STATE ESTABLISHMENT «DNEPROPETROVSK MEDICAL
ACADEMY OF MINISTRY OF HEALTH UKRAINE »
“Сonfirmed;”
at methodical meeting
of hospital pediatrics №1 department
Сhief of department
professor _____________V. A. Kondratyev
“______” _________________ 2013 y.
METHODICAL INSTRUCTIONS
FOR STUDENTS` SELF-WORK
WHILE PREPARING FOR PRACTICAL LESSONS
Educational discipline
module №
Substantial module №
Theme of the lesson
pediatrics
2
8
Course
Faculty
5
medical
Birth trauma
Dnepropetrovsk, 2013
Neonatal birth trauma
1. Actuality of the topic:
Injuries of organs and tissues which occur during the birth can cause further function
disorders of corresponding organs and systems. The most essential is the injury of Central
Nervous System. Early diagnostic and treatment as well as adequate rehabilitation
considerably enhance the prognosis.
2. Specific aims:
А. A student should know:
1. Definition of term “birth injury.”
2. Causes of birth traumas.
3. Classification of birth injuries.
4. Clinical signs of birth injuries of different localization:
А. Fracture of clavicle.
B. Trauma of muscle sternocleidomastoideus.
C. Cephalohematoma.
D. Intracranial birth injury.
E. Trauma of spine.
5. Additional diagnosing methods in patients with birth traumas.
6. Main complications which occur during birth traumas.
7. Phases of course in patients with birth CNS injury.
8. Principles of treatment of new-born after birth trauma depending on location.
9. Principles of rehabilitation after birth injuries.
В. A student should be able:
1. To determine clinical signs of birth injury.
2. To detect and analyze anamnesis factors which could have promoted birth injury during
the birth.
3. To carry out differential diagnosing between traumatic and other injuries of organs and
systems.
4. To formulate diagnosis of birth trauma.
6. To draw up a plan of the new-born baby with birth trauma.
7. To draw up a plan of treatment for infants with birth injury:
А. Fracture of clavicle.
Б. Injury of muscle sternocleidomastoideus.
C. Cerebral hemorrhage.
D. Spine injury.
8. To determine signs of complications for the child with birth trauma.
9. To draw up a plan of rehabilitation for children with birth injury.
3. Tasks for self work while preparing for the lesson.
3.1. List of main terms, parameters, characteristics a student has to master while
preparing for the lesson:
Term
Definition
Birth trauma of infants
Injury of organs and tissues of a fetus which happens during the birth.
The most severe injuries are those with cerebral hemorrhage and they
require special treatment
2
Birth tumor
Cephalohematoma
Interbrain traumatic
hematoma
Hemorrhage
Paralysis of diaphragm
nerve (СЗ, 4 or 5)
Fracture of clavicle
Paralysis of Erb
Intraventricular
hemorrhage
Subdural hemorrhage
Subarachnoid
hemorrhage
Adiponecrosis
Neurosonography
Computer tomography
Gathering of serous-blood fluid subcutaneously, outside periosteum,
with badly delineated edges; it can spread through linea media and
through stitch lines and is usually related to compression of fetus
head during the birth
Periosteum hemorrhage in infant’s skull area
Gathering of blood in brain matter which appears due to traumatic
hemorrhage and can cause brain compression. Being in the white
matter of brain it can create a cavity
Gathering of blood in tissues or body cavities due to increase of
penetrability or disorders in blood vessel integrity
It is a result of overstraining of lateral cervical muscles. It is
practically always one-sided and it is often connected with injuries of
plexus brachialis
Most often it is neonatal orthopedic injury. An infant has
pseudoparalysis on the injured side, crepitation, bone displacement,
spasm of muscle sternocleidomastoideus. Bone breaks (not
complete) can be without signs
Injury of the fifth and sixth cervical spinal nerves. The injured arm
is brought into motion and makes a rotation with straightened
elbow, forearm remains in prone position, wrist is arcuated.
Morpho, biceps, radiocarpal reflexes on the injured side are absent.
Grasp reflex is normal
It happens more often with pre-term children as a result of hypoxic
influences and small gestation age. Acute adynamy, tonic cramps
are typical, tremor of high magnitude, hypertension syndrome,
strabismus, vertical nystagmus, thermoregulation disorders,
abnormal breath rhythm and cardiac activity are present, congenital
and tendinous reflexes, sucking, swallowing are suppressed
Birth injury which happens most often during prolonged or fast birth
and causes displacement of brain ventriclesи, liquor ways, increase
of intracranial pressure. One of main death causes of infants is
compression of vital centers in medulla
Birth injury which occurs in children during prolonged birth,
especially in case of obstetrician interventions; most often in preterm babies and it is accompanied by anxiety, clonic-tonic cramps,
manifested vegetative-visceraldisorders, increase of muscular tone
and tendious reflexes, bulging of fontanel, Gref-s symptome,
strabismus, horizontal nystagmus; typical changes in spinal liquid:
xanthochromia, blood presence, cytosis up to 1,000 and more,
lymphoid cells, strongly positive Pandy’s reaction, general protein
0.3 – 1.3 g/l
Focal necrosis of subcutaneous fat, well-defined solid nodes 1-5 cm
in diameter in subcutaneous layer of buttocks, back, shoulders,
extremities. It develops at the age of 1-2 weeks old
Ultrasound brain study of an infant with a sensor in fontanel major
An X-ray method (unlike plain X-ray), which provides us with the
opportunity to get the screen of a specific cross-section of a human
body. The body can be studied by layers with the step of 1 mm
3
Magnetic-resonant
tomography.
This method with the use of electric-magnetic waves gives us a
chance to visualize brain, spinal cord and other internal organs with
high quality
3.2. Theoretical topics for the lesson:
Definition of term ”birth injury " (BI).
Frequency of BI among other infant’s diseases.
Causes of BI development.
Conditions impacting BI appearance.
Localization of BI.
Pathogenesis of different BI forms.
