Birth Injury and Trauma
Even a “normal” vaginal delivery can bring trauma and physical injury to a newborn. Birth injuries happen as a result of mechanical forces (forceps and vacuum), compression (pressure from labor), and traction (the baby gets stuck requiring pulling) during delivery. Problems at birth related to lack of oxygen are not discussed in this article. Birth trauma can happen either from the pressure of a prolonged labor, the small or irregular size of the mother’s pelvis, or certain delivery procedures like forceps or a vacuum to deliver the baby. Injuries can also happen if the fetus is in a breech or transverse position inside the mother’s uterus or with a premature birth. In general, large babies (over 4500g or 9lbs 14.73oz) are more likely to sustain birth injuries. Most injuries and trauma are temporary and reversible while others are permanent and there is no treatment to correct them.
Risk Factors for Birth Injuries
Factors that increase the risk for an injury to the baby during birth include:
- it’s the mother’s first birth
- the baby’s head is too large to fit through the mother’s pelvis
- labor that lasts longer than 24 hours
- pregnancy that goes longer than 42 weeks
- a quick (rapid) labor
- the baby stops moving down into the pelvis
- too little amniotic fluid
- abnormal presentation of the baby — feet first, shoulder first
- forceps or vacuum delivery
- baby needing to be turned or extracted
- very low birth weight or the baby is very premature (preterm birth)
- a very large birth weight baby
- large fetal head
- the fetus has a developmental disorder
Types of Birth Injuries
Assisted delivery—using vacuum extraction or forceps—can cause minor injuries to the baby. There may be bruising, swelling, tissue damage, and/or, very rarely, fractures. These minor injuries usually heal within a few weeks. The number of assisted deliveries has gone down due to the increase in the number of cesareans in recent years.
Injuries caused during delivery are categorized based on the type and location of the injury and include:
- head and face injuries
- neck injuries
- peripheral nerve injuries
- spinal cord injuries
- bone injuries
Head and Face Injuries
Checking out your newborn is normal. This article explains normal findings on a newborn’s head.
Caput Succedaneum is a swelling of the soft tissues and forms on the surface of the newborn’s head during a head-first delivery. This condition is caused from pressure created by the uterus pushing the baby’s head against the dilating cervix. It is more likely to occur during a prolonged delivery. It is also associated with head molding and too little amniotic fluid to cushion the baby’s head. During a delivery using a vacuum device, this condition is known as vacuum caput.
There may or may not be bruising or redness. It is most often seen on the part of the head that presents first. The swelling usually resolves on its own within a few days and does not cause complications or permanent injury.
Similar to caput succedaneum, subgaleal hematoma is also caused by pressure from the uterus, especially during a birth using vacuum extraction. The vacuum assist breaks the veins and blood accumulates under the skin in the space between the skull bones and the scalp. The swelling usually develops between 12-72 hours after birth. The bleeding may extend from around the eyes towards the ears or even cover the entire calvaria (skullcap or top o the head). This injury may be associated with anemia, low blood pressure, persistent metabolic acidosis, or hyperbilirubinemia. Because this condition is not easily identified, careful monitoring is required after the birth of the baby. On diagnosis, the baby should be constantly watched and monitored. In there is significant blood loss, fluids or blood transfusion may be needed. Phototherapy may also be considered in severe cases.
Cephalhematoma is a when the hemorrhage occurs between the skull and the periosteum. In this condition, the hemorrhage is limited as it occurs only over a single bone. In a very few cases, there may be an underlying bone fracture. The newborn may need testing for anemia or hyperbilirubinemia as a result of the hematoma being absorbed. Cephalhematoma usually requires no special treatment and resolves on its own over a few weeks.
This hemorrhage occurs in and around the brain mainly due to pressure during delivery or variation in blood pressure. Intracranial hemorrhage usually happens in deliveries of a premature baby. Presence of hematologic disorders, like hemophilia or a vitamin K deficiency, also increases the risk of intracranial hemorrhage. Hemorrhage at the subarachnoid space is the most common intracranial hemorrhage. Symptoms include breathing problems, seizures, and sluggishness. Intracranial hemorrhage is also associated with meningeal inflammation which results in non-obstructive hydrocephalus as the baby grows.
Subdural hemorrhage is caused by tears in the blood vessels. Subdural hemorrhage happens mainly in a difficult delivery, first time delivery, or when the baby is very large. Symptoms include an enlarging head, seizures, poor startle reflex and/or bleeding of the blood vessels in the retina. The most serious kind of intracranial hemorrhage is intraventricular and/or intraparenchymal hemorrhage. Hemorrhage generally occurs within three days of birth. In most cases, there are no symptoms, but in larger hemorrhages, symptoms include a bluish color to the skin, apnea (breathing problems) or even sudden collapse.
Though very rare, this condition can be caused by pressure in the blood vessels from using forceps or vacuum during delivery. In this condition, blood accumulates beneath the aponeurosis (that is the sheet-like fibrous tissue that connects muscles) of the skull. This is an emergency condition and requires an immediate blood transfusion to replace lost blood.
Other Head Injuries
Other head injuries include cuts and bruises that can happen during cesarean delivery or instrumental delivery with a vacuum or forceps. Infection can be a risk in these type injuries but most heal without problems. Steri-Strips may be used or sometimes cuts require stitches.
