Fetal Birth Injuries

1
Fetal Birth Injuries

• Dr. Ashraf Fouda
• Domiatte General Hospital

2
Definition

• The term birth injury is used to denote
• avoidable and unavoidable
• mechanical, hypoxic and ischemic injury
• affecting the infant
• during
• labor and delivery.

3
Definition

• Birth injuries may result from
• Inappropriate or deficient medical skill or
  attention.
• They may occur, despite skilled and competent
  obstetric care.

4
Incidence

• Has been estimated at 2-7/1,000 live births.
  Predisposing factors
• Macrosomia,
• Prematurity,
• Cephalopelvic disproportion,
• Dystocia,
• Prolonged labor, and
• Breech presentation.

5
Incidence

• 5-8/100,000 infants die of birth trauma, and
• 25/100,000 die of anoxic injuries
• Such injuries represent 2-3 of infant deaths.

6
Cranial Injuries
7
Erythema, abrasions, ecchymoses,

• Of facial or scalp soft tissues may be seen after
  forceps or vacuum-assisted deliveries.
• Their location depends on the area of application
  of the forceps.

8
Subconjunctival ,retinal hemorrhages and
petechiae of the skin of the head and neck

• All are common.
• All are probably secondary to a sudden increase
  in intrathoracic pressure during passage of the
  chest through the birth canal.
• Parents should be assured that they are temporary
  and the result of normal hazards of delivery.

9
Molding

• 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 disappear during the
  first weeks of life.
• Rarely, a hemorrhagic caput may result in shock
  and require blood transfusion.

10
Caput succedaneum

• 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.

11
Caput succedaneum

• Analogous swelling, discoloration, and distortion
  of the face are seen in face presentations.
• No specific treatment is needed, but if there are
  extensive ecchymoses, phototherapy for
  hyperbilirubinemia may be indicated.

12
Cephalhaematoma

• It is a subperiosteal haematoma most commonly
  lies over one parietal bone.
• It may result from difficult vacuum or forceps
  extraction .

13
Cephalhaematoma

• Management
• - It usually resolves spontaneously.
• - Vitamin K 1 mg IM is given.

14
(No Transcript)
15
(No Transcript)
16
Cephalohematoma

• Is a subperiosteal hemorrhage, so it is always
  limited to the surface of one cranial bone.
• There is no discoloration of the overlying scalp,
  and swelling is usually not 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.

17
Cephalohematoma

• Cranial meningocele
• is differentiated from cephalohematoma by
• Pulsation,
• Increased pressure on crying, and the
• Radiologic evidence of bony defect.
• 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.

18
Cephalohematoma

• A sensation of central depression suggesting( but
  not indicative )of an underlying fracture or bony
  defect is
• Cephalohematomas
• require no treatment, although phototherapy may
  be necessary to ameliorate hyperbilirubinemia.

19
Cephalohematoma

• Incision and drainage are 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.
• It may also be associated with a skull fracture,
  coagulopathy, and intracranial hemorrhage.

20
Diagnosis and Differential Diagnosis
21
Fractures of the skull

• May occur as a result of pressure from
• Forceps or from
• The maternal symphysis pubis.
• Sacral promontory, or
• Ischial spines.

22
Fracture Skull

• Usually occurs due to difficult forceps delivery.
• It may be
• (1) Vault fracture
• Usually affecting the frontal or parietal bone.
• It may be linear or depressed fracture.
• It needs no treatment unless there is
  intracranial haemorrhage.
• (2) Fracture base
• Usually associated with intracranial haemorrhage.

23
Fractures of the skull

• Linear fractures, the most common, cause no
  symptoms and require no treatment.
• Depressed fractures are usually indentations
  similar to a dent in a Ping-Pong ball they
  usually are a complication of forceps delivery or
  fetal compression.

24
Depressed fractures Ping-Pong ball
25
Fractures of the skull

• Affected infants may be asymptomatic unless there
  is associated intracranial injury.
• It is advisable to elevate severe depressions to
  prevent cortical injury from sustained pressure.

