Definition:
Birth injuries is defined as the injury that occurs
during the birth of baby due to prolonged labor, mal
presentation and the instrumental delivery such as:
vacuum and forceps delivery.
Forceps
Forceps
Forceps application
Common new born injuries
I. Skull injuries
II. Soft tissue injuries
III. Nerve injuries
IV. Fracture bone
I. Skull injuries:
The injury that occurs in meninges, brain and
great cerebral vein during the labor while
passing through the birth canal is known as
skull injuries.
It may be caused by instrumentation such as
forceps, vacuum and prolonged labor. Result
of skull injuries the child may survive with
impaired physical and mental states.
Etiological factors:
• Instrumental delivery
such as vacuum, forceps
delivery.
• Excessive stretching in
moulding.
• Excessive compression of
fetal head due to
contracted pelvis,
occipito- posterior
position and large baby.
• Rapid compression on
fetal head: Breech
delivery, precipitate labor.
Etiological factors:
• Upward compression as in breech delivery, face
presentation.
• Preterm baby because of lack of protection by their
soft skull bones and wide suture as well as delicacy
of the cerebral vessels and tissue, so they are prone
to intracranial injuries.
a) Caput succedaneum:
• While the head descends to press over the dilating
cervix, the over lying scalp is free from pressure,
but the tissues in contact around the scalp is
compressed.
• This interferes with venous return and lymphatic
drainage in the area of scalp, stagnation of fluid
occurs.
• Caput usually occurs after rupture of the
membrane.
Contin…..
Caput succedaneum
Causes
• Friction between the fetal skull and maternal pelvis
during the delivery.
• Cephalo-pelvic disproportion ( by compression of
bony pelvis)
• Precipitate labor
• Tearing of periosteum
• Prolonged pressure on the head
Clinical manifestation
• Soft, puffy swelling of part of the scalp in a new born,
present at birth.
• Swelling may or may not have some degree of
discoloration or bruishing.
• Cross the suture line
• Diffuse, pits on pressure
• A caput is always unilateral.
• Baby experience some discomfort so gentleness is
needed while caring and handling.
• Tends to decrease in size after delivery.
• Resolve by 24 – 48 hours of life with no longer
consequences.
Diagnosis
• A physical examination will confirm that the
swelling is a caput succedenum.
• No testing is necessary.
Nursing Management
• Provide explanation about the condition in very
simple way.
• Advise the mother to handle the baby very gently
and apply dressing in abrasion if needed.
Complication
• Jaundice – results as the bruise breaks down of Red
blood cells into bilirubin.
Cephalhematoma
• It is caused by the friction between the skull and
pelvis during delivery.
• The swelling with cephalhematoma is not present
at birth rather it develops within the first 24 to 48
hours after birth.
• The swelling is limited by the suture line of the
skull.
• It can cause hyperbilirubinemia when extensive,
the infant need blood transfusion.
Causes
• Cephalopelvic disproportion
• Precipitate labor
• Tearing of the periosteum
• Prolonged pressure on the head
• Friction between fetal skull and maternal pelvis.
Clinical features
• Swelling of the infant’s head 24-48 hours after birth
and enlarge slowly in the few days after birth.
• Discoloration of the swollen site due to presence of
coagulated blood.
• It is circumscribed, soft fluctuant and
incompressible
• Present bilateral
• Fracture of skull
• Swelling may persists for weeks usually 6-8 weeks.
Management
• No treatment is necessary
• The blood is absorbed and the swelling subsides
within 6-8 weeks of infant's life.
• Advise not to compress on affected region.
Caput Succedenum
Cephalohematoma
Condition marked by localized soft tissue
edema with poorly defined
outline
Condition marked by soft, fluctuant,
localized swelling with well-defined
outline
Caused by pressure of the fetal head
against the cervix during labor,
which decreases blood flow to the area
and results in edema
Caused by subperiosteal hemorrhage
Present at birth; does not increase in size
Appears after birth; increases in size for
2–3 days
Swelling crosses suture lines
Swelling does not cross suture lines
Disappears after birth within a few hours
to several days
Disappears from several weeks to even
months after birth
Complications are rare
Complications include defective blood
clotting, underlying skull fracture
or intracranial bleeding, and jaundice
c. Scalp injuries
• Minor injuries of scalp such as
abrasion in forceps delivery
(tip of the blade), incised
wound
inflicted
during
caesarean
section
or
episiotomy may be met with.