Clinical symptoms typical for BI of different location: muscle BI, bone BI, brain BI,
spine BI , BI of peripheral nervous system.
8. Value of additional methods while diagnosing BI.
9. Classification of birth injuries in nervous system.
10. Complications of BI .
11. Principles of therapy and rehabilitation of children with BI.
12. Prophylaxis of BI and their complications.
13. Outcomes of BI.
1.
2.
3.
4.
5.
6.
7.
3.3. Practical skills (tasks) mastering during practical lesson:
1. To collect complaints, case history and personal (life) history
2. To inspect the child consistently
3. To reveal early symptoms of the birth trauma
5. To evaluate the condition of the child and available clinical symptoms.
6. To evaluate the results of the additional methods of investigation
7. To make the clinical diagnosis according to classification.
8. To make the treatment plan.
9. To make recommendations of dispensary supervision.
4. Maintenance of the subject:
Definition of the term "birth trauma" (BT).
The birth trauma is a damage of the baby owing to the action of mechanical forces
(such as compression or traction) at the time of delivery. Damages can occur at the antenatal
period, during resucsitation, or delivery.
Prevalence of birth trauma.
Modern obstetrics technique considerably reduced mortality from birth trauma which
now occurs with the prevalence of 3,7 per 100000 live-born. Mortality depends upon the type
of birth trauma. Cephalohematoma is the most common BT. More serious traumas are seen
from 2 to 7 on 1000 live-born.
Causes of BT.
Process of the birth is set of such phenomena, as a squeezing, compression, contraction
and pulling. When it is associated with abnormal fetal size, position, and/or delay in the
development of nervous system, labor activity can lead to the tissue damage, edema,
hemorrhages or fractures at the newborn. The usage of obstetric instruments can enhance the
action of these forces, or cause damage independently. Appropriate use of obstetric
instruments can reduce asphyxia occurance. Though foot position leads to the greatest risk
4
and damage, extraction by Cesarean section doesn't guarantee that the baby won't be
damaged.
Features that predispose to the birth trauma
First labor
Small mother`s height
Pelvic anomalies at mother
Overdue or prompt childbirth
Long standing of prelying part of the fetus in one plane
Lack of waters
Wrong fetal position (for example, sciatic)
Use of forceps or vacuum extractor
Turn and fetal extraction
The infant with very low weight at the birth or deep prematurity
Fetus with the big head
Anomalies of fetal development
BT localization.
Classification of BT according to the classification: BT of soft tissues (muscles,
subcutaneous fatty cellulose, cephalohematoma), cerebral BT (injury of the skull bones,
intracranial hemorrhage: subdural, subarachnoid, intracerebral (parenchymatous),
intraventricular), BT of bones (fractures of the clavicle, tubular bones - humeral, femoral),
BT of the spinal cord, BT of peripheral nervous system (damage of the posterior nerve roots,
peripheral nerves).
Patogenesis of different forms of BT.
Causes of soft tissue damage: actual damage throughout the birth process, a squeezing
at the time of delivery, owing to fetal monitoring (plasing of electrodes on hairy part of the
head), a squeezing of the fetal head at the time of delivery, use of obstetric tools.
Damage of sterno-cleudo-mastoideus muscle (SCM). It is considered that SCMdamages to childbirth can be the cause of the congenital muscular torticollis.
Injury of skull bones. Compressional fractures are usually caused by the use of forceps
at the time of delivery. Fractures of the occipital bone are often caused by the difficult labour
at sciatic presentation and have poor prognosis. Forces which lead to the skull fractures, can
also cause closed injuries of the brain or ruptures of blood vessels that leads to subcutaneous
or intracranial bleedings. Fractures can be located below the level of cephalohematoma and
can lead to the attacks of hypotension or death.
Damage of the spinal cord is possible if the fetus has a big head. Children who have
sciatic presentation, are also belong to the risk group if have vaginal labor. The low
estimation by Apgar scale can display damage of the brain stem and/or a spinal cord.
Epidural hemorrhage is the most frequent injury of the brain which results in brain edema
and temporary denervation.
Paralysis of the diaphragmal nerve (C3, 4 or 5) can be result of overstretching of lateral
neck muscles. It is usually unilateral and often caused by the damage of the humeral plexus
(75% of patients).
Damage of the humeral plexus can be at traction of the head, neck, hands or trunk.
Hypotonic infants are especially sensitive to an excessive divergence of the segments of
bones and to the excessive extension.
Injury of bones. Changes are most often observed at sciatic presentation or the
transverse fetal position at infants with macrosomia, but can sometimes be observed after
Cesarean section. Usually it is caused by the traction and rotation of extremities.
Clinical symptoms
For the confirmation of the birth trauma careful medical examination of the infant
should be carried out with the consultation of neurologist. It is necessary to evaluate
5
symmetry of the structure and function, integrity and amplitude of movements of the joints
and to perform research of craniocerebral nerves.
Birth trauma of soft tissues.
Cephalohematoma ICD X code – X: Р 12.0
Cephalohematoma is a subperiosteal hemorrhage, hence always limited to the surface
of one cranial bone. No discoloration of the overlying scalp occurs, and swelling is not
usually visible until several hours after birth because subperiosteal bleeding is a slow
process. An underlying skull fracture, usually linear and not depressed, is occasionally
associated with cephalohematoma. Most cephalohematomas are resorbed within 2 wk–3 mo,
depending on their size. They may begin to calcify by the end of the 2nd wk.
Сephalohematomas require no treatment, although phototherapy may be necessary to
ameliorate hyperbilirubinemia. Incision plus drainage is contraindicated because of the risk
of introducing infection in a benign condition. A massive cephalohematoma may rarely result
in blood loss severe enough to require transfusion.
The subaponeurotic hematoma is located in the space between a skull periosteum
and the tendinous helmet with distribution from eyebrow arches and to the occipital region.
