����BIRTH INJURIES

MODERATOR: DR UCHE/DR AKINADE

1

PRESENTERS

• OKON-EYO VICTORIA
• OKORIE DAVID
• OKORO MAURICE
• OKUGBENI NATHANIEL
• OLAOYE TIOLUWANI
• OLORUNTOBA TOLUWANI
• OMILABU FAVOUR TOLUWALEYI
• ONASOGA KOLAPO
• ONOJA ALEXANDRA

​

2

OUTLINE

​

• INTRODUCTION
• DEFINITION
• EPIDEMIOLOGY
• AETIOLOGY/RISK FACTORS
• TYPES OF BIRTH INJURIES
• CONCLUSION
• REFERENCES

​

3

INTRODUCTION

• During child birth, injuries may occur. A lot are minor but they can also be severe.
• The majority of birth injuries are minor and unreported.
• These injuries may occur as a result of inexperienced or inadequate medical skills but they may also occur in the presence of skilled obstetrical care.
• Birth injuries are inevitable as long as babies are born.

​

4

• Birth injuries are mostly iatrogenic (medically induced) and as such have medicolegal implications.
• Most of these injuries can be handled and managed non operatively, but prompt identification of those that need surgery should be done.
• Injuries to the infant may result from mechanical forces (i.e compression, traction) during the birth process.
• Birth defects differ from birth injuries.

​

5

Definition

• A birth injury is defined as structural damage or functional deterioration of a newborn secondary to a traumatic event that occurred during labor, delivery or both.

​

6

EPIDEMIOLOGY

• Worldwide
• Incidence of 0.06- 0.08% of live births and accounts for less than 2% of neonatal deaths worldwide (Ojumah N, et al. 2017)
• Birth injuries have no race or sex predilection

​

7

• Africa
• Statistics on birth injuries are scarce
• However, some studies done in Mali and Morocco revealed frequencies of 0.68% and 0.26% respectively
• Reports from Egypt showed a frequency of up to 17%

​

8

• Nigeria
• An observational study by Pius S et al on neonatal birth injuries in Maiduguri, North-Eastern Nigeria revealed that the highest number of birth injuries occurred:

-Between 37-42 weeks of gestation

-Birth weight between 2500-4000g

- Infants delivered via spontaneous vaginal delivery

- The overall incidence from this study was 57/1000 live birth

​

9

• In a study carried out in the department of peadiatrics in Rivers state university teaching hospital it was found that thirty nine (39) out of the 5,692 babies delivered during the study period had birth injuries with an incidence 6.9 per 1000 live births.
• the common birth injuries were neurological (26.2%), extracranial (23.8%), and soft tissue injuries (21.4%).
• Cephalopelvic disproportions (36%), diabetes mellitus in pregnancy (32%) and prolonged labor (20%) were commonly found complications of mothers whose babies had birth injuries

10

• Neurological injuries were significantly associated with normal vaginal delivery and birth weights of greater than or equal to 4kg.
• Although majority of them were discharged mortality rate was 7.7%.

​

11

RISK FACTORS

INFANT RELATED

• Very low birth weight or extreme prematurity
• Fetal macrosomia (fetal weight >4kg)
• Fetal anomalies
• Twin gestation
• Fetal malpresentation (breech)

​

MATERNAL RELATED

• Primigravida
• Small maternal stature
• Maternal pelvic anomalies
• Poor maternal health
• Cephalopelvic disproportion

​

12

LABOUR RELATED

• Prolonged or extremely rapid labor
• Deep transverse arrest of the presenting part of the fetus
• Mode of delivery (use of forceps or vacuum extraction)
• Skill of attending physician

​

13

CLASSIFICATION OF BIRTH INJURIES

1. BASED ON TRAUMA

• Nerve injuries
• Soft tissue injuries
• Head and neck injuries
• Fractures

2. BASED ON OXYGEN DEPRIVATION

• Birth asphyxia
• Hypoxic-ischemic-encephalopathy

​

14

NERVE INJURIES

15

BRACHIAL PLEXUS INJURIES�

​

16

ERB’S PALSY

• 5th and 6th cervical nerve injury
• The infant looses the power to abduct the arm from the shoulder, rotate the arm externally and supinate the forearm and biceps reflex is absent.
• Moro reflex is absent on the affected side.
• The involved arm is held in the “waiter’s tip” position, with adduction and internal rotation of the shoulder, extension of the elbow, pronation of the forearm and flexion of the wrist and fingers