• On occasion the incised
wound
may
cause
hemorrhage and requires
stitches.
• The wound should be dressed
with an antiseptic solution
like: 2 % mercurochrome and
antibiotics ointment.
2 % mercurochrome
d. Fracture skull:
• Fracture of the vault of the
skull (frontal or anterior part
of the parietal bone) may be
of linear or depressed type.
• Causes:
• Effects of difficult forceps
delivery in disproportion or
due to wrong application of
the forceps (blades not
placed over the biparietal
diameter.
• Projected sacral promontory
of the flat pelvis may produce
depressed fracture even
though the delivery is
spontaneous.
Skull Fracture
Clinical features:
• The fracture
may be
associated with
cephalhaematoma,
extradural
or
subdural
hemorrhage or a hematoma.
• Fracture sometimes causes pressure symptoms
(swelling).
• Neurological manifestation may occur later on due
to compression effect.
Treatment:
• Treatment is conservative.
• In severe case aspirated or excised surgically
Figure
Tentorium tear
• Tentorium: The cerebellar
tentorium or tentorium
cerebelli is an extension of
the dura mater that
separates the cerebellum
from the occipital lobes.
• Due to excessive molding,
• Vacuum cup there is
compression
of
the
engaging diameter and
elongation of the diameter,
that put too much strain on
the muscles fibers and
tentorium tear occurs.
Clinical features
• Baby is delivered still born
• Respiratory depression
• APGAR is 0-3
• Frequent high pitch cry
• Neck retraction
• In co-ordination ocular movements
• Convulsion
• Vomiting and
• bulging of the anterior fontanel
Treatment and management
• The baby should be nursed in quiet
surroundings.
• Baby should be provided humidified oxygen.
• Maintain cleanliness of the air passage.
• Restrict handling the baby such as bathing,
weighting and measuring should be
withheld.
• Nasogastric tube feeding is advisable.
Treatment and management
• Fluid balance should be maintained.
• Administered vitamin K intramuscularly to prevent
further bleeding due to low thrombin level in
blood.
• Administer prophylactic antibiotics.
• Anticonvulsant is given to prevent convulsion.
Soft tissue injuries
• Bruises and lacerations on the face are caused by
forcep blades. These are treated with application of
antibiotics ointments.
Injury by application of forceps
Muscles:
• Sternocleidomastoid ( SCM) injury : Injury is
characterized by a well – circumscribed immobile
mass in the mid point of the sternocleidomastoid.
The head tilts towards the involved side.
• The patient cannot move the head normally. Head
is twisted to one side (Torticollis).
• This occurs during delivery of the anterior shoulder
in a vertex presentation or while rotating the
shoulder during a breech delivery.
Muscles:
• It usually presents 1 or 2 weeks after birth as
small painless lump of 2 cm on the side of the
neck.
• The swelling will resolve over several weeks.
• Muscles – stretching exercise should be taught
to parents to prevent from shortening of
muscles.
• Infants should sleep on the opposite side to the
injury to increase passive stretching.
Sternocleidomastoid hematoma:
• This appears about -10 days after birth and is
usually situated in the mid- position of the muscle
fibers.
• It is caused by rupture of the muscle fibers and
blood vessels, followed by a hematoma and
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 .
Management
• Management is conservative.
• Stretching of the involved muscles should be
done several times a day.
• Recovery is rapid (3-4 months) in majority of
cases.
• Surgery is needed if it persists after 6 months of
physical therapy.
Necrosis of the sub-cutaneous tissue
• This occur while the superficial skin remains intact.
After a few days, a small hard subcutaneous nodule
appears. It is the result of the fat necrosis due to
pressure, and takes 14-16 weeks to disappear.
Management
• No treatment is required and it has no clinical
importance.