A plexus is a network of nerves that supplies a specific area of the body.
Brachial Plexus Injuries
The brachial plexus is the nerve network that originates in the neck and shoulder controls the movement and sensation of the shoulder, arm and hand. Brachial plexus injuries range from a simple tear to hemorrhage within a nerve to severing of the nerve root from the spinal cord. These injuries happen most often in large babies. Dislocations or fractures of clavicle or humerus may also be present with this injury. Brachial Plexus injuries are usually caused due to breech (legs first) delivery, shoulder dystocia (where the shoulder gets stuck in the birth canal) or stretching of the neck in a cephalic (head-first) presentation. Brachial plexus injuries can be categorized into two types depending on the location of the injury. An upper brachial plexus injury, that is C5-C6, affects the shoulder and elbow. A lower brachial plexus injury is rare, that is C7-C8, T1, and affects the muscles of the forearm and hand.
One example of an upper brachial nerve injury is Erb’s palsy or Duchenne-Erb paralysis. This is the most common form of brachial plexus injury. In this condition damaged tissue in the upper brachial nerve causes palsy of the muscles of the upper arm and shoulder girdle. Treatment includes immobilization of the arm and passive range-of-motion exercises from the time the baby is a week old to prevent contractures.
Klumpke’s palsy or Dejerine-Klumpke palsy is caused from a lesion in the lower brachial nerve. In this condition there is paralysis of the lower forearm and hand. Treatment is passive range-of-motion exercises for all joints in the affected arm.
In both of Erb’s palsy and Klumpke’s palsy no major treatment is required and both usually resolve on their own by the time the baby is 3 months old. However, if problems continue, an MRI can be done to identify the extent of the injury and determine if surgical correction can be done to correct the problem. If the entire brachial plexus is injured, neurosurgical corrections may be needed but the outcome is poor and the chances are that the affected arm will have impaired growth.
Sternocleidomastoid Hematoma (congenital torticollis)
In this condition, the head of the baby is twisted to one side. This is generally caused due to the tightness of the sternocleidomastoid muscles (that is the muscle between the breastbone and collarbone that connects them to the skull behind the ear). The muscles can tighten during delivery or can be in that position in the mother’s womb. Congenital torticollis can also be caused by an abnormality of the vertebrae in the neck, such as fused bones or abnormal bone formation. Torticollis caused by an abnormality of the bones is called Klippel-Feil syndrome. If torticollis is diagnosed, the baby should be thoroughly tested to find out the cause since the treatment procedures and stretching exercises for congenital torticollis can cause serious problems if used to treat Klippel-Feil syndrome.
Cranial and spinal cord injuries can result from hyperextension, traction, and overstretching while rotating. Injury can range from localized paralysis to complete nerve or spinal cord damage.
Cranial Nerve Injuries
Among the 12 cranial nerves, the facial nerve is most prone to trauma during a vaginal delivery. Injury can be caused by the position of the fetus, the presence of uterine fibroids or pressure of forceps used during delivery. In most cases, the compression happens when the head passes by the sacrum. This condition often results in facial asymmetry because the facial muscles controlled by the injured nerve cannot move. It is visible when the baby cries — one side of the face smooth while the other side wrinkles up. Another form of this injury is mandibular asymmetry where both sides of the face can move but the maxillary and mandibular surfaces are not parallel. These conditions do not need treatment and usually resolve on their own in a week or so, but can take up to several months. Palsy that does not get better is often due to the nerve being absent. If an eye is involved, an eye patch and eye drops may be needed to protect the eye.
Peripheral Nerve Injuries
Peripheral nerves such as the radial, sciatic or obturator can be injured indirectly but associated with delivery. For example, an injection near the sciatic nerve may cause peripheral nerve injury. This causes paralysis of the affected nerve and surrounding connective tissues. Treatment consists of resting the affected area (nerves and muscles) until recovery. In most cases, there is complete recovery; however in rare cases neurosurgery may be needed.
Spinal Cord Injuries
Though this is very rare, spinal cord injuries generally happen in a breech delivery which involves excess traction to the spine or hyperextension of the baby’s neck while in the uterus. The most affected region is C5 to C7. The degree of injury can vary considerably. In a serious injury, the injuries are fatal as breathing is obstructed. Initially, there is spinal shock along with flaccidity around the injured area. There is slight sensation and movement which slowly develops into spasticity. With a complete spinal cord damage, the abdominal and surrounding muscles are paralyzed and the bladder and rectal sphincters lose control. Sweating and feeling is lost, which in turn causes fluctuation in body temperature. An MRI can show whether the damage is surgically treatable. Most babies can live for many years with proper treatment and care, which includes skin care to prevent ulcers, treatment of urinary or respiratory infections right away, and regular check ups to find associated problems such as problems passing urine.
Fractures are most often seen following a breech delivery, shoulder dystocia, or both in large babies. The clavicle is the most often fractured bone during birth. There is a relationship to this fracture and birth weight, midforceps delivery and shoulder dystocia. Associated injuries include spine, brachial plexus, and humerus injuries. Risk factors for shoulder dystocia include diabetes, large birth weight, and obesity in the mother.
Fractures of the long bones (thigh and humerus) can happen during delivery. These fractures are treated with splinting and watched for associated nerve injury. Separation of the shoulder and hip can also occur.
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