26
Fractures of the skull

• Fracture of the Occipital bone almost causes
  fatal hemorrhage due to disruption of the
  underlying vascular sinuses.
• It may result during breech deliveries from
  traction on the hyperextended spine of the infant
  with the head fixed in the maternal pelvis.

27
Intracranial- Intraventricular Hemorrhage
28
Intracranial Haemorrhage

• Causes
• Sudden compression and decompression of the head
  as in breech and precipitate labour.
• Marked compression by forceps or in cephalopelvic
  disproportion.
• Fracture skull.

29
Intracranial Haemorrhage

• Predisposing factors
• Prematurity due to physiological
  hypoprothrombinaemia, fragile blood vessels and
  liability to trauma.
• Asphyxia due to anoxia of the vascular wall .
• Blood diseases.

30
Intracranial Haemorrhage Sites

• Subdural results from damage to the superficial
  veins where the vein of Galen and inferior
  sagittal sinus combine to form the straight
  sinus.
• Subarachnoid The vein of Galen is damaged due to
  tear in the dura at the junction of the falx
  cerebri and tentorium cerebelli.
• Intraventricular into the brain ventricles.
• Intracerebral into the brain tissues .
• In (1) and (2) it is usually due to birth trauma,
  
• in (3) and (4) the foetus is usually a premature
  exposed to hypoxia.

31
Intracranial Haemorrhage

• Clinical picture
• 1- Altered consciousness.
• 2- Flaccidity.
• 3- Breathing is absent, irregular and periodic or
  gasping.
• 4- Eyes no movement, pupils may be fixed and
  dilated.
• 5- Opisthotonus, rigidity, twitches and
  convulsions.
• 6- Vomiting .
• 7- High pitched cry.   
• 8- Anterior fontanelle is tense and bulging.
• 9- Lumbar puncture reveals bloody C.S.F.

32
Intracranial Haemorrhage

• Investigations
• Ultrasound is of value.
• CT scan is the most reliable.
• MRI

33
Intracranial Haemorrhage

• Prophylaxis
• Vitamin K 10 mg IM to the mother in late
  pregnancy or early in labour.
• Episiotomy especially in prematures and breech
  delivery.
• Forceps delivery carried out by an experienced
  obstetrician respecting the instructions for its
  use.

34
Intracranial Haemorrhage Treatment

• Minimal handling, warmth and oxygen to the baby.
• No oral feeding for 72 hours.
• IV fluids.
• Vitamin K 1mg IM.
• Lumbar puncture is diagnostic and therapeutic to
  relieve the intracranial tension if the anterior
  fontanelle is bulging.
• Sedatives for convulsions.
• 60 cc. of 10 sodium chloride per rectum to
  relieve brain oedema.
• 1 cc of 50 magnesium sulphate IM to relieve
  brain oedema and convulsions.
• Antibiotics to guard against infections
  particularly pulmonary.

35
ETIOLOGY AND EPIDEMIOLOGY

• Intracranial hemorrhage may result from
• Birth trauma or
• Asphyxia and, rarely, from a
• Primary hemorrhagic disturbance or
• Congenital vascular anomaly.

36
ETIOLOGY AND EPIDEMIOLOGY

• Intracranial hemorrhages often involve the
  ventricles
• ( intraventricular hemorrhage IVH) of premature
  infants delivered spontaneously without apparent
  trauma.

37
CLINICAL MANIFESTATIONS

• The incidence of IVH increases with decreasing
  birthweight
• 60-70 of 500- to 750-g infants and
• 10-20 of 1,000- to 1,500-g infants.
• IVH is rarely present at birth however,
• 80-90 of cases occur between birth and the 3rd
  day .
• 50 occur on the 1st day.
• 20 to 40 of cases progress during the 1st wk of
  life.
• Delayed hemorrhage may occur in 10-15 of
  patients after the 1st wk of life.

38
CLINICAL MANIFESTATIONS

• The most common symptoms are
• Diminished or absent Moro reflex.
• Poor muscle tone.
• Lethargy.
• Apnea.
• Somnolence.

