Clinical Teaching Birth Injuries

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BIRTH INJURIES

Introduction:

As a result of the birth process ,some injuries occur that may be minor, where as others may be

more serious. Parental reaction to any injury sustained by their newborn infant at birth may be

out of proportion to the harm that has occurred.

Birth injuries:

It is defined as those sustained during Labour and delivery. Birth injuries may be severe enough

to cause neonatal

death , still birth or number of morbidities.

Risk factors:

Maternal

Primiparity

Short stature

Maternal pelvic anomalies

Prolonged or extremely rapid labour

Oligohydramnios

Deep transverse arrest of descent of presenting part of the fetus

Foetal

fetal head

Foetal anomalies

Interventional/ inorganic

Versions& extractions

Types of birth trauma and management


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HEAD & NECK INJURIES

1. Associated with foetal monitoring

Fetal scalp blood sampling for the estimation of PH- heomorrhage and infection

Foetal scalp electrode for FHR monitoring

2. Cephal hematoma

Definitipon: Subsperiosteal collection of blood secondary to rupture of blood vessels between

the skull and periosteum; its extent is well delineated by the suture line over few days

Complication:

Resolution: Very slow resorption

Management:

hyperbilirubinemia and infection

Rule out bleeding disorders

4. Caput Succedaneum

Definition: Serosanguinous , subcutaneous, extraperitoneal fluid collection with poorly defined

margins, it may extend across the midline & over the surface line and is usually associated with

head moulding.

Complications:


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alopecia

5. Vacuum

Resolution:

Slow resolution

5. Vacuum caput:

Definition : Serosanguiness fluid collection well defined by the position of the vacuum extractor

on the scalp

Complications

bilirubinemia are very rare, local infection with scalp abrations andlacerations

Resolution:With in few hours after birth

Management:

Treatment for blood loss, hyperbilirubinemia and infection

Rule out bleeding disorders

6. Intracranial haemorrhages:

i. Subependymal haemorrhage- IVH


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Clinical features: Due to blood loss- shock, pallor , respiratorty distress , DIC, jaundice, bulging

ant. frontanel, excessive somnolence,, hypotonia, weakness , seizures, temperature instability,

brain stem signs( apnoea, lost extra ocular movements, facial weakness)

Investigation:

Others- ABC, Haematocrit- low , thrombocytopenia, prolonged PT, PTT& hyper

bilirubinemia

Complications:

Post hemorrhagic hydrocephalus

Management:

- to maintain temperature, oxygen, & humidity

cally active agents,

haemorrhagic hydrocephalus

ii. Posterior fossa haemorrhage

Clinical features:

Bulging frontanel, increasing head circumference, lethargy, irritability

Investigations:


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Management:

open surgical evacuation of the clots

in the patient with neurologic symptoms

iii. Ant. fossa haemorrhage

Clinical features:

Neurological manifestations- focal neurological signs, irritability , lethargy, focal seizures,

hemiparesis, gaze preferences, sixth nerve dysfunction, 3rd nerve compression- dilated and

poorly reactive pupil

Investigation:

Complication: Hydrocephalus rarely

Management:

-anticonvulsants, blood loss correction

Nursing consideration:

Vigilant observation of the baby for possible associated complications such as infection or

rarely blood loss and hypovolemia

7. Skull fractures

Bones involved- Frontal, parital, occipital

complications:


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Management:

ray and CT scan for diagnosis

- observation

- neurological evaluation

- rays at 8-12 weeks to look for growing fractures

8. Facial mandibular fractures

Features:

Dislocation of the cartilaginous nasal septumComplications:- craniofacial malformations, ocular, respiratory

& mastication problems

Management:

CT scan

Nursing considerations:


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9. Ocular injuries

Types:

a. retinal and subconjunctival haemorrhages- vaginal delivery

b. ocular and periorbital injuries- forceps delivery

c.

d. HYphaema, Vittreous haemorrhage

e. local lacerations

f. palpebral oedema

g. orbital fractures with abnormal extra ocular muscle function

h. lacrimal gland / duct damage

Management:

10. Ear injuries

Types:Haematoma of the external pinna- Cauliflower ear

- refractory perichondritis

- Haemotympanum & ossicular disarticulation

Management:

11. Sternocledomastoid (SCM )muscle injury

Pathology:

Injury to the SCM muscle/ fascia disruption during delivery


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haematoma formation

Torticollis

Management:

Nursing Management:

Tilting the head away from the affected side so that the ear can be brought into contact with

the opposite shoulder

Rotating the chin towards the tight SCM muscle. When head is in the stretched position , it

should be held there for about 10 seconds

The exercise should be done 4-6 times in a day with about 20 repetitions of each exercise at

each time.

The infant is positioned in the crib sothat the head is supported by sandbags in the corrected

positions. This is done to prevent the flattening of the occiput or the development of facial

asymmetry

looks towards the side of the tight muscle.

aches for them

B. CRANIAL NERVE , SPINAL CORD & PERIPHARAL NERVE INJURIES

Commonly associated with breech deliveryCause- Hyper extension , traction,& over stretching with simultaneous rotation

Types- Localized neurapraxia to complete nerve and cord transaction

1. Cranial nerve injuries


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i. Facial nerve injury

Cause:Compression by the forceps blades

Clinical features:

- Assymmetrical crying facies, mouth drawn to normal side, wrinkles are

more on the normal side, forehead and eyelid unaffected, nasolabial fold is absent on the

affected side , corner of the mouth droops on the affected side

Peripheral nerve injury:- Asymmetrical crying facies

Peripharal nerve branch injury- asymmetrical crying facies, paralysis limited to forehead, eye

or mouth

Mangement:

