BIRTH INJURIES

INTRODUCTION:
As a result of the birth process, some injuries occur that may be minor, where as others may be
more serious. Parental reaction to any injury sustained by their newborn infant at birth may be out of
proportion to the harm that has occurred.
BIRTH INJURIES:
Birth injuries is an impairment of the infants body function or structure due to adverse influence that
occurred at birth. Injury commonly occurs during labour or delivery.
It is defined as those sustained during labor and delivery. Birth injuries may be severe enough to cause
neonatal death, still birth or number of morbidities.
RISK FACTORS:
Maternal
Primiparity
Short stature
Maternal pelvic anomalies
Prolonged or extremely rapid labor
Oligohydramnios
Deep transverse arrest of descent of presenting part of the fetus
Foetal
Abnormal presentation
Very low birth weight infant or extremely prematurity
Foetal macrosomia
Large fetal head
Foetal anomalies
Interventional/ inorganic
Use of mid forceps
Inappropriate vacuum application
Versions& extractions

SITE OF INJURY AND TYPE OF INJURY

SITE OF INJURY

TYPE OF INJURY

Soft tissues
Muscles
Nerve

Scalp
Skull
Intra cranial
Bones

Eye

Viscera

Skin lacerations, abrasions, fat necrosis

Sternocleidomastoid
Facial
Brachial plexus
Duchenne Erb(C5,C6)
Klumpke
Spinal Cord
Phrenic n
Horners Syndrome
Recurrent laryngeal nerve
Lacerations,abscess, hemorrhage
Cephalo hematoma
Subgaleal hematoma
Fracture
Hemorrhage Intraventricular
Subdural
Subarachnoid
Fracture clavicle
Hemerus
Femur
Skull
Nasal bones
Hemorrhage
Subconjunctiva
Vitreous
Retina
Rupture of liver, adrenal gland, spleen testicular
injury

SOFT TISSUE INJURIES:

Abrasions, laceration, Subcutaneous fat necrosis
Clinical features
:
Appear in first two weeks of life
Irregularly shaped , hard , non pitting, subcutaneous plaque with overlying dusky, red purple
discoloration
Sites:
Cheeks, arms, back , buttocks, thighs
MUSCLE INJURY
Sternocledomastoid (SCM )muscle injury
Sternocleidomastoid (SCM) injury (congenital torticollis) is characterized by a well circumscribed
immobile mass in the mid point of the SCM. The head tilts towards the involved side. The patient cannot
move the head normally.

Sternomastoid hematoma usually appears about 7-10 days after birth and is usually situated at the mid
position of the muscle. It is caused by rupture of the muscle fibers and blood vessels, followed by a
hematoma and cicatrical contraction. It may be associated with difficult breech delivery or attempted
delivery following shoulder dystocia or excessive lateral flexion of the neck even during normal
delivery. There is transient torticollis and it is wise not to massage.
Pathology:
Injury to the SCM muscle/ fascia disruption during delivery
haematoma formation
Affection of surrounding musculoskeletal structuresfibrosis
Torticollis
Management:
Treatment is conservative.
Stretching of the involved muscle should be done several times a day.
Recovery is rapid in majority of cases. Surgery is needed if it persists after 6 months of physical
therapy.
Nursing Management:
Stretching exercises to the affected SCM . It include,
Tilting the head away from the affected side so that the ear can be brought into contact with the
opposite shoulder
Rotating the chin towards the tight SCM muscle. When head is in the stretched position , it
should be held there for about 10 seconds
The exercise should be done 4-6 times in a day with about 20 repetitions of each exercise at
each time.
The infant is positioned in the crib so that the head is supported by sandbags in the corrected
positions. This is done to prevent the flattening of the occiput or the development of facial
asymmetry
The head should be rotated so that it tilts away from the involved side and so that the face looks
towards the side of the tight muscle.
Crib toys should be placed so that the neck is stretched when the infant reaches for them.
Proper demonstration of the exercise to the parents
NERVE INJURIES:
Commonly associated with breech delivery
Cause- Hyper extension , traction,& over stretching with simultaneous rotation
Types- Facial palsy, Brachial Palsy, Erbs palsy, Klumpkes Palsy, Brachial plexus injury, phrenic nerve
injury (C3,4 and 5)
Facial palsy