This hematoma can extend through the skullcap Its growth can be not visible for hours or
days, or be manifested as hemorrhagic shock and, even, death. The hairy part of head skin
can have excavations like edema; round eyes and auricles there can be bruises.
Caput succedaneum is a diffuse, sometimes ecchymotic, edematous swelling of the
soft tissues of the scalp involving the portion presenting during vertex delivery. It may
extend across the midline and across suture lines. The edema disappears within the first few
days of life. Analogous swelling, discoloration, and distortion of the face are seen in face
presentations. No specific treatment is needed, but if extensive ecchymoses are present,
hyperbilirubinemia may develop. Molding of the head and overriding of the parietal bones
are frequently associated with caput succedaneum and become more evident after the caput
has receded, but they disappear during the first weeks of life.
Adiponekroz (focal necrosis of subcutaneous fatty cellulose) – well located dense
knots, infiltrates of 1-5 cm in size in subcutaneous fatty cellulose of buttocks, backs,
shoulders, extremities. Occurs on 1-2 week of life. Skin over infiltrate or isn't changed, or
cyanotic, violet-red or red color. The general condition of the child is satisfactory,
temperature is normal.
Etiology of the disorder: local trauma, штекфnatal hypoxia, cooling. Prognosis
favorable. Infiltrates disappear independently without treatment in some weeks, sometimes3-5 months. Treatment usually should not be administered, sometimes thermal procedures
are prescribed (Sollyux, dry bandages with cotton wool), at widespread process vitamin E
can be administered.
Damage of the sterno-cleido-mastoideus muscle (SCM)
MKB code – X: Р 15.2
SCM can be affected during delivery. Induration of SCM can be palpated at the birth or
(most often) can develop after the first 2-3 weeks of life.
Erythema, abrasions, ecchymoses, and subcutaneous fat necrosis of facial or scalp
soft tissues may be noted after forceps or vacuum-assisted deliveries. Their location depends
on the area of application of the forceps. Ecchymoses may be seen after manipulative
deliveries and occasionally in premature infants for no discernible reason.
Birth trauma of bones.
Fracture of a clavicle. MKB-H code: Р 13.4
This bone is fractured during labor and delivery more frequently than any other bone;
it is particularly vulnerable with difficult delivery of the shoulder in vertex presentations and
the extended arms in breech deliveries. The infant characteristically does not move the arm
6
freely on the affected side; crepitus and bony irregularity may be palpated, and discoloration
is occasionally visible over the fracture site. The Moro reflex is absent on the affected side,
and spasm of the sternocleidomastoid muscle with obliteration of the supraclavicular
depression at the site of the fracture can be noted. Infants with greenstick fractures may not
have any limitation of movement, and the Moro reflex may be present. Fracture of the
humerus or brachial palsy may also be responsible for limitation of movement of an arm and
absence of a Moro reflex on the affected side. The prognosis is excellent. Treatment, if any,
consists of immobilization of the arm and shoulder on the affected side. A remarkable degree
of palpable callus develops at the site within a week and may be the initial evidence of the
fracture.
BT of nervous system.
Classification
A. BT of the central nervous system:
• Intracranial hemorrhage.
• Injury of bones of the skull.
• Damage of the spinal cord.
B. BT of peripheral nervous system:
Damage of cervical nerve roots
• a. Paralysis of a diaphragmal nerve (C3, 4 or 5)
• b. Damage of the brachial plexus
(a) Injury of the fifth and sixth cervical spinal nerves (Erb paralysis).
(b) Damage of the seventh and the eighth cervical and the first thoracis spinal nerves
(Klyumpke paralysis).
(c) Total brachial plexus injury.
Injury of the cranial nerves (unilateral damages of branches of facial (VII) and vagal
(X) nerve)
• a. Injury of a facial nerve.
(a) Injury of the central nerve
(b) Injury of a peripheral nerve
(c) Damage of the branch of a peripheral nerve
• b. Injury of the laryngeal nerve
Cerebral birth traumas.
According to the classification intracranial hemorrhages are divided into subdural,
epidural, subependimal and multiple small cerebral, subarachnoidal, intra-and
periventricular. Causes of hemorrhages: mechanical actions, hypoxia (small diapedese
hemorrhages are characteristic: subarachnoidal and subependimal intraventricular).
Subdural of hemorrhage. MKB code – X: Р 10.0 More often observes at long or
prompt childbirth. The subdural hematoma and edema of nearby tissues causes ventricular
dislocation, increase of intracranial pressure.
Clinical picture. Vascular shock (white asphyxia), hypertensive-hydrocephalic
syndrome, seizures, a tremor of big amplitude, asymmetry of congenital and tendon reflexes,
strengthening of the muscular tone. Subdural hemorrhages are one of the frequent causes of
neonatal mortality owing to the squeezing of the vital centers in the medulla oblongata
(respiratory and cardiomotor) and subcortical region.
Subarachnoidal of hemorrhage. MKB code – X: Р 10.3 occur at children at
prolonged labor, especially at obstetric interventions; more often at prematurely born (65 %).
Hemorrhages are, as a rule, multiple as a result of the rupture of small meningeal vessels in
parietal and temporal area and in the cerebellum.
7
Clinical picture. Excitement, clonik-tonic seizures, severe vegetative-visceral diorders
(dyspnea, tachycardia, disordered sleep, eructation), increase of the muscular tone and tendon
reflexes, bulging fontanel, Grefe symptome, squint, horizontal nistagmus.
Very characteristic abnormalities of the liquor: xantochromia, presence of blood, 1000
and more lymphocytic cells, positive Pandi's reaction, the general protein 0,3-1,3 g/l.
Intracerebral (parenchymal) hemorrhages.
MKB code – X: Р 10.9. Occurs more often at prematurely born children as a result of a
rupture of the Galen's sinus and vein resulting in blood collection in the posterior cerebral
fossa (at the rupture of sinus) or between cerebral hemispheres and on the basis (at the
rupture of the Galen`s vein of) leading to the squeezing of the brain stem.