39
CLINICAL MANIFESTATIONS

• Periods of apnea,
• Pallor, or cyanosis
• Failure to suck well
• Abnormal eye signs
• A high-pitched cry
• Muscular twitches, convulsions, decreased muscle
  tone, or paralyses
• Metabolic acidosis shock, and a
• Decreased hematocrit or its failure to increase
  after transfusion may be the first indications.
• The fontanel may be tense and bulging.

40
DIAGNOSIS

• Intracranial hemorrhage is diagnosed on the basis
  of the
• History,
• Clinical manifestations,
• Transfontanel cranial ultrasonography or
• Computed tomography (CT), and

41
DIAGNOSIS

• Lumbar puncture
• is indicated in the presence of signs of
• Increased intracranial pressure or
• Deteriorating clinical condition
• to identify gross subarachnoid hemorrhage or to
  rule out the possibility of bacterial meningitis

42
PROGNOSIS

• Neonates with
• ( massive hemorrhage associated with tears of the
  tentorium or falx cerebri)
• rapidly deteriorate and may die after birth.

43
PREVENTION

• The incidence of traumatic intracranial
  hemorrhage may be reduced by
• judicious management of cephalopelvic
  disproportion and operative delivery.

44
PREVENTION

• Fetal or neonatal hemorrhage due to
• Maternal idiopathic thrombocytopenic purpura
  (ITP) or
• Alloimmune thrombocytopenia
• may be prevented by maternal treatment with
• Steroids,
• Intravenous immunoglobulin, or
• Fetal platelet transfusion.

45
PREVENTION

• The incidence of IVH may be reduced by antenatal
  steroids and by postnatal administration of
  low-dose indomethacin.
• Vitamin K should be given before delivery to all
  women receiving phenobarbital or phenytoin during
  the pregnancy.

46
TREATMENT

• Seizures are treated with anticonvulsant drugs.
• Anemia-shock, requires transfusion with packed
  red blood cells or fresh frozen plasma.
• Acidosis is treated with slow administration of
  sodium bicarbonate.

47
TREATMENT

• Symptomatic subdural hemorrhage in large term
  infants should be treated by removing the
  subdural fluid collection by means of a spinal
  needle placed through the lateral margin of the
  anterior fontanel.

48
Spine and Spinal Cord

• 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
• (may produce fracture and separation of the
  vertebrae).

49
Spine and Spinal Cord

• Such injuries, rarely diagnosed clinically, are
  most likely to occur with shoulder dystocia.
• 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.

50
(No Transcript)
51
Spine and Spinal Cord

• Transection of the cord may occur with or without
  vertebral fractures.
• Hemorrhage and edema may produce neurologic signs
  that are not distinguished from those of
  transection
• (except that they may not be permanent).

52
Spine and Spinal Cord

• Areflexia,
• Loss of sensation, and
• Complete paralysis of voluntary motion
• Occur below the level of injury

53
Spine and Spinal Cord

• If the injury is severe, the infant, (who may be
  in poor condition owing to respiratory
  depression, shock, or hypothermia),
• May deteriorate rapidly to death within several
  hours before neurologic signs are obvious.

54
Spine and Spinal Cord

• The course may be protracted, with symptoms and
  signs appearing at birth or later in the 1st wk
  may not be recognized for several days.
• Constipation may also be present.

55
Spine and Spinal Cord

• The diagnosis is confirmed by
• Ultrasonography or MRI.
• Treatment of the survivors is
• supportive, including home ventilation patients
  often remain permanently injured.

56
Peripheral Nerve Injuries
57
Brachial Plexus Palsy

• It is due to over traction on
• the neck as in
• Shoulder dystocia.     
• After-coming head in breech delivery.

58
Brachial Plexus Palsy

• Erb's palsy
• It is the common, due to injury to C5 and C6
  roots.
• The upper limb drops beside the trunk, internally
  rotated with flexed wrist
• (policemans or waiters tip hand).

59
Brachial Plexus Palsy

• (2) Klumpkes palsy
• It is less common,
• Due to injury to C7 and C8 and 1st thoracic
  roots.
• - It leads to paralysis of the muscles of the
  hand and weakness of the wrist and fingers'
  flexors.

60
Brachial Plexus Palsy

• Treatment
• Support to prevent stretching of the paralyzed
  muscles.
• Physiotherapy massage, exercise and faradic
  stimulation.

