monitor, detect, and treat maternal infections

Failure to plan and carry out an emergency C-section

Failure to identify and treat a prolapsed umbilical cord

Failure to use birth-assisting tools correctly

Muscle-Related or Physical Injuries

Cerebral palsy is often misinterpreted as a muscle-related birth injury because in some cases, the infant has total loss of muscle control. However, cerebral palsy is a brain-related birth injury that affects the way the brain sends communication to the muscle groups.

Muscle-related injuries, however, are generally easy to diagnose as a clinical evaluation can pinpoint where the limited movement or paralysis is coming from. Somemuscle-related injuries maybe related to more blatant medical malpractice such as lacerations, bruises, or broken bones. This can alsocause other physical birth injuries such as skull fractures or cephalohematoma, the bruising of the area between the brain and the outer layers of skin.

Common muscle-related and physical injuries include:

Brachial PlexusBrachial plexushappens when the upper extremity of the arm is injured, usually during delivery. Symptoms include weakness in the affected arm and the inability touse certain muscles in the affected arm. The shoulder and hands may also be affected. Electrical-type shocks and a burning sensation down the affected arm is also common.

Erbs PalsyErbs palsy is a form of brachial plexus marked by the nerves of the upper arm being affected, usually after a birth injury. Infants with Erbs palsy may experience the loss of feeling and weakness in the affected. In severe cases, infants may have total paralysis in the affected arm.

Klumpkes PalsyKlumpkes palsy, another form of brachial plexus,is caused by damage to the lower nerves in the arm, affecting the arm, wrists, and fingers. Typically, an infant with Klumpkes palsy with have total paralysis in the affected area, and the hand usually takes on a permanent, claw-like shape.

Shoulder DystociaShoulder dystocia is a birth injury that occurs when an infants head and shoulders get trapped behind the mothers pelvic bone during delivery. Although shoulder dystocia only happens in 1% of all pregnancies, the complications that arise with this type of injury can be severe. Along with the risk of maternal hemorrhaging and uterine rupture, the baby may experience difficulties when breathing, a collarbone fracture, cerebral palsy, a brachial plexus fracture, and in some instances, death.

Birth Injuries Related to Infections or Developed Through Pregnancy

Sometimes the responsibility of who passes on the birth injury is fuzzy. In some instances,a birth injury is passed on from the mother, though aphysicians job is to detect and treat any maternal problems. A couple of these injuries are attributed to infections, such as the group B strep infection or meningitis, both infections that the mother can carry in the vagina without even knowing it (about 1 in every 4 mothers carry these infections without any symptoms or knowledge of these infections). Children can catch this from their mothers just by being born, by passing through the birth canal where these infections are stored.

Other birth injuries caught from the mother are injuries developed through pregnancy that the physician should have tested for or found early. These injuries include folic acid deficiency, anemia, and spina bifida. These birth injuries could have possibly been prevented by the mother taking supplements based on the physicians recommendations.

Additional, a birth injury that could happen at the end of pregnancy just before delivery is meconium aspiration syndrome, which occurs when the infantis under stress from a long and difficult delivery. Theinfantdefecates in the uterus and then breathes in the meconium, causing severe breathing problems after birth.

Injuries from Delivery

Birth injuries that arise during delivery is a common occurrence. These types of injuries occur from the use ofvacuum extractor or forceps, tools invented to assist in delivery. Other injuries from delivery mayinclude administering the wrong medication, mishandling the infant,resulting in broken bones, lacerations, or skull fractures. Depending on how the physician handles the delivery, an infantmay also experience injuries related to stress, high blood pressure, or hypertension.

Persistent Pulmonary Hypertension of the Newborn (PPHN)

PPHN occurs when the pulmonary article responsible for delivering oxygen to a newborn shuts down. In turn, the infant has a difficult time breathing, which can lead to rapid heartbeats, cyanosis, heart murmurs, and more. PPHN is often the result of a difficult birth, yet in many instances it arises due to medical negligence. For example, prescription-based medications such as Zoloft, Celexa, and Paxil have been linked to an increase in blood pressure and during pregnancy this canplace stress on the infant. Other causes include failure to treat maternal infections, failure to detect and prevent infant asphyxia, and performing an unnecessary C-section.