Clinical manifestations. Adinamia, muscular hypotonia changing to the hypertension,
asymmetry of the tone, reflexes; anizokoria, squint, ptosis, horizontal, vertical and rotator
nistgmus; disorders of the sucking, swallowing, vegetovascular dystonia.
Prognosis. Often unfavourable. The death can occur suddenly as a result of the
squeezing of the brain stem.
Intraventricular hemorrhages more often occurs at prematurely born children as a
result of the breech delivery. Children are in shock (white asphyxia). Characteristic signs are
acute adinamia, tonic seizures, tremor of big amplitude, hypertension-hydrocephalic
syndrome, squint, vertical, rotator nistagmus, disorders of thermal control, rhythm of
breathing and heart activity, suppression of congenital and tendon reflexes, sucking and
swallowing.
Fractures of the skull may occur as a result of pressure from forceps or from the
maternal symphysis pubis, sacral promontory, or ischial spines. Linear fractures, the most
common, cause no symptoms and require no treatment. Depressed fractures are generally a
complication of forceps delivery or fetal compression. Affected infants may be asymptomatic
unless they have associated intracranial injury. Fracture of the occipital bone with separation
of the basal and squamous portions almost invariably causes fatal hemorrhage because of
disruption of the underlying vascular sinuses. Such fractures may result during breech
deliveries from traction on the hyperextended spine of the infant with the head fixed in the
maternal pelvis.
BT of the spinal cord.
Injury to the spine/spinal cord is rare but can be devastating. Strong traction exerted
when the spine is hyperextended or when the direction of pull is lateral, or forceful
longitudinal traction on the trunk while the head is still firmly engaged in the pelvis,
especially when combined with flexion and torsion of the vertical axis, may produce fracture
and separation of the vertebrae. Such injuries, rarely diagnosed clinically, are most likely to
occur when difficulty is encountered in delivering the shoulders in cephalic presentations and
the head in breech presentations. The injury occurs most commonly at the level of the 4th
cervical vertebra with cephalic presentations and the lower cervical–upper thoracic vertebrae
with breech presentations. Transection of the cord may occur with or without vertebral
fractures; hemorrhage and edema may produce neurologic signs that are indistinguishable
from those of transection except that they may not be permanent. Areflexia, loss of sensation,
and complete paralysis of voluntary motion occur below the level of injury. If the injury is
severe, the infant, who from birth may be in poor condition because of respiratory
depression, shock, or hypothermia, may deteriorate rapidly to death within several hours
before any neurologic signs are obvious. Alternatively, the course may be protracted, with
symptoms and signs appearing at birth or later in the 1st wk; immobility, flaccidity, and
associated brachial plexus injuries may not be recognized for several days. Constipation may
8
also be present. Some infants survive for prolonged periods, their initial flaccidity,
immobility, and areflexia being replaced after several weeks or months by rigid flexion of the
extremities, increased muscle tone, and spasms.
The differential diagnosis includes amyotonia congenita and myelodysplasia
associated with spina bifida occulta. Ultrasonography or MRI confirms the diagnosis.
Paralysis of a diafragmalny nerve (SZ, 4 or 5) MKH Code – X: Р 14.2
Phrenic nerve injury (3rd, 4th, 5th cervical nerves) with diaphragmatic paralysis must
be considered when cyanosis and irregular and labored respirations develop. Such injuries,
usually unilateral, are associated with ipsilateral upper brachial palsy. Because breathing is
thoracic in type, the abdomen does not bulge with inspiration. Breath sounds are diminished
on the affected side. The thrust of the diaphragm, which may often be felt just under the
costal margin on the normal side, is absent on the affected side. The diagnosis is established
by ultrasonography or fluoroscopic examination, which reveals elevation of the diaphragm
on the paralyzed side and seesaw movements of the two sides of the diaphragm during
respiration.
Paralysis of Erba. MKB code - X: Р 14.0
Paralysis to Klyumpka. MKB CODE - X: Р 14.1
Total brachial plexus injury. MKB-H code: Р 14.3
Brachial plexus injury is a common problem, with an incidence of 0.6–4.6 per 1,000
live births. Injury to the brachial plexus may cause paralysis of the upper part of the arm with
or without paralysis of the forearm or hand or, more commonly, paralysis of the entire arm.
These injuries occur in macrosomic infants and when lateral traction is exerted on the head
and neck during delivery of the shoulder in a vertex presentation, when the arms are extended
over the head in a breech presentation, or when excessive traction is placed on the shoulders.
Approximately 45% are associated with shoulder dystocia. In Erb-Duchenne paralysis, the
injury is limited to the 5th and 6th cervical nerves. The infant loses the power to abduct the
arm from the shoulder, rotate the arm externally, and supinate the forearm. The characteristic
position consists of adduction and internal rotation of the arm with pronation of the forearm.
Power to extend the forearm is retained, but the biceps reflex is absent; the Moro reflex is
absent on the affected side. The outer aspect of the arm may have some sensory impairment.
When the injury includes the phrenic nerve, alteration in diaphragmatic excursion may be
observed fluoroscopically. Klumpke paralysis is a rarer form of brachial palsy; injury to the
7th and 8th cervical nerves and the 1st thoracic nerve produces a paralyzed hand and
ipsilateral ptosis and miosis (Horner syndrome) if the sympathetic fibers of the 1st thoracic
root are also injured. MRI demonstrates nerve root rupture or avulsion.
Additional investigations at BT diagnostics.
There are used X-ray investigation, neurosonography, computer tomography (CT),
magnetic resonance tomography. These methods allow not only to diagnose damage, its
localization, distribution, but also to carry out differential diagnostics.
The occipital hematoma can imitate brain hernia, ultrasonic investigation of the skull
should be carried out.
Radiological researches are used for the diagnostics of skull injuries. Cranial KT will
indicate the presence of intra cranialhemorrhage or edema. Myelography should be
preformed if there is suspition on damage of the spinal cord.