Cause:Compression by the forceps blades. It is involved by direct pressure of the forceps blades or by
hemorrhage and edema around the nerve.
Clinical features:
Assymmetrical crying facies, the eye of the affected side which remains open and eyelids are
immobile. On crying , the angle of the mouth is drawn over to the unaffected side. No nasolabial
fold is present. Sucking remains unaffected.
Mangement:
Protection of the eye, which remains open even during sleep, with synthetic tears (1% methyl
cellulose drops).
The condition usually disappears within weeks unless complicated by intracranial damage
Neurological and surgical consultation
Nursing management:
Feeding is first given by NG tube in order to prevent aspiration
When possible the infant should be feed orally using a soft nipple having a large hole
Eye shield to prevent drying of the conjunctiva and cornea
Gentle restraining of the hands
Brachial palsy
Either the nerve roots or the trunk of the brachial plexus are involved. The damage of the nerve is due to
stretching (common) or effusion or hemorrhage inside the sheath.
Causes :
Undue traction on the neck during attempted delivery of the shoulder.
hyperextension of neck to one side with forcible digital extension and abduction of the arm in an
attempt to deliver the shoulders
Erb paralysis(C5-6):
Affected arm in adducted and internally rotated with elbow extended (Waiters tip position)
Forearm is prone and wrist is flexed
The limb falls limply to the side of the body when passively adducted
Moros, biceps, radial reflexes absent on affected side
Grasp reflex intact
Klumpkes paralysis (C7& T1)
intrinsic muscles of the hand are affected & grasp is absent( claw Hand)
Biceps and radial reflex are present
Horners syndrome, if cervical sympathetic fibres of T1 are involved
injury to the entire brachial plexus the entire arm is flaccid , all reflexes are absent
Complications
Contractures
Management:
X ray studies to rule out bony injury, chest examination to rule out diagphragmatic involvement
Passive movements started after 7-10 days( After resolution of the nerve edema)
Splints to prevent wrist and digit contractures
Recovery:
improvement in 1-2 wks normal function

 no improvement is 6 months permanent deficit

Nursing Management:
The goal of the care is to prevent the contractures of the paralysed muscle
The arm should be partially immobilisd in a position of maximum relaxation so that the
nonparalysed muscles cannot exert pull on the affected muscles
By the use of splint or brace when the upper arm is paralysed, the arm is abducted 90 degrees and
rotate internally at the shoulder with the elbow flexed so that the palm of the hand is turned
towards the head
When the lower arms and hand areparalysed , the lower arm and the wrist are kept in a neutral
position and the hand is placed over a small pad
The infant is immobilized for 6months during part of the day and night
A longer period of immobilization may be necessary for some infants.
After 7-10 days , complete ROM exercises may be given gently several times each day inorder to
maintain muscle tone and prevent contraction deformity
Before or splint or brace is obtained , the nurse can pin the infants long shirt sleeve to the
mattress covering
When any form of immobilization is used , the fingers and hands must be observed for any
coldness or discolouration and the skin for signs of irritation
When a splint is used the parents must be taught how to apply it properly and how to provide the
skin care
They should be taught the proper dressing technique- affected hand first and on removing the
unaffected hand first
More physical contact and affection than normal child
Brachial plexus injury
The incidence is about .1 to 0.2% of shoulder dystocia, even in normal delivery, macrosomia,
malpresentation and instrumental delivery.
phrenic nerve palsy(C3, 4, & 5)
Unilateral and associated with brachial plexus injuries
Clinical features:
Respiratory distress ipsilaterally diminished breath sounds
Management:
USG/Fluroscopic studies- Paradoxical movements of the diaphragm
Pulmonary toilet
Refractory cases- diagphramatic placation, phrenic nerve pacing
Nursing management:
The neonate is placed on the affected side , and oxygen is given as necessary
The neonate is treated like any infant having respiratory difficulty
The infant should be feed intravenously , by gavage , and then orally as the condition improves
Observe for the symptoms of pulmonary infection, which may complicate the infants condition
SCALP INJURIES
1) Associated with foetal monitoring