Sources:

1. http://www.stanfordchildrens.org/en/topic/default?id=birth-injury-90-P023402. http://www.theguardian.com/lifeandstyle/2010/nov/14/scared-birth-trauma-midwives3. http://apt.rcpsych.org/content/7/4/257.full4. http://www.healthy.net/scr/article.aspx?Id=10585. http://www.healthy.net/Health/Article/Birth_Trauma_The_Most_Common_Cause_of_Development_Delays/10586. http://www.seattlechildrens.org/medical-conditions/airway/birth-asphyxia/7. http://www.aafp.org/afp/2004/0401/p1707.html Birth Injury Birth Injury Types Birth Trauma Caput Succedaneum Cognitive Developmental Disabilities Due to Birth Injuries C-Section Injuries Epidural Birth Injuries Fetal Lacerations Folic Acid Deficiency Anaemia Forceps Delivery Injury Group B Strep Infection Horners Syndrome Hydrocephalus Infant Bells Palsy Infant Bleeding of the Brain or Hemorrhage Infant Brain Ischemia Infant Broken Bones Infant Cephalohematoma Infant Cervical Dystonia Infant Chorioamnionitis Infant Cystic Fibrosis Infant Dystonia Disorder Infant Hypoxic Ischemic Encephalopathy (HIE) Infant Meningitis Infant Shoulder Dystocia Infant Skull Fractures Infant Spina Bifida Infant Spinal Cord Damage Infant Subconjunctival Hemorrhage Infant Torticollis Intellectual Disabilities in Babies and Children Kernicterus Klumpkes Palsy Maternal Infections Meconium Aspiration Syndrome Neonatal Stroke Persistent Pulmonary Hypertension of the Newborn (PPHN) Placental Birth Injuries Vacuum Extraction Injury Wrongful Birth Birth Injury Symptoms Birth Injury Causes Birth Injury Treatment Frequently Asked Birth Injury Questions Birth Injury Statistics Life Care Plans Life for a Child with a Birth Injury Birth Injury Financial Support When to Speak Up For Your Babys Birth Injury Governmental Services for Babies with Birth Injuries Support Groups for Families of Children with Birth Injuries How Birth Injuries Affect Mothers Information On Birth Injuries Cerebral Palsy Erbs Palsy Brachial Plexus Injury Infant Brain Damage Infant Wrongful DeathBirth Injury GuideCall Us Toll Free:877-415-6603 BIRTH INJURIES CEREBRAL PALSY ERBS PALSY BRACHIAL PLEXUS INJURY BRAIN DAMAGE WRONGFUL DEATH BLOG ABOUT US

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Types of Birth Injuries

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Sacramento Personal Injury Lawyers, Brain & Spinal>Injury & Death>Injured Children's Justice Center>Birth Injuries> Common Types of Birth Injuries

Common Types of Birth Injuries

Topics on this page:

Fetal Distress (Hypoxia) Cerebral Palsy Erb's Palsy Brachial Palsy/Brachial Plexus Injury Kernicterus (Severe Jaundice) Brain Injuries Caused by Forceps or Vacuum Extractors Umbilical Cord ComplicationsThe umbilical cord is the babys lifeline while it is in the womb, carrying oxygen, blood and nutrients to the fetus right up to the point of birth.

Umbilical Prolapseoccurs when the umbilical cord is "pinched in the birth canal, cutting off oxygen to the baby.

Umbilical Cord Compressionoccurs when the cord gets wrapped around the babys body during delivery, also cutting off or decreasing the flow of blood and oxygen to the baby.

Birth injuries occur whendoctors and medical staff fail to quickly free the umbilical cordfrom these dangerous positions.

Fetal Distress (Hypoxia)

Fetal distress, orhypoxia (read more), occurs when theunborn fetus is deprived of oxygen, often because of umbilical cord complications. The first indication offetal distressis anabnormal heart rate. The heart rate should be carefully monitored by doctors and medical staff usingelectronic fetal heart equipment or a fetal stethoscope. If an abnormality is found, there are immediate steps that can and should be taken to prevent birth injury, including:

Giving the mother more oxygen,

Turning the mother onto her left side, or

Delivering the child as quickly as possible using forceps or by Caesarean Section (C-Section)

back to topCerebral Palsy

The term"cerebral palsy (read more)refers to several different kinds of permanentbrain injuriesthat occur before, during, or shortly after birth.Victims of cerebral palsy can suffer a variety of symptoms including:

Limited movement (motor skills)

Speech difficulties

Learning disabilities

In an infant, symptomsmay include:

Being slow to reach development milestones like rolling over, crawling, sitting, or walking

Difficulty controlling muscles

Balance and coordination problems

Visual problems

Hearing problems

Epilepsy, seizures or spasms

Different types of cerebral palsy includespastic cerebral palsy,athetoid cerebral palsy, andataxic cerebral palsy.

back to topErbs Palsy

Erbs Palsy (read more)results from a very traumatic injury when the babys shoulder becomes stuck behind the mothers pubic bone during delivery. Severe nerve damage affecting the neck and arm can result.

