46-Fetal Birth Injuries

FETAL BIRTH INJURIES

Fetal birth injuries represent an

important commonly avoidable cause of neonatal morbidity and mortality. They vary from minor skin abrasions to severe intracranial haemorrhage. Prevention of serious birth trauma depends mainly upon the art of obstetrics and the experience of the obstetrician, and is considered a reflection of the improvements in antenatal and perinatal care.

TYPES OF FETAL BIRTH INJURIESBone injuries: 1-Skull fracture: Etiology: Difficult forceps delivery. Delivery through a contracted pelvis. Types: Fracture vault: linear or depressed (associated with intra-cranial haemorrhage so needs surgical intervention). Fracture base: usually associated with intra-cranial haemorrhage. Fracture mandible

Bone injuries2-Others bone injuries: Spine injuries. Fracture humerus Fracture femur. Fracture clavicle. Dislocation of hip. Dislocation of shoulders

Soft tissue birth injuries1-Intra-cranial haemorrhage over compression of cranial bones). 2-Cephalhaematoma (instrumental trauma especially ventouse). 3-Nerve Injuries (undue traction on neck, shoulders, and arms). 4-Visceral and Muscle Injuries. 5-Eye Injury. 6-Injury of hymen, or anal sphincter especially in breech presentation, during examination. 7-Skin and scalp Injuries by the scalpel on opening the uterus in a C.S.

INTRA-CRANIAL HAEMORRHAGEAETIOLOGY: Prematurity, due to: Fragile blood vessels. Hypoprothrombinaemia. Increased susceptibility to birth trauma. Breech delivery: due to sudden compression and decompression of cranial bones.

Aetiology Excessive compression, due to:Excessive moulding, in cases of cephalopelvic disproportion. Excessive compression by forceps (oblique application or persistent locking). Asphyxia: leads to hypoxia of the walls of blood vessels with subsequent leakage. Hemorrhagic disease of the newborn.

Sites of Haemorrhage: Intra-ventricular haemorrhage. Intra-cerebral haemorrhage. Subdural haemorrhage. Subarachnoid haemorrhage

Subdural and subarachnoid haemorrhages usually develop with traumatic delivery. The vein of Galen is torn due to tear in dura at jnction of falx cerebri with tentorium cerebelli (that results from excessive moulding due to increased antero-posterior diameter of the head)

Clinical features Stillbirth or neonatal asphyxia. Drowsy, refuse suckling with

sudden sharp cry. Convulsions and rigidity. Tense bulging anterior fontanelle. Vomiting

Differential Diagnosis Asphyxia neonatorum. Neonatal convulsions

Investigations: Brain CT scan.

TreatmentProphylactic Treatment Breech delivery: see breech presentation. Premature delivery: see prematurity. Vitamin K for the mother (10 mg IM early in labour when we suspect difficult delivery) Careful forceps application.

TreatmentActive Treatment Resuscitation with minimal handling. Chloral hydrate, Magnesium sulphate 50% 1 cc and Luminal. NaCl per rectum for edema. Dehydrating measures even lumbar puncture. Vitamin K for the fetus (1 mg IM). N.B.: Penicillin is used for prophylaxis against infection

3. NERVE INJURIES . Facial Nerve Palsy . Brachial Plexus Injury

Facial nerve palsy Cause:Compression of the nerve by blade of forceps results in edema and haematoma around the nerve. Clinical picture: unilateral and temporary Absent nasolabial fold. Angle of the mouth is deviated to the healthy side. Absent blinking on the affected side. Treatment: Conservative management. May need corticosteroids.

Bracial plexus injury Cause:Forcible lateral flexion of the head during delivery causes damage of the roots of brachial plexus (edema and haematoma around the nerves).

Bracial plexus injuryClinical picture: Upper injury (Erbs palsy):

Injury to C5 and C6.

Characters: Policeman tip position: The affected limb is adducted to the body and internally rotated. Elbow is extended. Wrist is flexed.

Bracial plexus injury Lower injury (Klumpke's palsy):

Injury to C7, C8 and T1.Characters: Wrist drop. Absent grasp reflex. Paralysis of small muscles of hands (atrophy).

Brachial plexus injury Treatment: Upper injury (Erb's palsy):Fixation ofthe affected limb in pharaohs position. Lower injury (Klumpkes palsy): Physiotherapy. Rarely, it may need plastic correction.

4. VISCERAL AND MUSCLE INJURY Visceral Injury:e.g. liver, spleen. It may occur during breech delivery

Muscle Injury: (Especially sternomastoid muscle) Cause: due to forcible traction onthe head (tilting of the head towards the affected side Clinical picture: It may subside or cause permanent torticollis Treatment: by passive stretching of muscle several times/day

Cepalhaematoma ( subperiosteal ) Cause Appearance Character Edges Skin Sutures Complications Treatment

Forceps or

ventouseDifficult delivery through contracted pelvis Few hours after birth

Well defined Normal No overlap & limited to one boneCalcification, infection and hyperbilirubinaemia Expectant treatment (disappears within few weeks)

Caput succedaneum Cause Appearance Edges Skin Sutures

Treatment Complications

Obstructed labour Ventouse At birth ILL defined May be ecchymotic Overlap sutures and cover more than 1 bone No treatment (disappears after 1 -2 days)