Protection of open eye- patches and synthetic tears 4th hourly

Nursing management:

by NG tube in order to prevent aspiration

ii. Recurrent laryngeal nerve injury

Clinical Feature;

Unilateral abductor paralysis(hoarse cry, respiratory stridor)

- Severe respiratory distress, asphyxia

Management:

Unilateral paralysis-small frequent feed to minimize risk of aspiration

l paralasis- intubation may be required

2. Spinal cord injuries

Cause:


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Clinical feature:

Low APGAR score

Motor function absent distal to the level of injury with loss of deep tenden reflexes

Management:

Neurological examinations and cervical spinal Xrays

T scan, myelogram, MRI if required

3. Cranial nerve root injuries

i. phrenic nerve palsy(C3, 4, & 5)

Unilateral and associated with brachial plexus injuries

Clinical features:

Respiratory distress ipsilaterally diminished breath sounds

Management:

USG/Fluroscopic studies- Paradoxical movements of the diaphragm

Refractory cases- diagphramatic placation, phrenic nerve pacing

Nursing management:

oxygen is given as necessary

improves


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may complicate the infants

condition

ii. Injuries to Brachial plexus

Clinical features:

Duchenne Erb paralysis(C5-6):

Affected arm in adducted and internally rotated with elbow extended (Waiters tip position)

The limb falls limply to the side of the body when passively adducted

Klumpkes paralysis (C7& T1)

intrinsic muscles of the hand are affected & grasp is absent( claw Hand)

the entire arm is flaccid , all reflexes are absent

Complications

Management:

Xray studies to rule out bony injury, chest examination to rule out diagphragmatic

involvement

-10 days( After resolution of the nerve edema)

Recovery:

-2 wks normal function

permanent deficit

Nursing Management:


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nonparalysed muscles cannot exert pull on the affected muscles

degrees and rotate internally at the shoulder with the elbow flexed so that the palm of the

hand is turned towards the head

neutral position and the hand is placed over a small pad

immobilization may be necessary for some infants.

-10 days , complete ROM exercises may be given gently several times each day inorder

to maintain muscle tone and prevent contraction deformity

Before or splint or brace is obtained , the nurse can pin the infants long shirt sleeve to the

mattress covering

coldness or discolouration and the skin for signs of irritation

be taught how to apply it properly and how to

provide the skin care

- affected hand first and on removingthe unaffected hand first

More physical contact and affection than normal child

C. BONE INJURIES

Common in breech delivery & shoulder dystocia in macrosomic infants

Cause: limb traction and rotation

1. Clavicular fracture

Most common injury

Clinical features:


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Palpable bony irregularity & sternocledomastoid muscle spasm

Management:

- ray studies of the chest, shoulders and cervical spine

2. Long bone injuries

Bones : Hemurus, femur

Clinical features:Swelling, crepitus and pain

Complication :injury to nerve in vicinity

Management :Splinting ; closed reduction & casting if required

3. Epiphyseal displacement

Cause :Rotation with strong traction

Clinical features:swelling, crepitus, pain

Management :X- ray not very useful as epiphyses are not ossified at birth Limb immobilization

for 10-14 days allows callus formation

D. INTRAABDOMINAL INJURIES

Types : Rupture/ Subscapular haemorrhage into liver spleen or adrenal gland

Clinical features:Abdominal distension, pallor, poor feeding, tachycardia, tachypnoea, shock etc

Management :Clinical examination and serial determinations of the haematocrit levels

-Abdominal USG

- Paracentesis in case of intraperitoneal bleeding

E. SOFT TISSUE INJURIES:

1) Patechiae and echymosis

eous resolution in 1 week.


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- Anemia; hyperbilirubinemia

2) Abrations And laceration

3) Subcutaneous fat necrosis

Clinical features :Appear in first two weeks of life Irregularly shaped , hard , non pitting,

subcutaneous plaque with overlying dusky, red purple discolouration

Sites :Cheeks, arms, back , buttocks, thighs

PREVENTION OF BIRTH INJURIES IN NEWBORN

A comprehensive antenatal and postnatal care is key to the success in the reduction of birth

trauma.

Antenatal Period:

the at risk babies

Intranatal period:

Normal delivery:

Preterm delivery:

Forceps delivery:

- LSCS

Ventouse delivery:

Vaginal breech delivery:


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Conclusion:

Since many of the birth injuries do not require treatment , the nurse can help to clear up the

misconceptions and alleviate anxieties by simple explanations.Assisting the parents to cope

with the more serious injuries requires more through explanations and constant support by

members of the health team.

Bibliography:

1. Wong D.L etal . Essentials Of Paediatric Nursing. 6th edition. Missouri: Mosby;2001

2. Marlow D.R. Redding B. Textbook of Paediatric nursing. 1st edition.Singapore: Harwourt Brace

& company; 1998

3. Judith S.A. Straight As in Pediatric Nursing. 2nd edition.Lippincott Williams and

Wilkins:Philadelphia; 2008

4. Parthasarathy IAP textbook of Paediatrics. 2nd edition. jaypee: NewDelhi; 2002

5. Hatfield N.T. Broadribbs introductory Paediatric nursing. 7th edition. Wolters Kluwer: New

Delhi; 2009

6. D.C Dutta. Textbook Of Obstetrics including Perinatology & Contraception. 6th edition. Central

Publication; Culcutta: 2004

7. Meharban Singh . Care of Newborn . 6th

edition. Published by Narinder K. Sagar; NewDelhi:2004

Clinical Teaching Birth Injuries

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