Necrosis of the sub-cutaneous tissue
Nerve injuries:
• 1.Facial palsy
• 2. Brachial palsy
• a. Erb's palsy: Upper brachial palsy
• b. Klumpke's palsy: Lower brachial palsy
Facial palsy ( peripheral)
• The facial (7th) nerve remains unprotected after its
exists through the stylomastoid foraman.
Causes:
• It is caused by direct pressure of the forceps blades
or by the hemorrhage and edema around the
nerves.
• Direct pressure on the ramus of mandible.
Stylomastoid foraman
Fig… of Ramus
Clinical features of facial palsy
• Unilateral facial weakness
• The eyelid of the
affected side remains
open while mouth is
drawn over to the
normal side.
• Paralyzed side is smooth.
• On crying, the mouth is
drawn to the un-injured
side of the face.
• Sucking remains affected.
Facial …..
• Diagnosis: It is made by noting the eye of the affected
side which remains open and fixed.
• Treatment and management:
• Protect the eyes, which remains open during the sleep.
• The condition usually disappear within weeks unless
complicated by intracranial damage.
• Maintain oral hygiene.
• If injury due to instrumental delivery dressing should
be applied on injury area.
• Apply antibiotic if injury is serious.
Brachial palsy
• The
brachial
plexus is a network
(plexus) of spinal
nerves (formed by the
anterior rami of the
lower four cervical
nerves
• (C5
(bending
of
elbow) C6 (helps in
wrist extension) C7
(elbow straighten), C8
( hand finger flexion)
, and T1 ( chest wall,
arm and hand).
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. Tearing of fibers
is rare.
• Causes:
• Undue traction on the neck during the shoulder dystocia.
• Treatment
• Immobilization and prevention of the contractures.
• Physical therapy and passive movements are advocated.
• Full recovery takes weeks or even months.
• X- ray, MRI should be done
a. Erb's palsy( Waiter tips position)
• This is the most common
type when 5th and 6th
nerve root are involved.
• The resulting paralysis
causes the arm to lie on
one side (adducted) with
extension of the elbow,
pronation of the forearm
and flexion of the wrist.
Winging of the scapula is
common.
• Moro reflex is absent.
Erb’s Palsy
Causes
• When the neck is twisted or stretched in delivery of the
baby in after coming head in breech presentation.
• Excessive lateral flexion of the neck when delivering the
shoulder in vertex presentation and forceps delivery.
• Treatment :
• The treatment consists of use of splint so as to hold the
affected arm .
• Passive movement should be advocated.
• If condition is fatal surgical intervention is needed.
b. Klumpke's palsy
• This type of palsy is due to
affection of the lower cord of the
plexus involving 7th and 8th cervical
or even the first thoracic nerve.
Affects in the movements of hand
• Clinical features:
• The arm is flexed at the elbow, the
wrist extended.
• The forearm is supinated and a
claw-like deformity of the hand is
observed.
• When is involved, there may be
homolateral ptosis ( drooping of
upper eye lids) with small pupil
due to sympathetic nerve
involvement( Horner's syndrome).
Treatment of klumpke’s palsy
Treatment:
• Immobilization and prevention of the contractures.
• Physical therapy and passive movements are
advocated.
• Full recovery takes weeks or even months.
• Surgical is recommended in severe cases.
Fractures
• The most commonly affected bones are those of
the skull, clavical, humerus, femur and spine.
a. Clavicle: Fracture can occur if there is shoulder
dystocia or during a birth by the breech. The affected
bone is usually the one, which is nearest the
maternal symphysis pubis. It is possible to feel a
distortion in the bone and crepitus formation during
an examination.
Fracture…
b Humerus: Mid-shaft fractures can occurs during a
birth by breech when extended arm is brought down
and born. Considerable deformity is evident on
examination and the baby will be reluctant to move
the arm owing to the pain.
c. Femur: Mid –shaft fractures can occur during a
birth by the breech when the extended legs are
brought down and born. Considerable deformity is
evident on examination and the baby will be
reluctant to move the leg owing to the pain.
Treatment
• In clinical fracture, a pad of cotton or wool is placed
in the axilla and the upper arm is lightly bandaged
to the side of the chest.
• In fracture femur, the whole length of the affected
limbs may be bandaged cast.
• Healing usually occurs in about 3 weeks.
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