17

KLUMPKE’S PALSY

• It involves the C8 and T1 nerves, resulting in weakness of the intrinsic hand muscles and long flexors of the wrist and fingers.
• The grasp reflex is absent but the biceps reflex is present.
• This is associated hematomas of the sternocleidomastoid muscle and fractures of the clavicle and humerus, with ipsilateral Horner’s syndrome.

18

TYPES OF KLUMUPKE’S PALSY

• Neuropraxia with temporary conduction block
• Axonotmesis with a severed axon, but with intact surrounding neuronal elements.
• Neurotmesis with complete postganglionic disruption of the nerve.
• Avulsion with preganglionic disconnection from the spinal cord.

19

DIAGNOSIS

• Physical examination
• Radiographs of the shoulder and upper arm

MANAGEMENT

• Initial treatment is conservative
• Arm is immobilized across the upper abdomen during the first week
• Physiotherapy
• Surgery may be considered if infants do not recover after 3-6 months.

20

21

FACIAL NERVE PALSY (BELL’S PALSY)

• Can be caused by pressure on the facial nerves during birth or by the use of forceps during birth.
• The affected side of the face droops and the infant is unable to close the eye tightly on that side. When crying, the mouth is pulled across to the normal side.

22

TREATMENT

• Protection of the involved eye by application of artificial tears and taping to prevent corneal injury.
• Neurosurgical repair of the nerve should be considered only after lack of resolution during 1 year of observation.

​

23

PHRENIC NERVE INJURY

• Phrenic Nerve provides the primary motor supply to the diaphragm, the major respiratory muscle.

​

• Results from a traumatic neonatal delivery from a stretch injury due to lateral hyperextension of the neck at birth.

​

• RISK FACTORS; Breech delivery, forceps delivery

​

24

• Injury to the phrenic nerve could cause paralysis or dysfunction of the ipsilateral Diaphragm leading to Respiratory Distress in new-born.

​

• On Examination - Decreased Breath Sounds and dullness to percussion of the affected side

​

• DIAGNOSIS- Chest Radiograph - shows elevation of the affected side of the diaphragm, mediastinal shift to the contralateral side.

​

25

• TREATMENT

- Initial treatment is supportive

- Respiratory Failure may be treated with Continuous Positive Airway Pressure (CPAP)

- If unresponsive, Surgical Plication of diaphragm is done

26

LARYNGEAL NERVE INJURY

• Damage to the Laryngeal nerve may affect a child’s ability to breathe and swallow
• Often occurs when infant’s head turns to the side during childbirth

​

• SYMPTOMS - Respiratory distress, Hoarse cry, aspiration

​

• DIAGNOSIS - Direct Laryngoscopy

​

• TREATMENT

- Intubation

- Tracheostomy

​

27

SPINAL CORD INJURY

• The clinical presentation is stillbirth or rapid neonatal death with failure to establish adequate respiratory function
• There is decreased or absent spontaneous movement
• Absent or periodic breathing
• Lack of response to pain stimuli below the level of the lesion

​

• DIAGNOSIS -MRI

- CT myelography

​

28

• PREVENTION is the most important aspect of medical care

​

• MANAGEMENT

- If cord injury is suspected in the delivery room, the head, neck and supine should be immobilized

- Supportive Therapy is important

​

29

SOFT TISSUE INJURIES

30

PETECHIAE AND ECCHYMOSES

• Petechiae are pin point subcutaneous hemorrhagic spots that do not blanch on pressure. They are non raised pinpoint hemorrhages( less than 3mm in diameter) caused by a sudden increase and then release of pressure during passage through birth canal

• Ecchymosis is a clinical manifestation characterized by reddish to bluish discoloration of the skin which results from the rupture of small capillaries beneath the skin and accumulation of blood in the surrounding skin. Ecchymosis are small hemorrhagic areas greater than 10 mm in diameter) that may occur after traumatic or breech delivery.

