Traumatic Injuries Related to Labour&Birth (1)

TRAUMATIC INJURIES RELATED TO LABOUR&BIRTH

MIHAI CRAIU MD PhDIMCC ALFRED RUSESCU

BIRTH TRAUMA• In the delivery room all newborn should

be carefully inspected for birth-inflicted trauma.

• Any findings, even trivial ones should be fully documented and presented as soon as possible to parents

• Appropriate explanation and reassurance are needed in such instances.

BIRTH TRAUMA• Significant birth injury accounts for

fewer than 2% of neonatal deaths and stillbirths in the United States;

• Still occurs occasionally, ~ 6-8 injuries per 1000 live births.

• Infant mortality due to birth trauma is in US ~7.5 deaths per 100,000 live births

BIRTH TRAUMAEvents predisposig to birth

trauma:• Materno-foetal

disproportion (large fetuses >4.5Kg , or small & short mother)

• Malpresentation (breech or facial present.)

BIRTH TRAUMAEvents predisposig to

birth trauma:• Instrumental

delivery (forceps, vacuum-extraction, intrauterine manual version)

• Excessive traction during labour

• Twin pregnancies• C-section

BIRTH TRAUMA• Soft tissue

– Abrasions – Erythema petechia – Ecchymosis – Lacerations – Subcutaneous fat necrosis

• Skull – Caput succedaneum – Cephalhematoma – Linear fractures

• Face – Subconjunctival

hemorrhage – Retinal hemorrhage

• Musculoskeletal injuries – Clavicular fractures – Fractures of long bones – Sternocleidomastoid injury

• Intra-abdominal injuries – Liver hematoma – Splenic hematoma – Adrenal hemorrhage – Renal hemorrhage

• Peripheral nerve – Facial palsy – Unilateral vocal cord

paralysis – Radial nerve palsy – Lumbosacral plexus injury

INJURIES TO THE SCALP & SKULL

CAPUT SUCCEDANEUM• Caput succedaneum is a

serosanguineous, subcutaneous, extraperiosteal fluid collection with poorly defined margins;

• It is caused by the pressure of the presenting part against the dilating cervix.

CAPUT SUCCEDANEUM• Caput succedaneum extends across

the midline and over suture lines and is associated with head moulding.

• Caput succedaneum does not usually cause complications and usually resolves over the first few days.

• Management consists of observation only.

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

CEPHALHEMATOMA• This complication has a mean

incidence of 6 percent (range: 1 to 26 percent) in vacuum-assisted deliveries.

• The extent of hemorrhage may be severe enough to cause anemia and hTA, although this is uncommon.

CEPHALHEMATOMA• The resolving hematoma predisposes to

hyperbilirubinemia

• Linear skull fractures may underlie a cephalhematoma (5-20% cephalhematomas)

• Resolution occurs over weeks,

occasionally with residual calcification.

SUBGALEAL HEMATOMA• Subgaleal hematoma is

bleeding in the potential space between the skull periosteum and the scalp galea aponeurosis.

SUBGALEAL HEMATOMA• 90% of cases result from vacuum

applied to the head at delivery. • It has a high frequency of occurrence of

associated head trauma (40%), such as intracranial hemorrhage or skull fracture.

• Watch for significant jaundice. • In the absence of shock or intracranial

injury, the long-term prognosis is good.

SUBGALEAL HEMATOMA• A fluctuant boggy mass is developing over the

scalp (especially over the occiput).• It spreads across the whole calvaria;• The swelling may obscure the fontanelle and

cross suture lines (distinguishing from cephalhematoma).

• The swelling develops gradually 12-72 hours after delivery, although it may be noted immediately after delivery in severe cases.

• Patients with subgaleal hematoma may present with hemorrhagic shock.

BIRTH TRAUMA• Soft tissue

– Abrasions – Erythema petechia – Ecchymosis – Lacerations – Subcutaneous fat necrosis

• Skull – Caput succedaneum – Cephalhematoma – Linear fractures

• Face – Subconjunctival

hemorrhage – Retinal hemorrhage

• Musculoskeletal injuries – Clavicular fractures – Fractures of long bones – Sternocleidomastoid injury

• Intra-abdominal injuries – Liver hematoma – Splenic hematoma – Adrenal hemorrhage – Renal hemorrhage

• Peripheral nerve – Facial palsy – Unilateral vocal cord

paralysis – Radial nerve palsy – Lumbosacral plexus injury

Musculoskeletal injuries

Clavicular fractures Fractures of long bones Sternocleidomastoid injury

BIRTH TRAUMA• Musculoskeletal

injuries – Clavicular fractures – Fractures of long

bones – Sternocleidomastoi

d injury

CLAVICULAR FRACTURES• Most common newborn orthopedic

injury• Signs

– Pain with movement and Moro reflex – Pseudoparalysis of ipsilateral extremity– Sternocleidomastoid muscle spasm on

affected side – Crepitus at fracture site

CLAVICULAR FRACTURESManagement• Immobilize arm and

shoulder 7-10 days • Safety pin on infants

sleeve to shirtCourse• Palpable callus

formation in 7 - 10 days • Heals in 4 - 6 weeks

BIRTH TRAUMA• Musculoskeletal

injuries – Clavicular fractures – Fractures of long

bones – Sternocleidomastoi

d injury

FRACTURES OF LONG BONES• Exceptionally rare condition• frequency of birth fractures of long

bones was 0.02%*

* Salonen IS - Birth fractures of long bones. Ann Chir Gynaecol. 1991;80(1):71-3.

BIRTH TRAUMA• Musculoskeletal

injuries – Clavicular fractures – Fractures of long

bones – Sternocleidomastoi

d injury

STERNOCLEIDOMASTOID INJURY• Incidence of

congenital torticollis is 0.3-2.0 %

• The head is typically tilted in lateral bending toward the affected muscle and rotated toward the opposite side.

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 0.5-2 per 1000 live births.

BRACHIAL PLEXUS INJURY• Traumatic lesions associated with

brachial plexus injury include:– fractured clavicle (10%), – fractured humerus (10%), – subluxation of cervical spine (5%), – cervical cord injury (5-10%), – facial palsy (10-20%).

BRACHIAL PLEXUS INJURY• Erb palsyErb 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 is usually present.

BRACHIAL PLEXUS INJURY• Klumpke paralysisKlumpke paralysis

(C7-8, T1) is rare and results 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.