61
(No Transcript)
62
BRACHIAL PALSY

• Injury to the brachial plexus may cause paralysis
  of the upper arm with or without paralysis of the
  forearm or hand or, more commonly, paralysis of
  the entire arm.
• Approximately 45 are associated with shoulder
  dystocia.

63
BRACHIAL PALSY

• 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.

64
(No Transcript)
65
In Erb-Duchenne paralysis

• The injury is limited to the 5th and 6th cervical
  nerves.
• The characteristic position consists of
• ( Adduction and internal rotation of the arm with
  pronation of the forearm).
• Moro reflex is absent on the affected side

66
(No Transcript)
67
In Erb-Duchenne paralysis

• There may be some sensory impairment on the outer
  aspect of the arm.
• The power in the forearm and the hand grasp are
  preserved unless the lower part of the plexus is
  also injured
• (the presence of the hand grasp is a favorable
  prognostic sign).

68
Klumpke's 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,
• (Horner syndrome)
• If the sympathetic fibers of the 1st thoracic
  root are also injured paralyzed hand
  and ipsilateral ptosis and miosis.

69
Klumpke's paralysis

• The mild cases may not be detected immediately
  after birth.
• Differentiation must be made from
• Cerebral injury
• Fracture, dislocation, or epiphyseal separation
  of the humerus
• Fracture of the clavicle.
• MRI demonstrates nerve root rupture or avulsion

70
common
uncommon
edema and hemorrhage
Laceration
71
The prognosis

• Depends 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.

72
The prognosis

• Involvement of the deltoid is usually the most
  serious problem and may result in a shoulder drop
  secondary to muscle atrophy.
• In general, paralysis of the upper arm has a
  better prognosis than paralysis of the lower arm.

73
Treatment

• Partial immobilization and appropriate
  positioning to prevent development of
  contractures.
• In upper arm paralysis the arm should be
  abducted, with external rotation at the shoulder
  and with full supination of the forearm and
  slight extension at the wrist with the palm
  turned toward the face.

74
Treatment

• In lower arm or hand paralysis the wrist should
  be splinted in a neutral position and padding
  placed in the fist.
• Gentle massage and range of motion exercises may
  be started by 7-10 days of age.

75
Treatment

• If the paralysis persists without improvement for
  3-6 months neuroplasty, neurolysis, end-to-end
  anastomosis, or nerve grafting
• offers hope for partial recovery.

76
PHRENIC NERVE PARALYSIS

• 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.

77
PHRENIC NERVE PARALYSIS

• The diagnosis
• is established by ultrasonography or fluoroscopic
  examination, which reveals elevation of the
  diaphragm on the paralyzed side
• There is no specific treatment
• infants should be placed on the involved side
  and given oxygen if necessary.

78
PHRENIC NERVE PARALYSIS

• Recovery usually occurs spontaneously by 1-3
  months rarely, surgical plication of the
  diaphragm may be indicated.

79
Facial Palsy (Bells palsy)

• It is usually due to pressure by the forceps
  blade on the facial nerve at
• Its exit from the stylomastoid foramen or
• In its course over the mandibular ramus.
• - It appears within 1-2 days after delivery due
  to resultant oedema and haemorrhage around the
  nerve.

80
Facial Palsy (Bells palsy)

• Manifestations
• There is paresis of the facial muscles on the
  affected side with
• Partially opened eye and
• Flattening of the nasolabial fold.
• The mouth angle is deviated towards the healthy
  side.
• Spontaneous recovery usually occurs
• within 14 days.

81
FACIAL NERVE PALSY

• When the infant cries, there is movement only on
  the non paralyzed side of the face, and the mouth
  is drawn to that side.
• On the affected side the forehead is smooth, the
  eye cannot be closed, the nasolabial fold is
  absent, and the corner of the mouth drops.

82
FACIAL NERVE PALSY

• The prognosis depends on whether the nerve was
  injured by pressure or whether the nerve fibers
  were torn.
• Care of the exposed eye is essential.

83
FACIAL NERVE PALSY

• Improvement occurs within few weeks.
• Neuroplasty may be indicated when the paralysis
  is persistent.