31

32

PETECHIAE AND ECCHYMOSES

• Periorbital and facial tissues in face presentations
• The scrotum or labia during breech deliveries

Management

• •Rest
• •Ice application
• •Pain relievers

33

Abarasions and Lacerations

34

• • May occur as scalpel cuts during cesarean delivery or during instrumental delivery (i.e, vacuum, forceps)
• • Infection remains a risk, but most uneventfully heal
• Management
• • Careful cleaning, application of antibiotic ointment, and observation
• • Lacerations occasionally require suturing

SUBCUTANEOUS FAT NECROSIS

• Subcutaneous fat necrosis (SCFN) of the newborn is a rare inflammatory disorder of the fat tissue presenting in term and post-term infants , consisting in a lobular form of panniculitis associated to painful, hard, and erythematous–violaceous nodules . SCFN usually has a favorable prognosis, with complete autoresolution of subcutaneous lesions within several weeks or months.
• Subcutaneous fat necrosis is usually a benign condition. Nevertheless, it may be associated with thrombocytopenia, hypoglycemia, hypercalcemia, and hypertriglyceridemia 2; these metabolic derangements may, in turn, represent a possible risk for serious complications
• This is not usually detected at birth.

35

CLINICAL FEATURES

• Irregular, hard, nonpitting subcutaneous plaques
• Overlying dusky, red-purple discoloration on the extremities, face, trunk or buttocks
• Calcification of nodules may be present

​

MANAGEMENT

• It is pivotal to monitor newborns with SCFN to avoid the risk of serious complications, with particular reference to hypercalcemia. Regular monitoring of serum calcium is recommended until the age of 6 months, in infants with personal history of SCFN

​

36

HEAD AND NECK INJURIES

37

CAPUT SUCCEDANEUM

• Caput succedaneum is swelling of the scalp in a newborn. It is most often brought on by pressure from the uterus or vaginal wall during a head-first (vertex) delivery.

CAUSES

• A caput succedaneum is more likely to form during a long or hard delivery. It is more common after the membranes have broken. This is because the fluid in the amniotic sac is no longer providing a cushion for the baby's head. Vacuum extraction done during a difficult birth can also increase the chances of a caput succedaneum.
• A caput succedaneum may be detected by prenatal ultrasound, even before labor or delivery begins. It has been found as early as 31 weeks of pregnancy. Very often, this is due to an early rupture of the membranes or too little amniotic fluid. It is less likely that a caput will form if the membranes stay intact.

​

38

Clinical Features.

• Soft, puffy swelling on the scalp of a newborn infant
• Possible bruising or color change on the scalp swelling area
• Swelling that may extend to both sides of the scalp
• Swelling that is most often seen on the portion of the head which presented first

Management.

• No specific Treatment
• Mainly observation

​

39

CEPHALHEMATOMA �

• This is an accumulation of subperiosteal blood, typically located in the occipital or parietal region of the calvarium. During the birthing process, shearing forces on the skull and scalp result in the separation of the periosteum from the underlying calvarium, resulting in the subsequent rupture of blood vessel.
• The bleeding is gradual; therefore, a cephalohematoma is typically not immediately evident at birth. A cephalohematoma instead develops during the following hours or days after birth, with the first one to three days of birth being the most common age of presentation.
• Because the cephalohematoma is deep to the periosteum, the boundaries are defined by the underlying calvarium. In other words, a cephalohematoma is confined and does not cross the midline or calvarial suture lines.

