Birth Trauma

• Injuries to the baby as a result of mechanical forces during the birth process.
• Nature of the trauma can either be mechanical or neurologic injuries.
• Operational word is labour/delivery.
• Amniocentesis, complications of intrauterine transfusion, complications from neonatal resuscitation ARE NOT BIRTH TRAUMA.

• Fetal:
  • LGA (Large for Gestational Age)
  • Breech presentation
  • Abnormal presentation
  • Preterm birth
• Delivery Mechanisms:
  • Instrumental delivery
• Maternal:
  • Advanced maternal age
  • High parity
  • Pelvic anatomy issues (such as CPD, short stature)

Birth fractures most commonly involve the clavicle with or without humeral fracture or brachial plexus injury. These fractures can be difficult to diagnose as the infant may be asymptomatic. Treatment is usually reassurance.

Humeral fractures can result from LGA (large for gestational age) babies or mid-forceps delivery, inexperience of the obstetrician. There may be an absence of the Moro reflex. Diagnosis is confirmed with an X-ray of the affected limb. Treatment involves immobilization of the affected limb.

Femoral fractures are associated with risk factors such as twin gestation, breech presentation, and prematurity. Treatment involves immobilization.

Caput succedaneum refers to a diffuse oedematous swelling of the scalp caused by pressure during delivery, leading to fluid accumulation external to the periosteum.

• It exhibits diffuse edges and is not limited to the suture lines.
• This condition is typically present at birth and tends to resolve over several days.
• Treatment primarily involves supportive care.

Cephalhaematoma is caused by haemorrhage under the periosteum of the infant's skull.

• It results in the formation of a firm, distinct swelling laterally that does not cross the suture lines.
• Onset may be delayed, and it often increases in size over the first 12-24 hours. It remains palpable over the next 2-3 weeks, during which time it develops a calcified rim.
• Complications may include neonatal jaundice and skull fractures.

Subgaleal Haemorrhage occurs when bleeding is not confined by the periosteum, leading to potential massive blood loss. Depending on the accumulated blood volume, it can be felt as a firm or fluctuant mass with poorly defined edges that may extend to the neck or forehead.

• Subgaleal haemorrhages are usually life-threatening.
• Suspect subgaleal haemorrhage within the first 24 to 48 hours of life in a baby with increasing heart rate (HR) and occipitofrontal circumference (OFC), along with decreasing packed cell volume (PCV).

Erb-Duchenne Paralysis:

• Injury limited to the 5th and 6th cervical nerves.
• The infant loses power to abduct the arm, rotate the arm externally, and supinate the forearm.
• Characteristic position: adduction and internal rotation of the arm with pronation of the forearm.
• Moro reflex and biceps reflex are absent on the affected side.
• Power of extension of the forearm and hand grasp are retained.

Klumpke’s Paralysis:

• Rarer form of brachial palsy.
• Injury involves the 7th and 8th cervical nerves and the 1st thoracic nerve.
• Produces a paralysed hand and ipsilateral ptosis and miosis (Horner’s syndrome) if sympathetic fibers of T1 are also injured.

Treatment:

Consists of partial immobilization and appropriate positioning to prevent contractures.

Phrenic Nerve Injury:

• Unilateral involvement of the 3rd to the 5th cervical nerve with diaphragmatic paralysis.
• Associated symptoms: cyanosis, irregular and labored breathing, abdomen does not move with respirations, diminished breath sounds on the affected side.
• Diagnosis: Made by ultrasound (USS) revealing diaphragmatic elevation on the paralyzed side.
• Treatment: No specific treatment – oxygen, lying on the affected side.

Facial Nerve Palsy:

• Results from pressure over the facial nerve in utero, labor efforts, or forceps use during delivery.
• Paralysis is Flaccid and when complete, involves the entire side of the face including the forehead.
• Signs: Movement only on the non-affected side when crying, mouth drawn to the non-affected side, smooth forehead on affected side, eyelid cannot close, absent nasolabial fold, drooping corner of the mouth.

Liver:

• Cause: Damage during breech deliveries. LGA, prematurity, perinatal asphyxia may contribute.
• Signs: Mass on the right upper quadrant, nonspecific signs include poor feeding, jaundice, pallor, tachypnoea, tachycardia.
• Complications: Shock and death if haematoma breaks through the capsule.
• Diagnosis: Made by ultrasound (USS), prompt supportive therapy, surgical repair may be required.

Splenic Rupture:

• May occur alone or in combination with hepatic rupture.

Adrenal Haemorrhage:

• Causes: Seen in breech delivery, in LGA babies or infants of diabetic mothers. Trauma, infections, anoxia, or severe stress may contribute.
• Symptoms: Profound shock and cyanosis, flank mass with skin discoloration and jaundice.