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Florida Heart CPR*
Birth Trauma
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INTRODUCTION
Injuries to the infant resulting from mechanical forces (compression, traction) during the
process of birth are categorized as birth trauma. Factors responsible for mechanical
injury may coexist with hypoxic-ischemic insult. One may predispose the infant to the
other. Lesions, which are predominantly hypoxic in origin, are not discussed in this
course. Significant birth injury accounts for less than 2% of neonatal deaths and
stillbirths in this country. It still occurs occasionally and unavoidably with an average of
6-8 injuries per 1000 live births. In general, larger infants are more susceptible to birth
trauma. Higher rates are reported for infants over 4500 grams.
The majority of birth traumas are self-limiting and have a favorable outcome. Nearly half
are potentially avoidable with recognition and anticipation of obstetric risk factors. Infant
outcome is the product of multiple factors. It is difficult to separate effects of a hypoxicischemic insult from those of traumatic birth injury.
Risk factors include large-for-date infants, especially over 4500 grams; instrumental
deliveries, especially forceps (mid-outlet), vacuum; vaginal breech delivery; and
abnormal or excessive traction during delivery.
Mortality/morbidity
Birth injuries account for fewer than 2% of neonatal deaths. From 1970-1985, infant
mortality resulting from birth trauma fell from 64.2-7.5 deaths per 100,000 live births, a
remarkable decline of 88%. This decrease reflects, in part, the technological
advancements for today's obstetrician to recognize birth trauma risk factors by
ultrasound and fetal monitoring prior to attempting vaginal delivery. Use of potentially
injurious instrumentation such as midforceps rotation and vacuum delivery also has
declined. The accepted alternative is a cesarean section delivery.
Causes
The process of birth is a blend of compression, contractions, torques, and traction.
When fetal size, presentation, or neurological immaturity complicates this event, such
intrapartum forces may lead to tissue damage, edema, hemorrhage, or fracture in the
neonate. The use of obstetrical instrumentation may further amplify the effects of such
forces or may induce injury alone. Under certain conditions, delivery by cesarean
section can be an acceptable alternative, but it does not guarantee an injury-free infant.
Factors predisposing to injury include the following:
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Cephalopelvic disproportion, small maternal stature, maternal pelvic anomalies
Prolonged or rapid labor
Deep transverse arrest of descent of presenting part of the fetus
Oligohydramnios
Abnormal presentation (breech)
Use of midcavity forceps or vacuum extraction
Versions and extractions
Very low birth weight infant or extreme prematurity
Fetal macrosomia
Large fetal head
Fetal anomalies
INJURIES WITH FAVORABLE LONG-TERM PROGNOSIS
Soft tissue
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Abrasions
Erythema petechia
Ecchymosis
Lacerations
Subcutaneous fat necrosis
Skull
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Caput succedaneum
Cephalhematoma
Linear fractures
Face
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Subconjunctival hemorrhage
Retinal hemorrhage
Musculoskeletal
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Clavicular fractures
Fractures of long bones
Sternocleidomastoid injury
Intra-abdominal
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Liver hematoma
Splenic hematoma
Adrenal hemorrhage
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Renal hemorrhage
Peripheral nerve
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Facial palsy
Unilateral vocal cord paralysis
Radial nerve palsy
Lumbosacral plexus injury
SOFT TISSUE INJURY
Soft tissue injury is associated with fetal monitoring, particularly with fetal scalp
blood sampling for pH or fetal scalp electrode for fetal heart monitoring, which
has a low incidence of hemorrhage, infection, or abscess at the site of sampling.
Cephalhematoma
Cephalhematoma is a subperiosteal collection of blood secondary to rupture of
blood vessels between the skull and the periosteum; suture lines delineate its
extent. Most commonly parietal, cephalhematoma occasionally may be observed
over the occipital bone.
The extent of hemorrhage may be severe enough to present as anemia and
hypotension. Resolving hematoma will predispose to hyperbilirubinemia. Rarely,
cephalhematoma may be a focus of infection leading to meningitis or
osteomyelitis. Linear skull fractures may underlie a cephalhematoma (5-20% of
cephalhematomas). Resolution occurs over weeks, occasionally with residual
calcification.
No lab work usually is necessary. Skull x-ray/CT scan are used if neurologic
symptoms are present. Usually, management consists of observation only.
Transfusion and phototherapy are necessary if blood accumulation is significant.
Aspiration is more likely to increase the risk of infection. The presence of a
bleeding disorder should be considered. Skull X-ray/CT scan also are used if
concomitant depressed skull fracture a possibility.
