Fetal Birth Injuries by Abhishek Jaguessar

8/4/2019 Fetal Birth Injuries by Abhishek Jaguessar

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Fetal Birth Injuries

BYBY

ABHISHEK JAGUESSARABHISHEK JAGUESSAR


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Definition

The term birth injuryis usedto denote:

avoidable and unavoidablemechanical,hypoxic and

ischemic injuryaffecting the infant

during


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Birth injuries mayresult from :

1.Inappropriate ordeficient medical skill orattention.

2.They may occur, despite

Definition


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IncidenceHas been estimated at 2-

7/1,000 live births.Predisposing factors:

1.Macrosomia,

2.Prematurity,

3.Cephalopelvic disproportion,4.Dystocia,

5.Prolonged labor, and


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5-8/100,000 infants dieof birth trauma, and

25/100,000 die of anoxic

injuries;Such injuries represent 2-

3% of infant deaths.

Incidence


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Cranial Injuries


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Erythema, abrasions,

ecchymoses,Of facial or scalp soft

tissues may be seenafter forceps or vacuum-

assisted deliveries.Their location depends

on the area of


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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 duringpassage of the chest through the birth

canal.

Parents should be assured that they are

temporary and the result ofnormalhazards

of delivery.


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MoldingMolding of the head andoverriding of the parietal

bones are frequentlyassociated with caputsuccedaneum and becomemore evident after the caputhas receded but disappear

during the first weeks of life.


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Caput succedaneum

Diffuse, sometimes ecchymotic,edematous swelling of the softtissues of the scalp involving theportion presenting during vertexdelivery.

It may extend across the midlineand across suture lines.

The edema disappears within the


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Analogous swelling,discoloration, and distortion of

the face are seen in facepresentations.

No specific treatment isneeded, but if there areextensive ecchymoses,

hotothera for

Caput succedaneumCaput succedaneum


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CephalhaematomaCephalhaematoma

It is a subperiosteal

haematoma mostcommonly lies over

one parietal bone.It may result from


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Management:

- It usually resolvesspontaneously.

- Vitamin K 1 mg IM is given.

Cephalhaematoma


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Cephalohematoma

Is a subperiosteal hemorrhage, so it isalways limited to the surface of onecranial bone.

There is no discoloration of theoverlying scalp, and swelling isusually not visible until several hours

after birth, because subperiostealbleeding is a slow process.

An underlying skull fracture, usually

linear and not depressed, is


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Cranial meningoceleis differentiated fromcephalohematoma by:

1. Pulsation,2. Increased pressure on crying, and

the

3. Radiologic evidence of bony defect.

Most cephalohematomas are

resorbed within 2 wk-3 mo,

Cephalohematoma


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A sensation of centraldepression suggesting( but

not indicative )of anunderlying fracture or bony

defect isCephalohematomas

require no treatment,

Cephalohematoma


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Incision and drainage arecontraindicated because of therisk of introducing infection in a

benign condition.

A massive cephalohematoma

may rarely result in blood losssevere enough to requiretransfusion.

Cephalohematoma


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Diagnosis and Differential Diagnosis


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Fractures of the skull

May occur as a result ofpressure from :

1.Forceps or from2.The maternal symphysis

pubis.

3 Sacral promontory or


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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 depressedfracture.

It needs no treatment unless there is


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1.Linear fractures, the mostcommon, cause nosymptoms and require notreatment.

2.Depressed fractures are

usually indentations similarto a dent in a Ping-Pong ball;

they usually are a

Fractures of the skullFractures of the skull


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Depressed

fractures

Ping-Pong

ball


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Affected infants may beasymptomatic unless

there is associatedintracranial injury.

It is advisable to elevatesevere depressions to


f


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Fracture of the Occipitalbone almost causes fatalhemorrhage due to

disruption of the underlyingvascular sinuses.

It may result during breechdeliveries from traction on

the h erextended s ine of



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Intracranial Haemorrhage:

Causes:1. Sudden compression and

decompression of the head as inbreech and precipitate labour.

2. Marked compression by forceps or in

cephalopelvic disproportion.

3. Fracture skull.


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Predisposing factors:1. Prematurity due to physiological

hypoprothrombinaemia, fragileblood vessels and liability to

trauma.

2. Asphyxia due to anoxia of thevascular wall .

3. Blood diseases.



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1. Subdural : results from damage to the

superficial veins where the vein of Galenand inferior sagittal sinus combine toform the straight sinus.

2. Subarachnoid: The vein of Galen isdamaged due to tear in the dura at thejunction of the falx cerebri and

tentorium cerebelli.

3. Intraventricular :into the brainventricles.

4. Intracerebral : into the brain tissues .

In (1) and (2) it is usually due to birth

Sites:


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Clinical picture:

1- Altered consciousness.

2- Flaccidity.