Birth trauma prognosis and treatment
No specific treatment for Caput succedaneum is needed, but if extensive ecchymoses
are present, hyperbilirubinemia may develop. Molding of the head and overriding of the
9
parietal bones are frequently associated with caput succedaneum and become more evident
after the caput has receded, but they disappear during the first weeks of life.
Subconjunctival and retinal hemorrhages are temporary and the result of normal
events of delivery.
Most cephalohematomas are resorbed within 2 wk–3 mo, depending on their size.
They may begin to calcify by the end of the 2nd wk. Сephalohematomas require no
treatment, although phototherapy may be necessary to ameliorate hyperbilirubinemia.
Incision plus drainage is contraindicated because of the risk of introducing infection in a
benign condition. A massive cephalohematoma may rarely result in blood loss severe enough
to require transfusion.
Patients with massive hemorrhage caused by tears of the tentorium or falx cerebri
rapidly deteriorate and may die after birth. In utero hemorrhage associated with maternal
idiopathic or, more often, fetal alloimmune thrombocytopenia may occur as severe cerebral
hemorrhage or a porencephalic cyst after resolution of a fetal cortical hemorrhage.
Ten to 15% of LBW neonates with intraventricular hemorrhage have hydrocephalus,
which may initially be present without clinical signs such as an enlarging head
circumference, apnea, bradycardia, lethargy, a bulging fontanel, or widely split sutures. In
infants in whom symptomatic hydrocephalus develops, clinical signs may be delayed 2–4 wk
despite progressive ventricular distention and compression (thinning) of the cerebral cortex.
Posthemorrhagic hydrocephalus is arrested or regresses in 65% of affected infants.
Progressive hydrocephalus requiring ventricular-peritoneal shunting,
intraparenchymal hemorrhage, and extensive PVL are associated with a poor prognosis. IVH
with intraparenchymal echodensities larger than 1 cm are associated with high mortality and
a high incidence of motor and cognitive deficits. Grade I–II IVH may be due to factors other
than severe hypoxia-ischemia and has a lower risk of long-term neurologic sequelae if it is
not associated with PVL or intraparenchymal hemorrhage.
Although no treatment is available for IVH, it may be associated with other
complications that require therapy. Seizures are aggressively treated with anticonvulsant
drugs, anemia-shock requires transfusion with packed red blood cells or fresh frozen plasma,
and acidosis is treated by the judicious and slow administration of sodium bicarbonate.
Neurosurgical placement of an external ventriculostomy catheter may be needed in the early
stage of uncontrolled, symptomatic posthemorrhagic hydrocephalus. When a VLBW infant is
large enough, a permanent ventricular-peritoneal shunt is placed.
Symptomatic subdural hemorrhage in large term infants should be treated by
removing the subdural fluid collection with a spinal needle placed through the lateral margin
of the anterior fontanel.
Full recovery of brachial plexus injury occurs in most patients, the prognosis
depending on whether the nerve was merely injured or was lacerated. If the paralysis was due
to edema and hemorrhage about the nerve fibers, function should return within a few months;
if due to laceration, permanent damage may result. In general, paralysis of the upper part of
the arm has a better prognosis than paralysis of the lower part does.
Treatment consists of partial immobilization and appropriate positioning to prevent
the development of contractures. In upper arm paralysis, the arm should be abducted 90
degrees with external rotation at the shoulder, full supination of the forearm, and slight
extension at the wrist with the palm turned toward the face. This position may be achieved
with a brace or splint during the first 1–2 wk. Immobilization should be intermittent through
the day while the infant is asleep and between feedings. In lower arm or hand paralysis, the
wrist should be splinted in a neutral position and padding placed in the fist. When the entire
arm is paralyzed, the same treatment principles should be followed. Gentle massage and
range-of-motion exercises may be started by 7–10 days of age. Infants should be closely
monitored with active and passive corrective exercises. If the paralysis persists without
10
improvement for 3–6 mo, neuroplasty, neurolysis, end-to-end anastomosis, and nerve
grafting offer hope for partial recovery.
No specific treatment of phrenic nerve paralysis is available; infants should be placed
on the involved side and given oxygen if necessary. Initially, intravenous feedings may be
needed; later, progressive gavage or oral feeding may be started, depending on the infant's
condition.
The prognosis of facial nerve palsy depends on whether the nerve was injured by
pressure or whether the nerve fibers were torn. Improvement occurs within a few weeks in
the former instance.
The prognosis of clavicular fracture is excellent. Treatment, if any, consists of
immobilization of the arm and shoulder on the affected side. A remarkable degree of
palpable callus develops at the site within a week and may be the initial evidence of the
fracture.
Satisfactory results of treatment of a fractured humerus are obtained with 2–4 wk of
immobilization during which the arm is strapped to the chest, a triangular splint and a
Velpeau bandage are applied, or a cast is applied. For fracture of the femur, good results are
achieved with traction-suspension of both lower extremities, even if the fracture is unilateral;
the legs, immobilized in a spica cast, are attached to an overhead frame. Splints are effective
for treatment of fractures of the forearm or leg. Healing is usually accompanied by excess
callus formation. The prognosis is excellent for fractures of the extremities.
Prevention of BT and its complications.
Appropriate use of obstetric tools.
Planned Cesarean section at the wrong fetal presentation, multiple pregnancy, clinically or
anatomic narrow pelvis.
Prevention of complications: timely identification and if it is necessary, treatment of bith
traumas.
Additional materials for the self-control
A. Control questions:
1. What is the birth trauma (BT)?
2. What is the pathogenesis of BT?
3. What factors causes BT?
4. What group of children is at increased risk of BT?
5. What are the possible localizations of BT?
6. What are the causes of BT of sterno-cleido-mustoideus muscle, clavicular fracture?
7. What are the causes of cephalogematoma formation?
8. What is the difference between cephalogematoma Caput succedaneum?
9. Name clinical symptoms of BT of sterno-cleido-mustoideus muscle, clavicular fracture.
10. Name clinical symptoms of cerebral BT.
11. Name the causes and mechanisms of spinal cord traumas.
12. What structures are damaged at BT of the spinal cord.
13. What are the clinical signs of spinal cord traumas?
14. Which methods of inspection should be carried out for confirmation of the diagnosis of
"birth trauma"?