Subgaleal hematoma
Subgaleal hematoma is bleeding in the potential space between the skull
periosteum and the scalp galea aponeurosis. Ninety percent result from vacuum
applied to the head at delivery. Subgaleal hematoma has a high frequency of
occurrence of associated head trauma (40%), such as intracranial hemorrhage or
skull fracture. The occurrence of these features does not correlate significantly
with the severity of subgaleal hemorrhage.
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The diagnosis is generally a clinical one, with a fluctuant boggy mass developing
over the scalp (especially over the occiput). The swelling develops gradually 1272 hours after delivery, although it may be noted immediately after delivery in
severe cases. The hematoma spreads across the whole calvarium. Its growth is
insidious, and subgaleal hematoma may not be recognized for hours. Subgaleal
hematoma may present as hemorrhagic shock. The swelling may obscure the
fontanelle and cross suture lines (distinguishing it from cephalhematoma). Watch
for significant hyperbilirubinemia. The long-term prognosis generally is good.
Lab work consists of a hematocrit evaluation. Management consists of vigilant
observation over days to detect progression. Transfusion and phototherapy may
be necessary. Investigation for coagulopathy may be indicated.
Caput succedaneum
Caput succedaneum is a serosanguinous, subcutaneous, extraperiosteal fluid
collection with poorly defined margins. It is caused by the pressure of the
presenting part against the dilating cervix. Caput succedaneum extends across
the mid line and over suture lines and is associated with head moulding. Caput
succedaneum usually does not cause complications. It usually resolves over the
first few days. Management consists of observation only.
Abrasions and lacerations
Abrasions and lacerations sometimes may occur as scalpel cuts during cesarean
section or during instrumental delivery (vacuum, forceps). Infection remains a
risk, but most will heal uneventfully.
Management consists of careful cleaning, application of antibiotic ointment, and
observation. Bring edges together using Steri-Strips. Lacerations occasionally
require suturing.
Subcutaneous fat necrosis
Subcutaneous fat necrosis usually is not detected at birth. Irregular hard,
nonpitting, subcutaneous plaques with overlying dusky, red-purple discoloration
on the extremities, face, trunk, or buttocks may be caused by pressure during
delivery. No treatment is necessary. Subcutaneous fat necrosis sometimes
calcifies.
PERIPHERAL NERVE INJURY
Brachial plexus injury
Brachial plexus injury occurs most commonly in large babies, frequently with
shoulder dystocia or breech delivery. Incidence for brachial plexus injury is 0.5-
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2.0 per 1000 live births. The majority of cases are Erb palsy; entire brachial
plexus involvement occurs in 10% of cases.
Traumatic lesions associated with brachial plexus injury are fractured clavicle
(10%), fractured humerus (10%), subluxation of cervical spine (5%), cervical cord
injury (5-10%), and facial palsy (10-20%). Erb palsy (C5-C6) is most common
and is associated with lack of shoulder motion. The involved extremity lies
adducted, prone, and internally rotated. Moro, biceps, and radial reflexes are
absent on the affected side. Grasp reflex usually is present. Five percent of
patients have an accompanying (ipsilateral) phrenic nerve paresis.
Klumpke paralysis (C7,8 T1) is rare, resulting in weakness of the intrinsic
muscles of the hand; grasp reflex is absent. If cervical sympathetic fibers of the
first thoracic spinal nerve are involved, Horner syndrome is present.
No uniformly accepted guidelines for determining prognosis exist. Narakas
developed a classification system (type I-V) based on the severity and extent of
lesion, providing clues to the prognosis in the first 2 months of life. According to
the collaborative perinatal study (59 infants), 88% of cases resolved in the first 4
months, 92% by 12 months, and 93% by 48 months. In another study of 28
patients with upper plexus involvement and 38 with total plexus palsy, 92%
recovered spontaneously.
Residual long-term deficits may include progressive bony deformities, muscle
atrophy, joint contractures, possible impaired growth of the limb, weakness of the
shoulder girdle, and/or "Erb engram" flexion of elbow accompanied by adduction
of shoulder.
Lab work consists of x-ray studies of the shoulder and upper arm to rule out bony
injury. The chest should be examined to rule out associated phrenic nerve injury.
Electromyogram (EMG) and nerve conduction studies occasionally are useful.
Fast spin-echo MRI can evaluate plexus injuries noninvasively in a relatively
short time, minimizing the need for general anesthesia. MRI can define
meningoceles and may distinguish between intact nerve roots and
pseudomeningoceles (indicative of complete avulsion). Carefully performed,
intrathecally enhanced CT scan myelography may show preganglionic disruption,
pseudomeningoceles, and partial nerve root avulsion. CT scan myelography is
more invasive and offers few advantages over MRI.