3- Breathing is absent, irregular andperiodic or gasping.

4- Eyes: no movement, pupils may be fixedand dilated.

5- Opisthotonus, rigidity, twitches andconvulsions.

6- Vomiting .


I t i l


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Investigations:1. Ultrasound is of value.

2. CT scan is the most reliable.3. MRI

Intracranial

Haemorrhage


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Prophylaxis:1. Vitamin K: 10 mg IM to the

mother in late pregnancy orearly in labour.

2. Episiotomy: especially in

prematures and breech delivery.3. Forceps delivery: carried out by

an experienced obstetricianres ectin the instructions for



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1. Minimal handling, warmth and oxygen to the

baby.2. No oral feeding for 72 hours.

3. IV fluids.

4. Vitamin K 1mg IM.5. Lumbar puncture: is diagnostic and therapeutic

to relieve the intracranial tension if the anteriorfontanelle is bulging.

6. Sedatives for convulsions.

7. 60 cc. of 10% sodium chloride per rectum torelieve brain oedema.

8. 1 cc of 50% magnesium sulphate IM to relieve

Intracranial Haemorrhage Treatment


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ETIOLOGY AND EPIDEMIOLOGYETIOLOGY AND EPIDEMIOLOGYETIOLOGY AND EPIDEMIOLOGYETIOLOGY AND EPIDEMIOLOGY

Intracranialhemorrhage may

result from:1.Birth trauma or

2.Asphyxia and, rarely,from a


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Intracranial hemorrhagesoften involve the

ventricles( intraventricular

hemorrhage [IVH]) ofpremature infants

ETIOLOGY AND EPIDEMIOLOGY

CLINICAL MANIFESTATIONS


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The incidence of IVH increases

with decreasing birthweight:1. 60-70% of 500- to 750-g infants and

2. 10-20% of 1,000- to 1,500-g infants.

IVH is rarely present at birth;however,

1. 80-90% of cases occur between birthand the 3rd day .

2. 50% occur on the 1st day.

3. 20% to 40% of cases progress during



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The most commonsymptoms are:

1.Diminished or absent Mororeflex.

2.Poor muscle tone.3.Lethargy.

4 A nea




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1. Periods of apnea,

2. Pallor, or cyanosis;3. Failure to suck well;4. Abnormal eye signs;

5. A high-pitched cry;6. Muscular twitches, convulsions,

decreased muscle tone, or paralyses;

7. Metabolic acidosis; shock, and a8. Decreased hematocrit or its failure to

increase after transfusion may be

the first indications.


DIAGNOSIS


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DIAGNOSIS

Intracranial hemorrhage isdiagnosed on the basis ofthe:

1.History,

2.Clinical manifestations,3.Transfontanel cranial

ultrasonography or DIAGNOSIS


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Lumbar punctureis indicated in the presence

of signs of:1. Increased intracranialpressure or

2.Deteriorating clinicalcondition

DIAGNOSIS

PROGNOSIS


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PROGNOSIS

Neonates with:( massive hemorrhage

associated with tearsof the tentorium or

falx cerebri)rapidly deteriorate and

PREVENTION


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PREVENTION

The incidence oftraumatic intracranial

hemorrhage may bereduced by:

judicious managementof cephalopelvic

PREVENTION


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Fetal or neonatalhemorrhage due to:

1.Maternal idiopathic

thrombocytopenic purpura(ITP) or2.Alloimmune

thrombocytopeniamay be prevented by maternal

treatment with:

PREVENTION

PREVENTION


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The incidence of IVH may bereduced by antenatalsteroids and by postnatal

administration of low-doseindomethacin.

Vitamin Kshould be givenbefore delivery to all women

receiving phenobarbital or

PREVENTION

TREATMENT


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TREATMENTSeizures are treated withanticonvulsant drugs.

Anemia-shock, requirestransfusion with packed redblood cells or fresh frozen

plasma.

Acidosis is treated with slow

TREATMENT


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Symptomatic subduralhemorrhage in large

term infants should betreated by removing the

subdural fluid collectionby means of a spinal

needle placed through

TREATMENT

Spine and Spinal Cord


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Spine and Spinal CordStrong traction exerted:

1.When the spine ishyperextended or

2.When the direction of pull islateral, or

1.Forceful longitudinal tractionon the trunk while the headis still firmly engaged in the

pelvis:



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Such injuries, rarelydiagnosed clinically, are mostlikely to occur with shoulder

dystocia.The injury occurs most

commonly at the level of the4th cervical vertebra withcephalic presentations and



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S i d S i l C dS i d S i l C d


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Transection of the cord mayoccur with or without

vertebral fractures.Hemorrhage and edema

may produce neurologicsigns that are notdistinguished from those of

Spine and Spinal CordSpine and Spinal Cord


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1.Areflexia,

2.Loss of sensation,and

3.Complete paralysis ofvoluntary motion

Occur below the level


S i d S i l C dS i d S i l C d


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If the injury is severe,the infant, (who may be

in poor condition owingto respiratory

depression, shock, orhypothermia),

May deteriorate rapidly to




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The course may beprotracted, with

symptoms and signsappearing at birth or

later in the 1st wk; maynot be recognized for

several da s




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The diagnosis isconfirmed by :

Ultrasonography or MRI.Treatment of the

survivors is:

supportive including



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Peripheral Nerve

Injuries

Brachial Plexus Palsy:


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It is due to overtraction on

the neck as in:

1. Shoulder dystocia.

2. After-coming head in breech

delivery.