84
Other peripheral nerves

• are seldom injured in utero or at birth except
  when they are involved in fractures or
  hemorrhages.

85
V) VISCERAL INJURIES

• (Liver, spleen and kidney)
• may be injured in breech delivery which should
  be avoided by holding the fetus from its hips.

86
Viscera (The liver )

• The liver is the only internal organ other than
  the brain that is injured with any frequency
  during birth.
• The damage usually results from pressure on the
  liver during delivery of the head in breech
  presentations.
• Incorrect cardiac massage is a less frequent
  cause.

87
Viscera (The liver )

• Hepatic rupture may result in the formation of a
  subcapsular hematoma.
• The hematoma may be large enough to cause anemia.
• Shock and death may occur if the hematoma breaks
  through the capsule into the peritoneal cavity.

88
Viscera (The liver )

• A mass may be palpable in the right upper
  quadrant the abdomen may appear blue.
• Early suspicion by means of ultrasonographic
  diagnosis and prompt supportive therapy can
  decrease the mortality of this disorder.
• Surgical repair of a laceration may be required.

89
Rupture of the spleen

• May occur alone or in association with rupture of
  the liver.
• The causes, complications, treatment, and
  prevention are similar.

90
Adrenal hemorrhage

• Occurs with some frequency, especially after
  breech delivery in LGA infants or infants of
  diabetic mothers.
• 90 are unilateral 75 are right sided.
• The symptoms are profound shock and cyanosis
• If suspected, abdominal ultrasonography may be
  helpful, and treatment for acute adrenal failure
  may be indicated

91
Fractures
92
BONE INJURIES

• These usually occur during difficult breech
  delivery.
• (A) Vertebral Column Injuries
• These are fatal if associated with spinal cord
  transection above C4 ,due to diaphragmatic
  paralysis.
• (B) Femur, Humerus and Clavicle
• Managed by splint to the long bone and a sling
  for clavicular fracture.

93
CLAVICLE

• This bone is fractured during labor and delivery
• more frequently than any other bone
• It is particularly vulnerable when there is
• Difficulty in delivery of the shoulder in vertex
  presentations and of
• The extended arms in breech deliveries.

94
(No Transcript)
95
CLAVICLE

• The infant characteristically does not move the
  arm freely on the affected side
• Crepitus and bony irregularity may be palpated,
  and
• Discoloration is occasionally visible over the
  fracture site.

96
CLAVICLE

• Treatment, consists of immobilization of the arm
  and shoulder on the affected side.
• A remarkable degree of callus develops at the
  site within a week and may be the first evidence
  of the fracture.
• The prognosis is excellent.

97
EXTREMITIES

• In fractures of the long bones, spontaneous
  movement of the extremity is usually absent.
• The Moro reflex is also absent from the involved
  extremity.
• There may be associated nerve involvement.

98
EXTREMITIES (Humerus)

• Satisfactory results of treatment for 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 bandage are applied, or
  a cast is applied.

99
EXTREMITIES

• In fracture femur good results are obtained
  with traction-suspension of both lower
  extremities, even if the fracture is unilateral
• The legs, immobilized in a cast, are attached to
  an overhead frame.
• Splints are effective for treatment of fractures
  of the forearm or leg.

100
EXTREMITIES

• Healing is usually accompanied by excess callus
  formation.
• The prognosis is excellent for fractures of the
  extremities.
• Fractures in preterm infants may be related to
  osteopenia

101
Dislocations and epiphyseal separations

• Rarely result from birth trauma.
• The upper femoral epiphysis may be separated by
  forcible manipulation of the infant's leg, as,
  for example, in breech extraction or after
  version.

102
Dislocations and epiphyseal separations

• The affected leg shows swelling, slight
  shortening, limitation of active motion, painful
  passive motion, and external rotation.
• The diagnosis is established radiologically
• The prognosis is good for the milder injuries.

103
MUSCLE INJURIES

• Strenomastoid injury
• Due to
• Exaggerated lateral flexion of the neck leading
  to torticollis and swelling in the muscle.
• It is usually improved within 2 weeks but
  permanent torticollis may continue.

104
Thank you