15. Make the plan of treatment of the newborn with BT.
16. How to feed the newborn with BT?
11
17. What outcomes are possible at BT?
18. What are the possible measures for the decrease in birth trauma?
19. Methods of prevention of BT.
B. Clinical cases
Case 1
A female infant is born by normal vaginal delivery after induction for prolonged
pregnancy. The prenatal course was unremarkable. Apgar scores are 6 at 1 minute and 9 at 5
minutes. When attempting to breastfeed at 2 hours of life, she develops opisthotonos-like
posturing, hyperextending her neck and arching her back. Physical examination reveals an
infant lying on a warmer, sucking vigorously on a nurse’s finger. Her weight is 3,520 g, heart
rate is 130 to 150 beats/min, respiratory rate is 30 to 40 breaths/min, pulse oximetry level is
98% to 100% on room air, and rectal temperature is 37°C (98.6°F). The remainder of
physical findings are normal, except for the abnormal posturing, which occurs when she is
touched.
White blood cell count is 27.9 x 109/L (27,900/cu mm), with 45% segmented
neutrophils, 5% bands, 36% lymphocytes, 4% monocytes, and 10% atypical lymphocytes.
Measurement of hematocrit, platelets, chemistry screen 7, and liver-associated enzymes
yields normal findings, as does ultrasonography of the head. Lumbar puncture reveals redtinged cerebrospinal fluid that does not clear. The fluid contains 35,453/cu mm erythrocytes
and 77/cu mm leukocytes (86% mononuclear and 14% polymorphonuclear cells), a glucose
level of 2.11 mmol/L (38 mg/dL), and a total protein level of 1.59 g/L (159 mg/dL). Gram
stain of the fluid reveals no organisms.
Computed tomographic (CT) scan of the head revealed increased attenuation over the
superior aspect of the left cerebellar hemisphere and to a lesser extent over the right
cerebellar hemisphere, extending along the tentorium.
Questions
1. What is the definitive diagnosis?
2. Write down confirmation of the diagnosis.
3. What are the risk factors of this disorder in the neonates?
4. How to treat this condition?
Case 2
An infant boy is born to a 33-year-old mother at 41 weeks of gestation. The mother has
had herpes simplex virus (HSV) infection but no active lesions at the time of delivery.
Artificial rupture of membranes yielding clear fluid occurs 9 hours prior to delivery, and the
delivery is uncomplicated and spontaneous. The baby has Apgar scores of 7 and 8, and the
initial physical examination shows all normal findings. At 24 hours after birth, while feeding,
the baby turns blue and appears to stop breathing. He responds to tactile stimulation with
improved color. Another apneic episode occurs, at which time his pink color again changes to
blue. The infant responds to bag-and-mask resuscitation with immediate improvement in
pulse oximetry saturation from 40% to 98%.
Compete blood count, chemistry panel, and radiograph of the chest all yield normal
results. Arterial blood gas levels are normal, with an arterial oxygen pressure of 200 torr
while receiving free-flow oxygen. Blood cultures and surface cultures for HSV are obtained.
Because of multiple apneic episodes occurring over the next hour, with desaturation down to
40% requiring intervention with bag-and-mask ventilation, the infant is intubated.
Lumbar puncture revealed frankly bloody fluid that did not clear during the procedure. The
cerebrospinal fluid (CSF) was xanthochromic and contained 460,000 erythrocytes and 748
12
leukocytes/mm3; the glucose level was 61 mg/dL (3.4 mmol/L) and protein level was greater
than 200 mg/dL (2,000 g/L); and no bacteria were seen on Gram stain. Fluid was sent for
polymerase chain reaction (PCR) testing for HSV.
Computed tomography (CT) of the head revealed blood filling the right lateral
ventricle and distending its posterior horn. There also was a small left subdural hematoma. A
repeat hematocrit performed 6 hours later showed a drop from 51% to 41%. Findings of
coagulation studies were within normal limits for a term newborn.
Questions
1. What is the definitive diagnosis?
2. Write down confirmation of the diagnosis.
3. What are the causes of apnea during the first days after birth?
4. What is the major complication of this condition?
C. Tests
Question 1. Routine head ultrasonography in infants <1,500 g to detect intracranial
hemorrhage is best described as:
1. Performed between 7 and 14 days and at 36-40 wk
2. Performed for anemia
3. Performed for seizures
4. Performed at birth and at 40 wk
5. Performed between 7 and 14 days and at 1 yr of age
Answer A. Explanation: In addition, nonroutine ultrasonography should be performed for
symptoms of intraventricular hemorrhage (IVH) and for the follow-up of abnormalities noted
on the first
ultrasound.
Question 2. The management of post-hemorrhagic hydrocephaly includes all of the
following except:
A. Serial head circumferences
B. Serial head ultrasound examinations
C. External ventricular drainage
D. Ventricular-peritoneal shunt
E. Repeated lumbar punctures
Answer E. Explanation: Although repeat lumbar puncture (LP) is often done, most
physicians do not believe that they avoid the need for a ventricular peritoneal (VP) shunt.
Most cases of dilated ventricles after IVH do not necessitate later placement of a shunt.