B hi l Pl P l


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(1)Erb's palsy:1.It is the common, due to

injury to C5 and C6 roots.2.The upper limb drops

beside the trunk, internallyrotated with flexed wrist

(policemans or waiters tip


Brachial Ple s Pals


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(2) Klumpkes palsy:- It is less common,

-Due to injury to C7 andC8 and 1st thoracic

roots.- It leads to paralysis of

the muscles of the hand




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Treatment Support to prevent

stretching of theparalyzed muscles.

Physiotherapy:massage, exercise and



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BRACHIAL PALSYBRACHIAL PALSY


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Injury to the brachialplexus may cause paralysisof the upper arm with orwithout paralysis of theforearm or hand or, more

commonly, paralysis of theentire arm.



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These injuries occur in :

1.Macrosomic infants and whenlateral traction is exerted on the

head and neck during delivery ofthe shoulder in a vertexpresentation,

1. When the arms are extendedover the head in a breech

presentation, or


ANATOMY OF THE BRACHIAL PLEXUS


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8

7

9

4

5

6

3

2

1

Roots

Trunks

Cords

Nerves

Ulnar

Median

Radial

7

8

9

5

Lateral

Posterior

Medial

4

6

Upper

Middle

Lower

1

2

3

InIn Erb Duchenne paralysisErb Duchenne paralysis


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InIn Erb-Duchenne paralysisErb-Duchenne paralysis

The injury is limited to the 5thand 6th cervical nerves.

The characteristic positionconsists of:

( Adduction and internalrotation of the arm with

pronation of the


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InIn Erb Duchenne paralysisErb Duchenne paralysis


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There may be some sensoryimpairment on the outeraspect of the arm.

The power in the forearm andthe hand grasp are preserved

unless the lower part of theplexus is also injured;

(the resence of the hand

InIn Erb-Duchenne paralysisErb-Duchenne paralysis

Klumpke's paralysisKlumpke's paralysis


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Klumpke s paralysisKlumpke s paralysisIs a rarer form of brachialpalsy;

Injury to the 7th and 8th

cervical nerves and the 1stthoracic nerve produces a

paralyzed hand,(Horner syndrome)

If the sympathetic fibers of the

Klumpke's paralysisKlumpke's paralysis


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The mild cases may not be

detected immediately afterbirth.

Differentiation must bemade from :

1. Cerebral injury;

2. Fracture, dislocation, orepiphyseal separation of the

humerus;

Klumpke s paralysisKlumpke s paralysis


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common uncommon

edema and hemorrhage Laceration

The prognosisThe prognosis


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The prognosisThe prognosisDepends on whether thenerve was merely injured orwas lacerated.

If the paralysis was due toedema and hemorrhage about

the nerve fibers, functionshould return within a few

months;



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Involvement of the deltoid isusually the most serious

problem and may result in ashoulder drop secondary tomuscle atrophy.

In general, paralysis of theupper arm has a better


TreatmentTreatment


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TreatmentTreatmentPartial immobilization andappropriate positioning toprevent development of

contractures.In upper arm paralysis: the

arm should be abducted, withexternal rotation at theshoulder and with full

TreatmentTreatment


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In lower arm or handparalysis: the wrist

should be splinted in aneutral position and

padding placed in thefist.

Gentle massage and range

TreatmentTreatment

TreatmentTreatment


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If the paralysis persistswithout improvement

for 3-6 months:neuroplasty, neurolysis,end-to-end anastomosis,

or nerve grafting

TreatmentTreatment

PHRENIC NERVE PARALYSISPHRENIC NERVE PARALYSIS


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Phrenic nerve injury (3rd,4th, 5th cervical nerves)with diaphragmatic

paralysis must beconsidered when cyanosis

and irregular and laboredrespirations develop.

Such in uries usuall



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The diagnosis

is established byultrasonography or

fluoroscopic examination,which reveals elevation of the

diaphragm on the paralyzedside

There is no specific treatment:




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Recovery usually

occursspontaneously by 1-

3 months; rarely,surgical plication of


Facial Palsy (Bells palsy):Facial Palsy (Bells palsy):


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Facial Palsy (Bells palsy):Facial Palsy (Bell s palsy):

- It is usually due to pressureby the forceps blade on the

facial nerve at:1. Its exit from the stylomastoid

foramen or2. In its course over the

mandibular ramus.