If the baby can move one arm but not the other, or if the arm hangs down at the side of the body, Erbs Palsy may be the problem. The condition can be temporary, with full recovery of movement and sensation, butpermanent paralysisor numbness may result in very serious cases.

back to topBrachial Palsy/Brachial Plexus Injury

Brachial palsyoccurs when the brachial plexus (the group of nerves that supplies the arms and hands) is injured. It is most common when there is difficulty delivering the baby's shoulder, calledshoulder dystocia.

Lack of muscle control and a loss of sensation or strength in the arm, hand or wrist are common symptoms. Intense pain is often felt from the neck down to the arm. If the injury caused bruising and swelling around the nerves, movement should return within a few months. Tearing of the nerve may result in permanent nerve damage.

Abrachial plexusinjury could be the result of medical negligenceat birth where the baby's shoulders have been injured through the use of forceps and, in turn, the brachial plexus nerves have been stretched and torn.

back to topKernicterus (Severe Jaundice)

Kernicterus (read more)is a form of brain damage caused by excessive jaundice. The substance which causes jaundice "bilirubin produced by the liver is so high that it can move out of the blood into brain tissue.

When babies begin to have brain damage from excessive jaundice, they have difficulty staying awake and alert, they have a high-pitched cry and seem to lack muscle tone oract "floppy (hypotonic), followed byincreased muscle tone (hypertonic), witharching of the head and back. As the damage continues, they may develop fever, may arch their heads back into a very contorted position known asopisthotonusorretrocollis.

When the first symptoms appear it is an emergency situation.The brain damage can be prevented only if the treating doctor administers the right treatment quickly and without any interruption.

back to topBrain Injuries Caused by Forceps & Vacuum Extractors

Physicians use forceps and vacuum extractors, either separately or together, to help pull the fetus through the birth canal. Use of these devices to pull, twist, and manipulate the position of the fetus can result intraumatic brain and spinal cord injury, as well as skull fracture.

Contact a Sacramento Birth Injury Attorney

The experiencedmedical malpractice attorneysat Kershaw, Cutter & Ratinoff understand that birth injury and birth trauma cases can be complex and demanding.Our attorneyshaverecoveredmillions of dollars in damagesfor injured children and their families who have been the victims ofcareless doctors and medical staffs.

Our years of experience and our well-trained paralegals and administrative staff give us the advantage, even under the most difficult circumstances. We care about our clients and treat the injured children and their families with genuine concern, because we understand the devastating effects birth injuries can have on them.

If yourchild has suffered birth injury or trauma, please fill out and submit the contact form on this page for a free and confidential case evaluation, or call us toll-free at(888) 285-3333.

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BIRTH INJURIES

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Common Types of Birth Injuries

Hypoxic Brain Injury Cerebral Palsy Erb's Palsy Brain Injuries Caused by Forceps and Vacuum Extractors Kernicterus (Severe Jaundice)

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If your child has been injured due to someone else's careless or negligent act, call us for a free and confidential case evaluation888-285-3333FREE.

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Eric Ratinoff Offers Free Seminar to Educate Insurance Brokers and their Clients about Filing Disability Insurance ClaimsKCR's Brooks Cutter and Eric Ratinoff win $7.6 million dollar spinal cord injury medical malpractice caseKershaw, Cutter & Ratinoff partners William Kershaw, Brooks Cutter and Eric Ratinoff named to the California Super Lawyers list of top attorneys in California for 2011KCR's Eric Ratinoff to Walk a Mile in Her Shoes to support WEAVEKCR Client and Attorney Stuart Talley appear at Senate Committee on Aging over the DePuy ASR Hip Replacement SystemKCR Develops new website to inform clients and public about the consequences of high cobalt & chromium blood levelsTBI Caregivers Support: Caring for Caregivers Free Social Networking ClassKCR Featured in ABC Diane Sawyer World News Hip Recall StoryC. Brooks Cutter Selected to Serve on California Attorney General Kamala Harris' Mortgage Fraud & Consumer Protection Work GroupFacebook Charity Promotion Spreads with help from the Sacramento Business JournalKershaw, Cutter & Ratinoff featured in Sacramento Magazine's November "Best of Sacramento" issueNew!KCR Class Action Podcast now on iTunesorMP3William Kershawpresents at the 9th annualSan Francisco Class Action Litigation ConferenceAugust 12-13, 2010 at theMarriott Marquis Hotel55 Fourth Street, San Francisco, CA 94103

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We know thatchildren injured at birthhave the capacity to grow and, in many cases, to overcome many of their disabilities. In order to unlock their full potential, babies and children who were injured at birth require specialized care, medical treatment and therapies, assistive devices, and educational opportunities. They may be victims of medical malpractice, but they do not have to live their lives as victims.