 Fetal scalp blood sampling for the estimation of PH- heomorrhage and infection
Foetal scalp electrode for FHR monitoring
2) Cephal hematoma
Definition: it is the collection of blood between the pericranium and the flat bones of the skull,usually
unilateral and over a parital bone.it is due to the rupture of a small emissary vein from the skull and may
be associated with fracture of the skull bone. This may be caused by forceps delivery but also may be
met with following normal labour. It is never present at birth but gradually develops after 12-24 hours.
Prognosis:
Prognosis is good.
Rarely suppuration occurs.
Complication:
Hypotension
Infection
Associated skull fractures
Resolution:
Slow resolution occurs over 1-2 months , occasionally with residual calcification
Management:
Observation
No active reatment is required
Prevention of infection is necessary
A head CT should be taken if neurological symptoms are suspected
Transfusion and photo therapy(extensive haematomas)
Rule out bleeding disorders
Aspiration for smear & culture if infection is suspected
Skull X -rays and CT scan to diagnose depressed skull fractures
3) Subgaleal hematoma
Definition: Blood that has invaded the potential space between the skull periosteum and scalp galea
aponeurosis , and the area that extend posterior from the orbital ridges to the occipital and laterally to
the ears
Complication:
Spread of hematoma leading to hemorrhage , shock and death, periorbital and auricular
ecchymosis
Infection
Resolution: Very slow resorption
Management:
Observation
Treatment for blood loss, hyperbilirubinemia and infection
Rule out bleeding disorders
and antibiotics if infection occurs

INTRACRANIAL HAEMORRHAGES:
Intracranial hemorrhage (ICH) may be
(a) External to the brain (epidural, subdural or subarachnoid spaces);
(b) in the parenchyma of brain (cerebrum or cerebellum);
(c) into the ventricles from subependymal germinal matrix or choroid plexus.
TYPES:
TRAUMATIC
Extradural hemorrhage:
Usually associated with fracture skull bone.
Subdural :
Slight hemorrhage may occur following:
o fracture of skull bone
o rupture of the inferior sagittal sinus or
o rupture of small veins leaving the cortex.
Massive hemorrhage may occur following
o Tear of the tentorium cerebelli thereby opening up the straight sinus or rupture of the vein of
Galen or its Faix cerebri tributaries
o Injury to the superior sagittal sinus.
Clinical presentation:
Nuchal rigidity
Coma
apnea
bulging fontanelle (increased intracranial pressure) nonreactive pupils
seizures may be present.
Pathophysiology:
Normally, the faix cerebri is attached to the tentorium cerebelli and both help in anchoring the base of
the skull to the vault.
During excessive moulding, there is compression of the diameter of engagement (occipitofrontal In
detlexed head) with elongation of the diameter at right angle to it (mentoivertical).
This results in upward movement of the vault from the base. As a result, too much strain is put on the
vertical fibetri of tentorium cerebellicalled stress fibers.
If the moulding is excessive or applied suddenly, these fibers are torn.
As a result, it allows excessive elongation of the vault until the tear etends to involve the straight sinus
or vein of Galen or its tributaries.
The resulting hemorrhage may be supratentorial or bublentoriid.
Excessive moulding of the head lead to elongation of the mentovertical diamtter tear of the tentorium
cerebelli
Causes:
Excessive moulding in deflexed vertex with gross disproportion

