BIRTH

TRAUMA
IN
NEWBORNS

DR VANESSA LEE WAN MUN

PAEDIATRICIAN HOSPITAL MELAKA 23 OCTOBER 2018
 At the end of this lecture
1. Explain the different causes of birth injuries
– Soft tissue
– Bone
– Nerves
– Visceral
– Intracranial
2. Explain the presentation and management of
the birth injuries
 TYPES OF BIRTH TRAUMA

SOFT TISSUE
1. Cephalohematoma BONE
2. Subaponeurotic 1. Clavicle
VISCERAL
hematoma 2. Long bone
1. Hepatic rupture
3. Caput succedaneum 3. Epiphyseal
2. Splenic rupture
4. Subconjunctival displacement
hemorrhage
5. Laceration/abrasion
6. Subcutaneous fat NERVE
necrosis 1. Brachial plexus
2. Facial nerve INTRACRANIAL
3. Laryngeal nerve 1. Subarachnoid
4. Phrenic 2. Epidural
nerve/diaphragmatic 3. Subdural
paralysis
5. Spinal cord
 Introduction
• Definition : Injuries that occur during birth
process
• Incidence : 2 to 7 per 1000 live births
• Risk factors :
– Fetal factors  LBW, macrosomia,anomalies,
prematurity, abnormal presentation
– Maternal factors  CPD, small stature, pelvic
abnormalities, oligohydramnios,
– Prolonged labour, Instrumental deliveries
SOFT TISSUE INJURY
SCALP SWELLINGS
 SOFT TISSUE INJURY
CEPHALOHEMATOMA
• Bleeding below periosteum
• Confined within margins of
skull suture
• Increased risk with vacuum
metal cup
• Resolution within weeks
• Complications : jaundice,
calcification of hematoma

MANAGEMENT :
Reassurance, monitoring of
COH
 SOFT TISSUE INJURY
CAPUT SUCCEDANEUM
• Subcutaneous fluid
collection
• Extraperiosteal; poorly
defined margins, cross
sutures
• Associated with molding
• Resolves within days

MANAGEMENT : Reassurance;
observation
 SOFT TISSUE INJURY
SUBAPONEUROTIC
HEMATOMA
• bleeding in the potential
space between periosteum
and the scalp galea
aponeurosis
• fluctuant, boggy mass
developing over the scalp
• Crossing suture lines
• Usually 12-72 hours
• HEMORRHAGIC SHOCK!
MANAGEMENT :
vigilant monitoring (hourly)
Blood transfusion
Phototherapy
SUBCONJUNCTIVAL HEMORRHAGE
• Benign condition
• Risk factors: prolonged
labour; excessive force
during delivery; big
baby; cord round neck
• Resolves spontaneously
over 2-4 weeks
SOFT TISSUE INJURY
ABRASION/LACERATION

MANAGEMENT
1. KEEP CLEAN AND DRY
2. WATCH FOR INFECTION
 BONE INJURY
• Unpredictable, unpreventable
CLAVICLE FRACTURE complication
• Incidence : 0.2 – 3.5%
• Risk Factors
– shoulder dystocia
– birth weight
– midforceps delivery /vacuum
*Can occur in NORMAL
DELIVERY; NORMAL NEWBORNS
• Clinical exam
– Crepitus
– Deformity
– Pseudoparalysis
• Heals within 7-10 days; good
prognosis
• Tx : reduce pain immobilization
 NERVE INJURY

1. Brachial plexus
2. Facial nerve
3. Laryngeal nerve
4. Phrenic nerve/diaphragmatic paralysis
5. Spinal cord
 BRACHIAL PLEXUS INJURY
• Incidence 0.5-2 per 1000 Four fold rise with
live births shoulder dystocia
• Large babies, shoulder
dystocia, breech delivery
• Associated with:
– fractured clavicle
– fractured humerus
– subluxation of cervical
spine
– cervical cord injury
– facial nerve palsy
 BRACHIAL PLEXUS INJURY

Erb’s palsy  lack of Klumpke paralysis 

shoulder motion; absent grasp is absent ± Horner’s
moro, biceps and radial Syndrome
reflexes; grasp present; ±
ipsilateral phrenic nerve
 BRACHIAL PLEXUS INJURY
• Prognosis: • Management
– 88% resolved by 4 months – Immobilization then
– 92% resolved by 12 months passive range of
movement
• Long term complications:
– Surgery
– Bony deformities
– Muscle atrophy/weakness
– Joint contractures
– Impaired growth
 CRANIAL NERVE INJURY
• Result from hyperextension, traction, over
stretching with rotation
• Temporary or permanent
• Commonest : facial nerve;
laryngeal nerve
• Most recover within first week
• Full resolution several months
Management : eye protector; methylcellulose eye drops 4
hourly,
Consult neurologist/surgeon ig no improvement by 7-10days
VISCERAL INJURY

1. Hepatic Rupture
2. Splenic Rupture
 VISCERAL INJURY
• Uncommon
• Fulminant or insidious
• Hemorrhage most serious complication
– Leading to hypovolaemic shock
– Suspect in infant with shock, pallor, unexplained
anemia, abd distention
INTRACRANIAL INJURY

1. Subarachnoid
2. Intraparenchymal
3. Subdural
4. Intraventricular
 INTRACRANIAL BLEED
• Pathophysiology varies depending on types
• Risk factors : traumatic birth; hypoxic ischemic
injury (HIE)
• Complications : hypovolaemia, anemia, seizures
• Diagnosis :USG brain  CT scan

MANAGEMENT : Symptomatic treatment,

Treat co-existing pathologies,
Monitoring for hydrocephalus,
Correcting precipitating factors  correct coagulopathy, anemia,
electrolytes, maintain normal BP
 INTRAVENTRICULAR BLEED
• 15-20% in preterm < 32 weeks
• Term  venous/sinus thrombosis & thalamic infarction
• Related to birth trauma/HIE
• Presentation : seizures, apnea, irritability, lethargy,
anemia, full fontanelle
• Diagnosis: Serial USG brain
• Prevention : antenatal steroids, avoid unnecessary
fluid boluses, avoid ↓BP, bolus sedation
MANAGEMENT : Symptomatic treatment, Treat co-existing
pathologies, Monitoring for hydrocephalus, Correcting
precipating factors  correct coagulopathy, anemia, electrolytes,
maintain normal BP
 SENARIO

• You notice a neonate

of 8 hours of life pale,
with enlarging scalp
swelling.

• What do you suspect?

• What do you do?
– Take the vital signs immediately and monitor
– Call the doctor to evaluate
– Question : Is there a reason for the injury?
: Is the injury serious and require
immediate action
: Was it an instrumental delivery?
 SUMMARY
• Birth traumas sometimes cannot be avoided

• However, must anticipate problems by

understanding mechanisms of injury and actively
looking for risk factors

• Understanding mechanism helps counselling

family in the event of trauma

• Nurses are important first line staff in contact

with family
 REFERENCES
• Tricia Lacy Gomella et al Neonatology Management,
Procedures, On Call Problems, Diseases and Drugs 6th Edition
McGraw-Hill (2009)
• Emedicine.medscape.com/article/980112
• Ahn E S et al. Neonatal clavicular fracture: recent 10 year
study. Pediatr. Int. 2015;57(1):60-3.
• Kaplan B et al. Fracture of the clavicle in the newborn
following normal labor and delivery. Int J Gynaecol Obstet.
1998 Oct;63(1):15-20.