Our lawyers are dedicated to providing children with the means to be successful. Optimal care for a child who was injured at birth is expensive, often costing in the millions of dollars over the course of a childs lifetime. When that injury was caused by a medical mistake, a birth injury lawsuit may be the only way to provide for a childs extraordinary needs.

Regardless of whether an injured child has won a medical malpractice lawsuit, or has not yet initiated a medical malpractice lawsuit, there are governmental, public and electronic resources available to help parents make the most of the money they have. Click on the sections listed below to find out what you can do to unlock your extraordinary childs potential.

Life Care Plans: A life care plan is a document that outlines the services and devices necessary to care for your child. It is customized based on your childs injury, the resources available near where you live, and the costs in your area.

Governmental Services: The federal and state governments offer extensive services to children with disabilities, including medical assistance, social security, specialized public education, and more.

Educational Resources: Parents of children at birth must know how to navigate the special education system in order to help their children grow to their full potential.

Electronic/Internet Resources: From online support groups to medical resources, the internet has numerous comprehensive and reliable sources of information for parents of children with disabilities

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Birth injury consists of a physical injury sustained by a newborn during

labor and delivery. Most injuries are minor and resolve rapidly. Other injuries

may require some intervention. A few are serious enough to be fatal.

Types of birth injuries include:

Scalp (e.g., caput succedaneum, cephalohematoma).

Skull (e.g., linear fracture, depressed fracture).

Intracranial (e.g., epidural or subdural hematoma, cerebral contusion).

Spinal cord (e.g., spinal cord transaction or injury, vertebral artery injury).

Plexus (e.g., total brachial plexus injury, Klumpke paralysis).

Cranial and peripheral nerve (e.g., radial nerve palsy, diaphragmatic

paralysis).

Key Factors

Maternal, intrapartum, obstetric birth techniques, and newborn

factors may predispose the newborn to injuries. These include:

Fetal macrosomia.

Abnormal or difficult presentations.

Uterine dysfunction leading to precipitate or prolonged labor.

Cephalopelvic disproportion.

Multifetal gestation.

Congenital abnormalities.

Internal FHR monitoring.

Forceps or vacuum extraction.

External version.

Cesarean birth.

Diagnostic and Therapeutic Procedures and Nursing Interventions

Birth injuries are normally diagnosed by CT scan, x-ray of suspected area of

fracture, or neurological exam to determine paralysis of nerves.

Data Collection

Monitor the newborn for signs and symptoms of birth injuries, which

include:

Irritability, seizures, and depression. These are all signs of a subarachnoid

hemorrhage.

Facial flattening and unresponsiveness to grimace that accompanies crying or

stimulation, and the eye remaining open are symptoms to assess for facial

paralysis.

Weak or hoarse cry, which is characteristic of laryngeal nerve palsy from

excessive traction on the neck.

Flaccid muscle tone, which may signal joint dislocations and separation

during birth.

Flaccid muscle tone of the extremities, which is suggestive of nerve plexus

injuries or long bone fractures.

Limited motion of an arm, crepitus over a clavicle, and absence of Moro

reflex on the affected side, which are symptoms of clavicular fractures.

Flaccid arm with the elbow extended and the hand rotated inward, absence

of the Moro reflex on the affected side, sensory loss over the lateral aspect

of the arm, and intact grasp reflex, which are symptoms of Erb-Duchenne

paralysis (brachial paralysis).

Localized discoloration, ecchymosis, petechiae, and edema over the

presenting part. These are seen with soft tissue injuries.

Nursing assessments for birth injuries include:

Reviewing maternal history and looking for factors that may predispose

the newborn to injuries.

Apgar scoring that might indicate a possibility of birth injury. Neonates in

need of immediate resuscitation should be identified.

Initial head to toe physical assessment and continued assessment

upon each contact with the neonate.

Vital signs and temperature.

NANDA Nursing Diagnoses

Injury related to birth trauma

Impaired physical mobility related to brachial plexus injury

Impaired gas exchange related to diaphragmatic paralysis

Acute pain related to injury

Nursing Interventions

Nursing interventions for birth injuries include:

Administering treatment to the newborn based on the injury and

according to the primary care providers prescriptions.

Preventing further trauma by decreasing stimuli and movement.

Educating the infants parents and family regarding the injury and the

management of the injury.

Promoting parent-newborn bonding.

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