Question 3. A 12-day-old, large-for-gestational-age infant is noted to have Erb palsy. You
should do all of the following except:
1. Refer for immediate neuroplasty
2. Refer for physical therapy
3. Reassure the family
4. Determine if the clavicle is fractured
5. Look for additional nerve involvement (phrenic)
Answer A. Explanation: Most Erb palsies resolve rapidly with immobilization, rehabilitation,
and positioning. If there is no improvement between 3-6 mo, a referral for surgical evaluation
is indicated
13
Question 4. A term baby of an uncomplicated pregnancy is born limp, cyanotic, and apneic
after a difficult vaginal delivery. Possible considerations in the differential diagnosis include
all of the following except:
1. Prolapsed umbilical cord
2. Central nervous system trauma
3. Administration of morphine to the mother
4. Klumpke paralysis
Answer D. Explanation: Klumpke paralysis involves injury to the 7th and 8th cervical nerves
and the 1st thoracic nerve. It is usually unilateral, due to traction injury of the brachial
plexus. Administration of local anesthetic into the fetal scalp
Question 5. After intubation and resuscitation, the patient in Question 70 remains limp but
appears aware and looks around, although the baby does not cry when the toes are pinched.
The most likely diagnosis is:
1. Congenital botulism
2. Narcotic overdose
3. Transection of the spinal cord
4. Congenital myasthenia gravis
5. Neurosyphilis
Answer C. Explanation: Transection of the spinal cord may occur in vertex and breech
positions and may be noted with normal vertebral body anatomy. It would manifest as in this
patient, and also with shock, hypothermia, and bowel and bladder dysfunction. With time,
hypotonia resolves into hypertonia and hyperreflexia.
Question 6. An infant girl is born via spontaneous vaginal delivery at 28-week gestation
because of an incompetent cervix. Which of the following features of her clinical course in
the neonatal intensive care unit (ICU) is most likely to correlate with her clinical outcome 5
years from now?
A. Administration of surfactant
B. Apnea of prematurity
C. Grade IV intraventricular hemorrhage
D. Retinopathy of prematurity stage 1 on initial ophthalmologic examination
E. Umbilical artery catheterization
Answer C. Intraventricular hemorrhage is a complication in preterm infants. It is associated
with seizures, hydrocephalus, and periventricular leukomalacia. A grade IV bleed involves
the brain parenchyma, putting this child at higher risk for neurodevelopmental handicap.
Question 7. A 1-day-old infant who was born by a difficult forceps delivery is alert and
active. She does not move her left arm, however, which she keeps internally rotated by her
side with the forearm extended and pronated; she also does not move it during a Moro reflex.
The rest of her physical examination is normal. This clinical picture most likely indicates
A. Fracture of the left clavicle
B. Fracture of the left humerus
C. Left-sided Erb-Duchenne paralysis
D. Left-sided Klumpke paralysis
E. Spinal injury with left hemiparesis
Answer C.
Question 8. A30-day-old, former 24-weeks gestation, 600 g neonate had a difficult initial
respiratory course complicated by a tension pneumothorax. She had serial head ultrasound
14
evaluations during the first weeks of life. All previous studies revealed a normal immature
brain. Now, the head ultrasound reveals an abnormality. Among the following, which is most
likely?
A grade II intraventricular hemorrhage
B grade IV intraventricular hemorrhage
C aqueductal stenosis
D periventricular leukomalacia
E vein of Galen aneurysm
Answer D. Periventricular leukomalacia (PVL) is characterized by focal necrotic lesions in
the periventricular white matter. Cranial ultrasound can detect focal echo denisities and/or
cystic lesions surrounding the lateral ventricles that are diagnostic of PVL. Other imaging
techniques may be needed to detect more diffuse injury. These lesions are rarely found in
infants greater than 32 weeks gestation. Premature infants are predisposed to the
development of PVL due to the complex interaction between the cerebral vasculature and
regulation of cerebral blood flow that is gestatonal age dependent. Actively differentiating or
myelinating periventricular glial cells are also vulnerable to injury. The findings of PVL may
not be evident until 1 month of age or later. Congenital anomalies of the brain and
intraventricular hemorrhage usually are readily apparent on imaging in the first days of life.
Question 9. Aterm 4.3-kg infant is delivered vaginally to a 33-year-old woman with
juvenile-onset diabetes. The delivery was complicated by severe shoulder dystocia and the
infant experienced a brachial plexus injury with limited movement of the right arm. At 72
hours of age, the infant is noted to be tachypneic but he is pink and well perfused. Which of
the following is the most likely explanation for his tachypnea?
A respiratory distress syndrome (RDS)
B diaphragmatic paralysis
C pulmonary hemorrhage
D pneumothorax
E cystic adenomatoid malformation of the lung
Answer B. Brachial plexus injury results from stretching of the plexus and nerve roots. The
upper roots (C5 and C6) are most vulnerable to injury. Phrenic nerve injury on the same side
of the injury may occur, which results in diaphragmatic paralysis. This risks are highest for
brachial plexus injury if the infant is large for gestational age and/or if the labor and delivery
is complicated. Respiratory distress syndrome is uncommon in term infants and almost
always presents initially in the first 24 hours of life. Pulmonary hemorrhage, pneumothorax,
and cystic adenomatoid malformation can cause cyanosis and respiratory distress but have no
association with brachial plexus injury.
Question 10. A 5-day-old, large-for-gestational-age, 4,500-g boy has a bilirubin level of 21
mg/dL. There is no anemia or polycythemia, but on examination he has a large
cephalohematoma. The next therapeutic activity should be to:
A. Aspirate the hematoma
B. Perform an incision and drainage of the hematoma
C. Undertake prophylactic blood transfer
D. Administer phototherapy
E. Perform exchange transfusion
Answer D. Explanation: Phototherapy is clearly indicated. Aspiration or incision and
drainage (I + D) should not be done to manage a cephalohematoma.
15
Question 11. The newborn girl has 7/8 points on the Apgar scale at 1-5 minutes. At the time
of delivery there was observed short-term difficulties while taking out shoulders. After the
birth the child has disordered function of the proximal part of the upper extremity. Shoulder
is positioned inside, an elbow is straightened out, the forearm is pronated, hand is flexed like
"the doll hand”. What is the clinical diagnosis at this child?