Management consists of prevention of contractures. Immobilize limb gently
across the abdomen for the first week and then start passive range of motion
exercises at all joints of the limb. Use supportive wrist splints. Best results for
surgical repair appear to be obtained in the first year of life. Several investigators
recommend surgical exploration and grafting if there is no function in the upper
roots at 3 months of age, though the recommendation for early explorations far
from universal. Complications of brachial plexus exploration include infection,
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poor outcome, and burns from the operating microscope. Patients with root
avulsion do not do well. Palliative procedures involving tendon transfers have
been of some use. Latissimus dorsi and teres major transfers to the rotator cuff
have been advocated for improved shoulder function in Erb palsy. One
permanent and 3 transitory axillary nerve palsies have been reported from the
procedure.
CRANIAL NERVE AND SPINAL CORD INJURY
Cranial nerve and spinal cord injuries result from hyperextension, traction, and
overstretching with simultaneous rotation. They may range from localized
neurapraxia to complete nerve or cord transection.
Cranial nerve injury
Unilateral branches of the facial nerve and vagus nerve, in the form of recurrent
laryngeal nerve, are most commonly involved in cranial nerve injuries and result
in temporary or permanent paralysis.
Compression by the forceps blade has been implicated in some facial nerve
injury, but most facial nerve palsy is unrelated to trauma.
Physical findings for central nerve injuries are asymmetric facies with crying. The
mouth is drawn towards the normal side, wrinkles are deeper on the normal side,
and movement of the forehead and eyelid is unaffected. The paralyzed side is
smooth with a swollen appearance; the nasolabial fold is absent; and the corner
of the mouth droops. There is no evidence of trauma on the face.
Physical findings for peripheral nerve injuries are asymmetric facies with crying.
Sometimes evidence of forceps marks is present. With peripheral nerve branch
injury, the paralysis is limited to the forehead, eye, or mouth.
The differential diagnosis includes nuclear genesis (Möbius syndrome),
congenital absence of the facial muscles, unilateral absence of the orbicularis
oris muscle, and intracranial hemorrhage.
Most infants begin to recover in the first week, but full resolution may take
several months. Palsy that is due to trauma usually will resolve or improve,
whereas palsy that persists often is due to absence of the nerve.
Management consists of protecting the open eye with patches and synthetic
tears (methylcellulose drops) every 4 hours. Neurologic and surgical consultation
should be sought if no improvement is observed in 7-10 days.
Diaphragmatic paralysis secondary to traumatic injury to the cervical nerve roots
supplying the phrenic nerve can occur as an isolated finding or in association
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with brachial plexus injury. The clinical syndrome is variable. The course is
biphasic; initially the infant experiences respiratory distress with tachypnea and
blood gases suggestive of hypoventilation (hypoxemia, hypercapnia, acidosis).
Over the next several days, the infant may improve with oxygen and varying
degrees of ventilatory support. Elevated hemi-diaphragm may not be observed in
the early stages. Approximately 80% of lesions involve the right side and about
10% are bilateral.
The diagnosis is established by ultrasound or fluoroscopy of the chest, which
reveals the elevated hemi-diaphragm with paradoxical movement of the affected
side with breathing.
The mortality for unilateral lesions is approx. 10-15%. The majority of patients
recover in the first 6-12 months. An outcome for bilateral lesions is poorer.
Mortality approaches 50% and prolonged ventilatory support may be necessary.
Management consists of careful surveillance of respiratory status, and
intervention, when appropriate, is critical.
Laryngeal nerve injury
Disturbance of laryngeal nerve function may affect swallowing and breathing.
Laryngeal nerve injury appears to result from an intrauterine posture in which the
head is rotated and flexed laterally. During delivery, similar head movement,
when marked, may injure the laryngeal nerve, accounting for approximately 10%
of vocal cord paralysis attributed to birth trauma. The infant presents with a
hoarse cry or respiratory stridor, most often caused by unilateral laryngeal nerve
paralysis. Swallowing may be affected if the superior branch is involved. Bilateral
paralysis may be caused by trauma to both laryngeal nerves or, more commonly,
by a CNS injury such as hypoxia or hemorrhage involving the brain stem.
Bilateral paralysis often presents with severe respiratory distress or asphyxia.
