Birth InjuriesExcluding Scalp and
Intracranial Injuries
Adapted from a presentation by
Vandana Nayal
Skull fractures
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Bones of the skull are less mineralized at
birth and thus more compressible.
Follow repeated forceful contact of the fetal
skull against the maternal pelvis
Linear fractures of the skull are
accompanied by soft tissue changes and
cephalhematoma
Depressed fractures are visible palpable
indentations in the smooth contour of the
skull( ping-pong) ball
Prognosis
Simple fractures heal without sequelae
 Leptomeningeal cyst may develop, if
detected early, cyst can be excised
successfully and brain atrophy
prevented
 Repeat radiographs within 2-3 months
to detect early widening of the fracture
line
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Facial nerve palsy
Prolonged 2nd stage and midforceps
delivery
 Central paralysis- limited to lower 1/2
or 2/3 of the contralateral side
 Peripheral-entire side of the face
 Persistently open eye on the affected
side
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Vocal cord paralysis
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Uncommon injury, unilateral- symptom free
or hoarseness with mild inspiratory stridor or
bilateral-stridor, left more common than right
Unilateral- gentle handling and frequent
small feedings, usually resolves within 6
wks
Bilateral is caused by hypoxia or
hemorrhage into the brain stem
Bilateral-immediate intubation,
tracheostomy required in most patients.
Fracture of the clavicle
Complete and some greenstick
fractures may be apparent shortly after
birth. Obvious callus at 7-10 days of
age
 Movement of the arm may be affected
 Pain subsides in 7-10 days
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Brachial palsy
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Erb-Duchenne- C5+ C6 –upper arm
paralysis,Moro, biceps and radial reflexes
are absent, grasp reflex is intact, ipsilateral
phrenic nerve injury with respiratory distress
Klumpke-lower arm paralysis-C8+T1-rareintrinsic muscles of the hand and the long
flexors of the wrist and fingers affected,
grasp reflex is absent and tendon reflexes
are present, ipsilateral Horner, delayed
pigmentation of the iris- sensory deficit-ulnar
Paralysis of the entire arm- all reflexes
absent,flaccid, sensory deficit up to shoulder
Eval and Therapy
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Thorough physical-palpate sternomastoid,
fractures of clavicle, humerus or ribs
Abdominal asymmetry- indicate paralysis of
hemidiaphragm, ocular asymmetry- Horner
syndrome
CT, MRI or myelography for avulsions
Electromyography is unreliable in predicting
extent of damage
Exercises involving shoulder rotation,elbow
flexion and extension, wrist flexion, thumb
abduction,adduction and opposition
Treatment
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Infant evaluated every month and if no
improvement in deltoid, biceps and triceps
function occurs by 3rd month, good outcome
without surgery is not likely
Primary brachial plexus exploration during
the fourth month
Exploration,evaluation and repair of the
injury has resulted in 90% of patients having
useful function above the elbow
Function below the elbow has resulted in
50% to 70% recovery
Phrenic nerve paralysis
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Difficult breech delivery
Recurrent episodes of cyanosis, irregular
and labored respirations
Breathing is almost completely thoracic, no
bulging of the abdomen, excursions on the
involved side are ineffectual
Areas of atelectasis appear bilaterally
US shows abnormal motion of the
diaphragm
Fluoroscopy only for the equivocal case
Treatment
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O2 for cyanosis or hypoxemia, IV fluids,
gavage feedings, antibiotics are indicated if
pneumonia occurs
If bilateral, assisted ventilation shortly after
delivery
Infants who did not recover diaphragmatic
function within 30 days did not demonstrate
recovery-disruption of the phrenic nerve
Candidates for plication of the diaphragm
early in the 2nd month of life
Injuries to spine and spinal cord
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Result from breech deliveries, brow and
face presentations
High cervical-Stillborn, respiratory
depression, shock, hypothermia
Upper or mid-cervical region-flaccidity and
immobility of the lower limbs, cardiac
function is strong, urinary retention may be
the first symptom, paralysis of the
abdominal wall, intercostal muscles may be
affected , sensation is absent over the lower
half of the body, absent DTR, constipation,
brachial plexus involved in 20%
Spinal cord injuries
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3rd group-C7-T1- survive for long periods,
transient paraplegia, skin is dry and scaly,
muscle atrophy, contractures and bony
deformities, bladder distention and constant
dribbling followed by paraplegia in flexion,
spontaneous micturition, mass reflex and
profuse sweating over the involved part of
the body
4th group- partial spinal cord injury and CVA.
subtle neurologic signs of spasticitycerebral palsy
Treatment
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Infants affected at birth require basic
resuscitative measures
In case of vertebral fracture-immediate
neurosurgical consultation for reduction and
relief of cord compression, followed by
appropriate immobilization
Position of paralyzed parts should be
changed every 2 hrs, indwelling urinary
catheter should be inserted
Urology consult
Injuries to intra-abdominal organs
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Rupture of the liver- large infants,
IDM,breech
May appear normal from 1-3 days of life,
any infant with shock, abdominal distension,
pallor, anemia, and irritability with no
evidence of blood loss
Crit and hgb stable initially, then sudden
circulatory collapse, with rupture of the
hematoma through the capsule
Abdomen is rigid, bluish discoloration of the
overlying skin. CT scan may help in
diagnosing subcapsular hematoma
Treatment
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Prompt transfusion of prbcs and correction
of coagulation disorder
Laparotomy with evacuation of the
hematoma and repair of any lacerations
Any fragmented, devitalized liver tissue
should be removed
Blood transfusion and the tamponade of
intra-abdominal pressure might be adequate
therapy in some infants
Rupture of the spleen
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Large infants in breech position,
erythroblastosis, congenital syphilis
Underlying clotting defect
Clinical signs of hemoperitoneum and blood
loss
Left upper quadrant mass and medial
displacement of the gastric bubble
Packed rbc’s and exploratory laparotomy
Attempt to repair and preserve the spleen
Adrenal hemorrhage
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Increased size and vascularity at birth
Macrosomic, IDM, cong syphilis,
neuroblastoma, hemorrhagic disease
Fever, tachypnea, cyanosis, mass in flank
and purpura
Adrenal insufficiency, poor feeding,
vomiting, uremia, convulsions and shock
US- initially solid appearance then cystic
Blood , IVF and corticosteroids
Laparotomy, evacuation of clots if extends
to peritoneal cavity