Facial Palsy (Bells palsy):Facial Palsy (Bells palsy):


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Manifestations:

1. There is paresis of the facial muscleson the affected side with:

2. Partially opened eye and:3. Flattening of the nasolabial fold.

4. The mouth angle is deviated towards

the healthy side.

Spontaneous recovery usually

occurs

Facial Palsy (Bell s palsy):Facial Palsy (Bell s palsy):

FACIAL NERVE PALSYFACIAL NERVE PALSY


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When the infant cries, there ismovement only on the non

paralyzed side of the face,and the mouth is drawn tothat side.

On the affected side theforehead is smooth, the eye

cannot e close the




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The prognosis dependson whether the nerve

was injured by pressureor whether the nerve

fibers were torn.Care of the exposed eye




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Improvementoccurs within fewweeks.

Neuroplasty may beindicated when the


Oth i h lOth i h l


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Other peripheralOther peripheral

nervesnerves

are seldom injuredin utero or at birth

except when theyare involved in

V) VISCERAL INJURIESV) VISCERAL INJURIES


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V) VISCERAL INJURIESV) VISCERAL INJURIES

((Liver, spleen andLiver, spleen and

kidney)kidney)may be injured inmay be injured in

breech delivery whichbreech delivery whichshould be avoided byshould be avoided by

holding the fetus fromholding the fetus from

Viscera (Viscera (The liver )The liver )


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Viscera (Viscera (The liver )The liver )The liver is the only internalorgan other than the brainthat is injured with any

frequency during birth.The damage usually results

from pressure on the liverduring delivery of the head inbreech presentations.



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Hepatic rupture may resultin the formation of asubcapsular hematoma.

The hematoma may belarge enough to causeanemia.

Shock and death may occur




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A mass may be palpable in

the right upper quadrant; theabdomen may appear blue.

Early suspicion by means ofultrasonographic diagnosis

and prompt supportivetherapy can decrease themortality of this disorder.

(( ))

Rupture of the spleenRupture of the spleen


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Rupture of the spleenRupture of the spleen

May occur alone or in

association with rupture of the

liver. The causes, complications,

treatment, and prevention aresimilar.

Adrenal hemorrhageAdrenal hemorrhage


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ggOccurs with some frequency,

especially after breech deliveryin LGA infants or infants ofdiabetic mothers.

90% are unilateral; 75% are rightsided.

The symptoms are profoundshock and cyanosis

If suspected abdominal


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FracturesFractures

BONE INJURIES


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BONE INJURIES

These usually occur duringdifficult breech delivery.

(A) Vertebral Column

Injuries:These are fatal if associated with

spinal cord transection above C4 ,dueto diaphragmatic paralysis.

(B) Femur, Humerus and

Clavicle:

CLAVICLE


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This bone is fractured during

labor and delivery

more frequently than any

other bone;

It is particularly vulnerable

when there is:1. Difficulty in delivery of the

shoulder in vertex


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CLAVICLE


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The infant characteristicallydoes not move the arm

freely on the affected side;Crepitus and bonyirregularity may bepalpated, and

Discoloration is occasionally

CLAVICLE

CLAVICLE


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Treatment, consists ofimmobilization of the armand shoulder on the

affected side.

A remarkable degree of

callus develops at the sitewithin a week and may be

EXTREMITIES


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EXTREMITIES

In fractures of the longbones, spontaneousmovement of the extremityis usually absent.

The Moro reflex is alsoabsent from the involvedextremity.

(Humerus)


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Satisfactory results oftreatment for a fracturedhumerus are obtained with

2-4 wk of immobilization

(during which the arm isstrapped to the chest).

A triangular splint and a

(Humerus)

EXTREMITIES


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In fracture femur : goodresults are obtained withtraction-suspension of both

lower extremities, even if thefracture is unilateral;

The legs, immobilized in acast, are attached to anoverhead frame.

EXTREMITIESEXTREMITIES


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Healing is usuallyaccompanied by excess

callus formation.Theprognosis is

excellent for fractures ofthe extremities.

EXTREMITIESEXTREMITIES

Dislocations andDislocations and


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Dislocations andDislocations and

epiphyseal separationsepiphyseal separationsRarely result from birth

trauma.The upper femoral epiphysis

may be separated byforcible manipulation of the

infant's le as for exam le


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MUSCLE INJURIESMUSCLE INJURIES


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MUSCLE INJURIES

Strenomastoid injuryDue to :

Exaggerated lateral flexionof the neck leading to

torticollis and swelling in themuscle.

It is usually improved within


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Fetal Birth Injuries by Abhishek Jaguessar

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