Direct laryngoscopic examination is necessary to make the diagnosis and to
distinguish vocal cord paralysis from other causes of respiratory distress and
stridor in the newborn. Differentiate from other rare etiologies, such as
cardiovascular or CNS malformations or a mediastinal tumor.
Paralysis often resolves in 4-6 weeks, though recovery may take as long as 6-12
months in severe cases. Treatment is symptomatic. Small frequent feeds, once
the neonate is stable, minimize the risk of aspiration. Infants with bilateral
involvement may require gavage feeding and tracheotomy.
Spinal cord injury
Spinal cord injury incurred during delivery results from excessive traction or
rotation. Traction is more important in breech deliveries (minority of cases), and
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torsion in vertex deliveries. True incidence is difficult to determine. The lower
cervical and upper thoracic region for breech delivery and upper and midcervical
region for vertex delivery are the major sites of injury.
Major neuropathological changes consist of acute lesions, which are
hemorrhage, especially epidural, intraspinal, and edema. Hemorrhagic lesions
are associated with varying degrees of stretching, laceration, and disruption or
total transaction. Occasionally the dura may be torn, and rarely the vertebral
fractures or dislocations may be observed.
The clinical presentation is stillbirth or rapid neonatal death with failure to
establish adequate respiratory function, especially in cases involving the upper
cervical cord or lower brain stem. Severe respiratory failure may be obscured by
mechanical ventilation and may cause ethical issues later. The infant may
survive with weakness and hypotonia, and the true etiology may not be
recognized. A neuromuscular disorder or transient hypoxic ischemic
encephalopathy may be considered. Most infants will later develop spasticity that
may be mistaken for cerebral palsy.
Prevention is the most important aspect of medical care. Obstetrical
management of breech deliveries, instrumental deliveries, and pharmacological
augmentation of labor must be appropriate. Occasionally, injury may be
sustained in utero.
The diagnosis is made by MRI or CT myelography. Little evidence indicates that
laminectomy or decompression has anything to offer. A potential role for
methylprednisolone exists. Supportive therapy is important.
BONE INJURY
Fractures most often are observed following breech delivery and/or shoulder
dystopia in macrosomia infants.
Clavicular fracture
The clavicle is the most frequently fractured bone in the neonate during birth and
most often is an unpredictable, unavoidable complication of normal birth. Some
correlation with birth weight, midforceps delivery, and shoulder dystocia exists.
The infant may present with pseudoparalysis. Examination may reveal crepitus,
palpable bony irregularity, and sternocleidomastoid muscle spasm. X-ray will
confirm the fracture.
Healing usually occurs in 7-10 days. Arm motion may be limited by pinning the
infant's sleeve to the shirt. Assess other associated injury to spine, brachial
plexus, or humerus.
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Long bone fracture
Loss of spontaneous arm or leg movement is an early sign of long bone fracture,
followed by swelling and pain on passive movement. The obstetrician may feel or
hear a snap of fracture at the time of delivery. X-ray of the limb will confirm the
diagnosis.
Femoral and humeral shaft fractures are treated with splinting. Closed reduction
and casting is necessary only when displaced. Watch for evidence of radial nerve
injury with humeral fracture. Callus formation occurs, and complete recovery is
expected in 2-4 weeks. In 8-10 days, the callus formation is sufficient to
discontinue immobilization. Orthopedic consultation is recommended.
X-ray will distinguish this condition from septic arthritis.
Epiphysial displacement
Separation of humeral or femoral epiphysis occurs through the hypertrophied
layer of cartilage cells in the epiphysis. The diagnosis is made clinically based on
the finding of swelling around the shoulder, crepitus, and pain when the shoulder
is moved. Motion is painful and the arm lies limp by the side. As the proximal
humeral epiphysis is not ossified at birth, it is not visible on x-ray. Callus appears
in 8-10 days and is visible on x-ray.
Management consists of immobilizing the arm for 8-10 days. Fracture of the
distal epiphysis is more likely to have a significant residual deformity than is
fracture of the proximal humeral epiphysis.
INTRA-ABDOMINAL INJURY
Intra-abdominal injury is relatively uncommon and sometimes can be overlooked
as a cause of death in the newborn. Hemorrhage is the most serious acute
complication, and the liver is the most commonly damaged internal organ.
Signs and symptoms of intraperitoneal bleed
Bleeding may be fulminant or insidious but ultimately will present with circulatory
collapse. Intra-abdominal bleed should be considered for every infant presenting
with shock, pallor, unexplained anemia, and abdominal distension. Overlying
abdominal skin may have bluish discoloration. X-ray is not diagnostic but may
suggest free peritoneal fluid. Paracentesis is the procedure of choice.
