BIRTH TRAUMA BIRTH INJURY
Category: Child Health
Abstract : Birth injuries to the infant resulting from mechanical forces (ie, compression,
traction) during the process of birth are categorized as birth trauma. Factors
responsible for mechanical injury may coexist with hypoxic-ischemic insult. One
may predispose the infant to the other. Lesions that are predominantly hypoxic
in origin are not discussed in this article. Significant birth injury acco
Birth injuries to the infant resulting from mechanical forces (ie, compression,
traction) during the process of birth are categorized as birth trauma. Factors
responsible for mechanical injury may coexist with hypoxic-ischemic insult. One
may predispose the infant to the other. Lesions that are predominantly hypoxic
in origin are not discussed in this article.
Significant birth injury accounts
for fewer than 2% of neonatal deaths and stillbirths in this country. It still
occurs occasionally and unavoidably with an average of 6-8 injuries per 1000
live births. In general, larger infants are more susceptible to birth trauma.
Higher rates are reported for infants weighing more than 4500 g
Most
birth traumas are self-limiting and have a favorable outcome. Nearly half are
potentially avoidable with recognition and anticipation of obstetric risk
factors. Infant outcome is the product of multiple factors. Separating the
effects of a hypoxic-ischemic insult from those of traumatic birth injury is
difficult.
Risk factors include large-for-date infants, especially larger
than 4500 g; instrumental deliveries, especially forceps (midcavity) or vacuum;
vaginal breech delivery; and abnormal or excessive traction during
delivery.
Mortality/morbidity: Birth injuries account for fewer than 2%
of neonatal deaths. From 1970-1985, rates of infant mortality resulting from
birth trauma fell from 64.2 to 7.5 deaths per 100,000 live births, a remarkable
decline of 88%. This decrease reflects, in part, the technologic advancements
for today's obstetrician to recognize birth trauma risk factors by
ultrasonography and fetal monitoring prior to attempting vaginal delivery. Use
of potentially injurious instrumentation such as midforceps rotation and vacuum
delivery has also declined. The accepted alternative is a cesarean
delivery.
Causes: The process of birth is a blend of compression,
contractions, torques, and traction. When fetal size, presentation, or
neurologic immaturity complicates this event, such intrapartum forces may lead
to tissue damage, edema, hemorrhage, or fracture in the neonate. The use of
obstetric instrumentation may further amplify the effects of such forces or may
induce injury alone. Under certain conditions, delivery by cesarean delivery can
be an acceptable alternative, but it does not guarantee an injury-free
birth.
Factors predisposing to injury include the following:
• Prima
gravida
• Cephalopelvic disproportion, small maternal stature, maternal
pelvic anomalies
• Prolonged or rapid labor
• Deep transverse arrest of
descent of presenting part of the fetus
• Oligohydramnios
• Abnormal
presentation (breech)
• Use of midcavity forceps or vacuum extraction
•
Versions and extractions
• Very low birth weight infant or extreme
prematurity
• Fetal macrosomia
• Large fetal head
• Fetal anomalies
INJURIES WITH FAVORABLE LONG-TERM PROGNOSIS
• Soft tissue
o
Abrasions
o Erythema petechia
o Ecchymosis
o Lacerations
o
Subcutaneous fat necrosis
• Skull
o Caput succedaneum
o
Cephalhematoma
o Linear fractures
• Face
o Subconjunctival
hemorrhage
o Retinal hemorrhage
• Musculoskeletal injuries
o Clavicular
fractures
o Fractures of long bones
o Sternocleidomastoid injury
•
Intra-abdominal injuries
o Liver hematoma
o Splenic hematoma
o Adrenal
hemorrhage
o Renal hemorrhage
• Peripheral nerve
o Facial palsy
o
Unilateral vocal cord paralysis
o Radial nerve palsy
o Lumbosacral plexus
injury
Soft tissue injury is associated with fetal monitoring,
particularly with fetal scalp blood sampling for pH or fetal scalp electrode for
fetal heart monitoring, which has a low incidence of hemorrhage, infection, or
abscess at the site of sampling.
Cephalhematoma
Cephalhematoma is a
subperiosteal collection of blood secondary to rupture of blood vessels between
the skull and the periosteum; suture lines delineate its extent. Most commonly
parietal, cephalhematoma may occasionally be observed over the occipital
bone.
The extent of hemorrhage may be severe enough to cause anemia and
hypotension. Resolving hematoma predisposes to hyperbilirubinemia. Rarely,
cephalhematoma may be a focus of infection leading to meningitis or
osteomyelitis. Linear skull fractures may underlie a cephalhematoma (5-20% of
cephalhematomas). Resolution occurs over weeks, occasionally with residual
calcification.
No laboratory studies usually are necessary. Skull
radiography or CT scanning is used if neurologic symptoms are present. Usually,
management consists of observation only. Transfusion and phototherapy are
necessary if blood accumulation is significant. Aspiration is more likely to
increase the risk of infection. The presence of a bleeding disorder should be
considered. Skull radiography or CT scanning is also used if concomitant
depressed skull fracture is a possibility.
Subgaleal
hematoma
Subgaleal hematoma is bleeding in the potential space between the
skull periosteum and the scalp galea aponeurosis. Ninety percent of cases result
from vacuum applied to the head at delivery. Subgaleal hematoma has a high
frequency of occurrence of associated head trauma (40%), such as intracranial
hemorrhage or skull fracture. The occurrence of these features does not
correlate significantly with the severity of subgaleal hemorrhage.
The
diagnosis is generally a clinical one, with a fluctuant boggy mass developing
over the scalp (especially over the occiput). The swelling develops gradually
12-72 hours after delivery, although it may be noted immediately after delivery
in severe cases. The hematoma spreads across the whole calvarium. Its growth is
insidious, and subgaleal hematoma may not be recognized for hours. Patients with
subgaleal hematoma may present with hemorrhagic shock. The swelling may obscure
the fontanelle and cross suture lines (distinguishing it from cephalhematoma).
Watch for significant hyperbilirubinemia. The long-term prognosis generally is
good.
Laboratory studies consist of a hematocrit evaluation. Management
consists of vigilant observation over days to detect progression. Transfusion
and phototherapy may be necessary. Investigation for coagulopathy may be
indicated.
Caput succedaneum
Caput succedaneum is a serosanguinous,
subcutaneous, extraperiosteal fluid collection with poorly defined margins. It
is caused by the pressure of the presenting part against the dilating cervix.
Caput succedaneum extends across the midline and over suture lines and is
associated with head moulding. Caput succedaneum does not usually cause
complications. It usually resolves over the first few days. Management consists
of observation only.
Abrasions and lacerations
Abrasions and
lacerations sometimes may occur as scalpel cuts during cesarean delivery or
during instrumental delivery (ie, vacuum, forceps). Infection remains a risk,
but most heal uneventfully. Management consists of careful cleaning, application
of antibiotic ointment, and observation. Bring edges together using
Steri-Strips. Lacerations occasionally require suturing.
Subcutaneous fat
necrosis
Subcutaneous fat necrosis is not usually detected at birth.
Irregular, hard, nonpitting, subcutaneous plaques with overlying dusky
red-purple discoloration on the extremities, face, trunk, or buttocks may be
caused by pressure during delivery. No treatment is necessary. Subcutaneous fat
necrosis sometimes calcifies.
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