 Rapid compression of the head during delivery of the after-coming head of breech or in
precipitate labour
Forcible forceps traction following wrong application of blades
Clinical features: The hemorrhage may be fatal and the baby is delivered stillborn or with severe
respiratory depression. In lesser affection, the baby recovers from the respiratory depression. Gradually,
the feature of cerebral irritation appears such as, frequent high pitch cry, neck retraction, incoordinate
ocular movements, convulsion, vomiting and bulging of anterior fontanelle.
ANOXIC
Intraventricular Hemorrhage-The pathogenesis of IVH in the term infant is more likely due to trauma
(difficult delivery) or perinatal asphyxia. In the preterm infant IVH is mainly due to
ischemia/reperfusion.
Clinical presentation:
clinically silent, seizures, apnea, irritability, lethargy, vomiting or a full fontanelle.
Diagnosis:
neuroimaging studies: Real time portable cranial ultrasonography is the procedure of choice in
the term newborn.
IVH is diagnosed by head CT or CUS.
MRI is also helpful.
SubarachnoidThis may be due to tear of some tributary veins running from the brain to one of the
sinuses. The symptoms may appear late (one week).
Clinical presentations are:
Seizures
irritability and lethargy with focal neurological signs.
Intracerebral- Small petechial hemorrhage may occur in the brain substance (parenchyma) due to
anoxia. It usually occurs in mature babies following prolonged labor.
Clinical features are vague
loss of weight
flaccid limbs
worried and anxious expression.
Risk factors for GMHAVH:
Extreme prematurity
birth asphyxia
the need for vigorous resuscitation at birth
presence of neonatal seizures
sudden elevation of blood pressure.
PREVENTION:
Comprehensive antenatal and intranatal care is the key to success in the reduction of intracranial
injuriesAntenatal prevention of IVH/GMH:
Tocolysis with indomethacin should be avoided.
In utero transfer of preterm labor to a center with NICU.
Cesarean delivery before active phase of labour in preterm infants.
Antenatal steroids can reduce the risk by three fold.
To prevent or to detect at the earliest, intrauterine fetal asphyxia by intensive fetal monitoring.

 To avoid traumatic vaginal delivery in preference to cesarean section.

Difficult forceps should be avoided.
Administration of vitamin K 1 mg intramuscularly soon after birth in susceptible babies.
Postnatal prevention:
Avoid birth asphyxia
fluctuation of blood pressure
correct acid base abnormalities
Surfactant therapy is found helpful
INVESTIGATIONS:
Ultrasionography is used to detect intraventricular hemorrhage;
Doppler ultrasonography can detect any change in cerebral circulation;
CT scan is useful to detect cortical neuronal injury;
Magnetic resonance imaging( MRI) is used to evaluate any hypoxic ischemic brain injury;
CSF Elevated RBCs, WBCs and protein
MANAGEMENT:
Supportive care: To maintain normal circulatory volume, cerebral perfusion, serum electrolytes
and blood gases.
Packed red blood cells transfusion may be needed where IVH is large.
Thrombocytopenia and coagulation parameters should be corrected, seizures should be treated.
TREATMENT:
Follow-up with serial neuroimaging cranial ultrasound (CUS or CT) to detect any progressive
hydrocephalus.
Anticonvulsant
Phenobarbitone-3-5 mg/kg/day in divided doses at 12 hourly intervals intramuscularly or
orally
Phenytoin 20 mg/kg intravenously as loading dose at the rate of 1 mg/kg/min followed by
maintenance dose of 5 mg/kg/day with cardiac monitoring;
Diazepam 0.1 mg/kg intravenously thrice daily.
Open surgical evacuationSerial CT is indicated before surgical intervention.
The infant should be monitored for any hydrocephalus.
Surgical removal of the clot including the capsule may have to be done to prevent development
of neurological sequelae;
Rarely subdural-peritoneal shunting may be needed.
Neurosurgeon is consulted.
PROGNOSIS:
Depends upon the severity, brain lesion, birth weight and gestational age of the infant
FRACTURES
skull
Bones involved- Frontal, parital, occipital
complications:
Brain contusions

 Disruption of blood vessels

seizures
hypotension & death
dural laceration
Management:
X ray and CT scan for diagnosis
linear fractures with no neurological manifestations- observation
depressed fractures- neurological evaluation
Repeat X- rays at 8-12 weeks to look for growing fractures
Facial mandibular fractures
Features:
Facial asymmetry
Ecchymosis
Oedema
Crepitance
Respiratory distress
Poor feeding
Dislocation of the cartilaginous nasal septum
Complications:
unrecognized and untreated facial fractures- craniofacial malformations, ocular, respiratory &
mastication problems
Management:
protection of airway
plastic surgeon; ENT reference
Cranial CT scan
Treatment of fractures
Nursing considerations:
Maintain proper body alignment
Gentle handling
Careful during dressing
Immobilization
Relief of pain
SPINAL CORD INJURIES
Cause:
Hyperextented head
Vaginal breech delivery
Clinical feature:
Alert yet flaccid
Low APGAR score
Motor function absent distal to the level of injury with loss of deep tenden reflexes
Temperature instability