Hepatic rupture
The most common lesion is subcapsular hematoma, which increases to 4-5 cm
before rupturing. Symptoms of shock may be delayed. Lacerations are less
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common, often caused by abnormal pull on peritoneal support ligaments or effect
of excessive pressure by the costal margin. Infants with hepatomegaly may be at
higher risk. Other predisposing factors include prematurity, postmaturity,
coagulation disorders, and asphyxia. In cases associated with asphyxia, vigorous
resuscitative effort (often by unusual methods) is the culprit. Splenic rupture is at
least a fifth as common as liver laceration. Predisposing factors and mechanisms
of injury are similar.
Rapid identification and stabilization of the infant are the keys to management,
along with assessment of coagulation defect. Blood transfusion is the most
urgent initial step. Persistent coagulopathy may be treated with fresh frozen
plasma, transfusion of platelets, etc.
Hepatic rupture has no specific predilection for any race and has equal sex
distribution. It usually presents immediately following birth or becomes obvious
within the first few hours or days.
Recognition of trauma necessitates a careful physical and neurological
evaluation of the infant to establish whether additional injuries exist.
Occasionally, injury may result from resuscitation. Symmetry of structure and
function should be assessed as well as specifics such as cranial nerve
examination, individual joint range of motion, and scalp/skull integrity.
REFERENCES
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Chadwick LM, Pemberton PJ, Kurinczuk JJ: Neonatal subgaleal
haematoma: associated risk factors, complications and outcome. J
Paediatr Child Health 1996 Jun; 32(3): 228-32
Donn SM, Faix RG: Long-term prognosis for the infant with severe birth
trauma. Clin Perinatol 1983 Jun; 10(2): 507-20
Farnoff AA, Martin RJ, eds: Neonatal-perinatal medicine: Diseases of the
fetus and infant. St. Louis: Mosby; 1996.
Gilbert WM, Tchabo JG: Fractured clavicle in newborns. Int Surg 1988
Apr-Jun; 73(2): 123-5
Gresham EL: Birth trauma. Pediatr Clin North Am 1975 May; 22(2): 31728
Jennett RJ, Tarby TJ, Kreinick CJ: Brachial plexus palsy: an old problem
revisited. Am J Obstet Gynecol 1992 Jun; 166(6 Pt 1): 1673-6; discussion
1676-7
King SJ, Boothroyd AE: Cranial trauma following birth in term infants. Br J
Radiol 1998 Feb; 71(842): 233-8
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Florida Heart CPR*
Birth Trauma Assessment
1. Factors responsible for _______ may coexist with hypoxic-ischemic insult.
a. Neurological injury
b. Mechanical injury
c. Cardiovascular
d. None of the above
2. The majority of birth traumas are:
a. self-limiting and have a favorable outcome
b. one hundred percent preventable
c. due to protocol error
d. fatal
3. Factors predisposing to injury include the following:
a. Very low birth weight infant or extreme prematurity
b. Prolonged or rapid labor
c. Use of midcavity forceps or vacuum extraction
d. All of the above
4. Irregular hard, nonpitting, subcutaneous plaques with overlying dusky, red-purple
discoloration on the extremities, face, trunk, or buttocks may be caused by
pressure during delivery. This is usually not detected at birth, and is known as:
a. Brachial plexus injury
b. Subcutaneal fat necrosis
c. Caput succedaneum
d. Subgaleal hematoma
5. Brachial plexus injury occurs most commonly in:
a. Low birth weight babies
b. Large babies
c. Babies born to obese mothers
d. Babies born to mothers over 40
6. Cranial nerve and spinal cord injuries result from
a. Hyperextension
b. Traction
c. Overstretching with simultaneous rotation
d. All of the above
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7. Physical findings for _______ injuries are asymmetric facies with crying.
a. Peripheral nerve
b. Central nerve
c. Spinal column
d. A and B
8. Spinal cord injury incurred during delivery results from:
a. Excessive traction or rotation
b. Vaginal breech delivery
c. Vacuum delivery
d. Forceps
9. Fractures most often are observed following ______ and/or shoulder dystopia in
macrosomia infants.
a. Cesarean delivery
b. Breech delivery
c. Emergency delivery
d. Home delivery
10. Intra-abdominal injury is relatively uncommon and sometimes can be overlooked
as a cause of death in the newborn. _______ is the most serious acute
complication, and the ______ is/are the most commonly damaged internal organ.
a. Sepsis, kidneys
b. Hemorrhage, kidneys
c. Sepsis, liver
d. Hemorrhage, liver
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