​

40

Clinical Features

• It may be unilateral or bilateral, and appears within hours of delivery as a soft, fluctuant swelling on the side of the head.  
• Limited by suture lines.  
• Rarely can cause anemia and hypotension  
• Resolves within 2 weeks to 3 months

Diagnosis

• Skull radiograph to identify skull fracture.
• CT scan if there is neurologic symptom

​

​

Treatment

• Mainly observation
• Transfusion
• Phototherapy

​

41

42

SUBGALEAL HEMORRHAGE �

• Also known as subaponeurotic hemorrhage.
• This is bleeding into the space between the galea aponeurotica and the periosteum, caused by rupture of emissary veins.
• The most common risk factor for subgaleal hemorrhage is vacuum assisted delivery.
• Diagnosis is clinical.
• Clinical features include: pallor, periorbital edema, increased head circumference, generalized scalp swelling, increased heart rate and pulse rate.
• Subgaleal hemorrhage can lead to hypovolemia

43

MANAGEMENT

• Vigilant observation
• Blood transfusion
• Phototherapy
• Surgery

44

TORTICOLLIS

• "Twisted neck"
• Mostly congenital
• Causes include: trauma to sternocleidomastoid muscle at birth most common cause), shortened neck, abnormal development of SCM,congenital abnormalities of the upper spine
• Features include: limited movement of head and neck, asymmetry of head and face

45

MANAGEMENT

• Physical therapy: passive muscle stretching exercises under the guidance of a physiotherapist.
• Surgery to correct the affected sternocleidomastoid muscle.

46

SHOULDER DYSTOCIA

• Shoulder dystocia occurs during the delivery when an infant's shoulders become lodged in the mothers pelvis.
• This occurs often when the baby is proportionately too big for the birth canal(Cephalopelvic disproportion)

​

47

TURTLE SIGN

• Appearance &retraction of the foetal head with erythematous puffy face indicates facial flushing from shoulder impaction with maternal pelvis

​

• TREATMENT

Dystocia can be managed:

• With uterotonic agents
• Assited fetal traction
• Through cesarean section
• Episiotomy

​

48

FRACTURES

49

SKULL FRACTURES

• Fractures of the skull are rare
• Fractures are ocassionally assiociated with intracranial hemorrahages seizures and death as contusion of the underlying brain may have occured
• Fractures may occur as a result of pressure from forceps, maternal symphysis pubis ,sacral promontory or ischial spines

50

LINEAR SKULL FRACTURES

The most common, cause no symptoms and require no treatment

• Usually affect the parietal bones
• The pathogenesis is related to compression from the application of forceps or from the skull pushing against he maternal symphysis or ischeal spines.
• It is rarely associated with dura tear, with leptomeningeal cyst.

​

51

DEPRESSED SKULL FRACTURES

• These are usually identations similar to that in a ping-pong ball
• They are usually a complication of forceps delivery or fetal compression

​

DIAGNOSIS

• X-RAY:is required to diagnose skull fractures

​

TREATMENT

Indications of nonsurgical management include

• Depressions less than 2 cm in width and depressions over a major venous sinus
• Without neurologic symptoms

​

52

Indications of surgery include

• Radiographic evidence of bone fragments in the cerebrum
• Presence of neurologic deficit
• Signs of increased intracranial pressure and cerebrospinal fluid beneath the galeal

53

54

LONG BONE FRACTURES

• Clinical features
• Flail extremity after delivery
• Deformity
• Decreased movement of the affected extremity
• Swelling, excessive crying and crepitus
• The Moro reflex is absent in the involved extremity

​

• Diagnosis
• Plain radiograph
• Treatment
• Immobilization and splinting
• Closed reduction and casting
• Spica cast and Pavilik Hamess

​

55

56

BASED ON OXYGEN DEPRIVATION

57

BIRTH ASPHYXIA

• Birth asphyxia refers to oxygen deprivation at birth.
• It is defined as interrupted gas exchange resulting in failure of a newborn to initiate and maintain spontaneous respiration after birth evident by delayed cry after birth or at least 1 minute after.