 Constipation and urinary retension

Sensory level if cord is transected
Management:
Resuscitation and prevention of further injuries
Head to be immobilized
Neurological examinations and cervical spinal Xrays
CT scan, myelogram, MRI if required
Attention to bowel/ bladder function
EYE INJURIES
Ocular injuries
Types:
a. retinal and subconjunctival haemorrhages- vaginal delivery
b. ocular and periorbital injuries- forceps delivery
c. Disruption of descenets membranes of the CorneaScarringAstigmatism & Amblyopia
d. HYphaema, Vittreous haemorrhage
e. local lacerations
f. palpebral oedema
g. orbital fractures with abnormal extra ocular muscle function
h. lacrimal gland / duct damage
Management:
Ophthalmic consultations
PREVENTION OF BIRTH INJURIES IN NEWBORN
A comprehensive antenatal and postnatal care is key to the success in the reduction of birth trauma.
Antenatal Period:
To screen out the at risk babies
To employ liberal use of LSCS
Intranatal period:
Normal delivery:
Continuous foetal monitoring
Attention during episiotomy
The neck should not be unduely stretched
Preterm delivery:
To prevent anoxia
To avoid strong sedative
Liberal episiotomy and use of forceps to minimize intracranial compression
To administer inj. Vit K to minimize or prevent haemorrhage from the traumatized area
Forceps delivery:
Difficult cases- LSCS
Proper application of pressure
Ventouse delivery:
Avoid in preterm
Vaginal breech delivery:

Proper selection of cases

NURSING MANAGEMENT IN BIRTH INJURIES

Nursing Diagnoses
(a) Injury related to birthtrauma
(b) Impaired physical mobility related to brachial plexus injury
(c) Impaired gas exchange related to diaphragmatic paralysis
(d) Acute pain related to injury
Nursing Interventions
Nursing interventions for birth injuries include:
Administering treatment to the new born 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 theinjury.
Promoting parent-newborn bonding.
CONCLUSION:
Since many of the birth injuries do not require treatment , the nurse can help to clear up the
misconceptions and alleviate anxieties by simple explanations.Assisting the parents to cope with the
more serious injuries requires more through explanations and constant support by members of the
health team.

BIBLIOGRAPHY:
1. D.C Dutta. Textbook Of Obstetrics including Perinatology & Contraception. 7th edition. Central
Publication; Culcutta: 2013. Page no 483-487.
2. Meharban Singh . Care of Newborn . 6th edition. Published by Narinder K. Sagar; NewDelhi:
2004. Page no 325,400.
3. Lowdermilk ,Perry, Cashion. Maternity Nursing.8th edition. Mosby Publishers. Page no-775.
4. Wong D.L etal . Essentials Of Paediatric Nursing. 6th edition. Missouri: Mosby;2001
5. Marlow D.R. Redding B. Textbook of Paediatric nursing. 1st edition.Singapore: Harwourt Brace
& company; 1998
6. Judith S.A. Straight As in Pediatric Nursing. 2nd edition.Lippincott Williams and
Wilkins:Philadelphia; 2008
7. Parthasarathy IAP textbook of Paediatrics. 2nd edition. jaypee: NewDelhi; 2002
8. Hatfield N.T. Broadribbs introductory Paediatric nursing. 7th edition. Wolters Kluwer: New
Delhi; 2009.
9. Fraser Cooper. Myles text book for midwives. 14 th edition. Churchill Livinstone

Publishers. .
10. Lynna Y.Littileton. Maternity nursing care. 1st edition. Delmar lerning pubishers. Page no
895.