A.Djushen-Erb paresis
B.Trauma of the thoracic spine
C.Osteomyelitis of the right hand
D.Intracranial hemorrhage
E.Trauma of the soft tissues of the right hand
Question 12. The newborn on the 1 minute after birth has respirations - 26/min, heart rate 90/min, muscular tone is reduced. While suctioning by catheter from the nose and the mouth
the child reacts by the grimace, skin is cyanotic. Auscultation: over lungs the weakened
breathing, heart sounds are sonorous. In 5 minutes: respirations - 40/min, breathing is
rhythmical, heart rate -120/min, acrocyanosis, muscular tonus is lowered. What is the most
probable diagnosis at this child?
A.Birth trauma of the newborn
B.Asphyxia of the newborn
C.Haemolytic disease of the newborn
D.Haemorrhagic disease of the newborn
E.Sepsis of the newborn
Question 13. Term infant experienced ante - and intranatal hypoxya, was born in the
asphyxia (an evaluation at the Apgar scale is 2/5 points). Agitation is progressing after birth,
vomiting, nistagmus, cramps, strabismus, spontaneous reflexes of Moro and Babinsky are
observed. What localization of the intracranial hemorrhage is the most probable in this case?
A.Small hemorrhages in the brain tissue
B.Subdurale hemorrhage
C.Periventricle hemorrhage
D.Hemorrhage into brain ventricles
E.Subarahnoidale hemorrhage
Question 14. Lumbur puncture is performed at the newborn, having suspected intracranial
birth trauma. Bloody liquor was obtained. What hemorrhage took place in this case?
A.Subarahnoide
B.Cefalogematoma
C.Epidurale
D.Supratentoriale
E.Subtentoriale
Question 15 . Term infant, born from 1st not complicated pregnancy, complicated delivery,
has cephalogematoma. Since 2 day jaundice was observed, since 3 – neurological disorders:
nistagmus, Grefe symptom. Urine is yellow, feces is of golden-yellow color. Mother has
blood A (II) Rh-negative, child – A (II) Rh-positive. Since 3 day child has Hb of 200g/l,
erhythrocytes - 6,1x10*12/l, bilirubin - 58 mcmol/l caused by increase in undirect fraction,
Ht - 0,57. How this joundice can be explained?
A.Physiological jaundice
B.Hemolitic disease of the newborn
C.Cranial birth trauma
D.Biliary atresia
E.Fetal hepatitis
16
Question 16. The child is 1 month old. The labour was complicated by weakness of labour
activity, difficulties while taking out shoulders. Objectively: the left hand lies along the
trunk, its upper part and forearm is pronated and flexed in the elbow joint, the palm is turned
back and outside. The reflex of Moro is negative at the left, Babkin and Robinson reflexes
are considerably reduced. Muscular hypotonia of the left upper extremity is detected. What is
the most probable pathology that causes such clinical manifestations?
A.Djushen - Erb paralysis
B.Dezherin - Kljumpke paralysis
C.Left sided hemiparesis
D.Upper paraparesis
E.2-sided hemiplegia
Question 17. At the newborn (complicated delivery) active movements in the right hand are
absent from the time of birth. The condition is abnormal. The Moro reflex is absent at the
right side. Tendinous-periostal reflexes are severely diminished. What is the most probable
diagnosis?
A.Traumatic plexitis, distal type
B.Osteomyelitis of the right humeral bone
C.Traumatic plexitis, total type
D.Traumatic fracture of the right humeral bone
E.Intracranial birth trauma
Question 18. The newborn is 1 day old. There were difficulties while taking out shoulders
during the labour. Weight is 4300,0. The right hand hangs down along a trunk, the hand is
pronated, movements in a hand are absent. Positive scarf symptome. Specify the most
probable diagnosis:
A.Proximal type of the right obstetric paralysis
B.Distale type of the right obstetric paralysis
C.Total right obstetric paralysis
D.Gemiparesis
E.Tetraparesis
4. LITERATURE FOR STUDENTS
1. Nelson Textbook of Pediatrics. - 18th ed. / Ed. by R. Kliegman et al.-Philadelphia:
Saunders Co, 2007.- 3146 p.
2. Pediatry. Guidance Aid / За ред. О.В. Тяжка; О.П. Вінницька, Т.І. Лутай – К. : Медицина, 2007 . –
158 с.
3. Current Pediatric Diagnosis & Treatment (CPDT). - 18th ed./ Ed. By W.W.Hay et al. - The
McGraw-Hill Companies. – 2006.
4. Current pediatric therapy -18th ed. / Ed. by F.D.Burg et al. - Elsevier Inc. – 2007.
5. Nelson Essentials of Pediatrics -5th ed. / Ed. by B.S.Siegel, J.J.Siegel. - Elsevier Inc. –
2007.
6. Examination of the Newborn. A Practical Guide / Ed. by Helen Baston and Heather
Durward. - the Taylor & Francis e-Library. - 2005.
7. Fetal and neonatal secrets. - second edition . / Ed. by R.A.Polin, A.R.Spitzer. - Elsevier.2006.
8. Key Topics in Neonatology / Ed. by R.H. Mupanemunda, M. Watkinson. - Oxford
Washington DC. -1999.
17
Performed by ass. Vaculenko L.I., ass. Tkachenko N.P.
Approved “_____”____________20____y.
Сhief of the department, professor
Protocol №_____
V. A. Kondratyev
Reconsidered
Approved “_____”____________20____р.
Сhief of the department, professor
Protocol №_____
V. A. Kondratyev
Reconsidered
Approved ““_____”____________20____р.
Сhief of the department, professor
Protocol №_____
V. A. Kondratyev
Reconsidered
Approved “_____”____________20____р.
Сhief of the department, professor
Protocol №_____
V. A. Kondratyev
Reconsidered
Approved ““_____”____________20____р.
Сhief of the department, professor
Protocol №_____
V. A. Kondratyev
Reconsidered
Approved “_____”____________20____р.
Сhief of the department, professor
Protocol №_____
V. A. Kondratyev
Reconsidered
Approved ““_____”____________20____р.
Сhief of the department, professor
Protocol №_____
V. A. Kondratyev
18