​

58

59

HYPOXIC ISCHAEMIC ENCEPHALOPATHY(HIE)

• HIE is the brain damage that results from insufficient levels of oxygen and blood flowing to the infant’s brain.
• It is characterized by clinical and laboratory evidence of acute or subacute brain injury due to asphyxia
• It may manifest as drowsiness, seizures and altered muscle tone
• Multiorgan systems involvement is the hallmark of HIE

​

60

• Three pathophysiologic mechanisms involved in an asphyxia event include:
• Loss of vascular autoregulation
• Altered CHO and energy metabolism
• Toxic effects of synaptically released excitatory amino acids

​

61

CLASSIFICATION OF HIE

1. MILD HIE
1. Muscle tone may be slightly increased and deep tendon reflexes may be brisk during the first few days.
2.  Transient behavioral abnormalities, such as poor feeding, irritability, or excessive crying or sleepiness (typically in an alternating pattern), may be observed.
3.  Typically resolves in 24h

​

2. MODERATE HIE

• The infant is lethargic, with significant hypotonia and diminished deep tendon reflexes
• The grasping, Moro, and sucking reflexes may be sluggish or absent.
• The infant may experience occasional periods of apnea

​

62

• Seizures typically occur early within the first 24 hours after birth.
• Full recovery within 1-2 weeks is possible and is associated with a better long-term outcome

3. SEVERE HIE

•  Seizures can be delayed and severe and may be initially resistant to conventional treatments.
• The seizures are usually generalized, and their frequency may increase during the 24-48 hours after onset, correlating with the phase of reperfusion injury
• As the injury progresses, seizures subside.
• At that time, wakefulness may deteriorate further, and the fontanelle may bulge, suggesting increasing cerebral edema

​

​

63

Other symptoms include the following:

• Stupor or coma is typical; the infant may not respond to any physical stimulus except the most noxious.
•  Breathing may be irregular, and the infant often requires ventilatory support.
•  Generalized hypotonia and depressed deep tendon reflexes are common.
• Neonatal reflexes (e.g, sucking, swallowing, grasping, Moro) are absent

64

• Disturbances of ocular motion, such as a skewed deviation of the eyes, nystagmus, bobbing, and loss of conjugate eye movements may be revealed by cranial nerve examination.
•  Pupils may be dilated, fixed, or poorly reactive to light.
•  Irregularities of heart rate and blood pressure are common during the period of reperfusion injury, as is death from cardiorespiratory failure.

​

65

GENERAL TREATMENT FOR BIRTH INJURIES

• Once this permanent brain damage occurs, much of the care available is supportive and palliative, with the exception of hypothermia therapy to reduce the severity of injury for hypoxic-ischemic encephalopathy (HIE).
• Hypothermia therapy should be given within the first six hours of birth.

​

66

• Babies with birth injuries are often provided with numerous therapies to help them maximize their skills and development. These include:
• physical therapy (to help with gross motor skills)
• occupational therapy (to help with fine motor skills)

​

67

PREVENTION

PRIMARY PREVENTION

• Early registration and regular follow ups for antenatal care services
• Screening of babies at risk and continuous fetal monitoring
• Manage existing health issue. Examples : diabetes, hypertension
• Administration of tocolytics to prevent preterm labor
• Proper attention during episiotomy
• Neck should not be unduly stretched

​

68

SECONDARY PREVENTION

• Immediate resuscitation
• Early diagnosis and prompt treatment
• Multidisciplinary approach to management

​

TERTIARY PREVENTION

• Physiotherapy

69

CONCLUSION

• Birth injuries occur due to mechanical injuries during delivery.
• Most birth injuries have a favorable outcome and are self limiting
• Nearly half of birth injuries are avoidable with early recognition and anticipation of obstetric risk factors.

​

70

REFERENCE

• Ojumah N, Ramdhan R C, Wilson C, et al. (December 12, 2017) Neurological Neonatal Birth Injuries: A Literature Review. Cureus 9(12): e1938. doi:10.7759/cureus.1938
• Chadwick LM, Pemberton PJ, Kurinczuk JJ. Neonatal subgaleal hematoma: associated risk factors, complications and outcome. J paediatr child health. 1996 June. 32(3): 228-32.
• Levine MG, Holroyde J, Woods JR Jr et al., birth trauma: Incidence and predisposing factors. Obstet Gynecol. 1984 Jun. 63(6): 792-5.

​

71

• Pius et al, incidence and characteristics of neonatal birth injuries in Maiduguri North-Eastern Nigeria, 2018

​

72

73