Birth Injury

Birth Injury

birth injury is avoidable and unavoidable mechanical and hypoxic-ischemic injury incurred by an infant during labor and delivery.

These injuries may result from inappropriate medical skill or attention, or may occur, despite skilled and competent obstetric care, independently of any acts or omissions.

Definition does not include injury from amniocentesis, intrauterine transfusion, scalp blood sampling, or resuscitation procedures

incidence 2-7 /1,000 live births.

Predisposing factors

            macrosomia,

            prematurity,

            cephalopelvic disproportion,

            dystocia,

            prolonged labor,

            breech presentation.

Cranial Injuries

Caput succedaneum

diffuse,

ecchymotic,

edematous swelling of the soft tissues of the scalp during vertex delivery

extend across the midline crosses suture lines.

The edema disappears in a few days of life.

Similar swelling, discoloration of the face seen in face presentations.

No treatment is needed,

phototherapy for hyperbilirubinemia

Molding of the head and overriding of the parietal bones disappear during the first weeks of life.

hemorrhagic caput may result in shock and require blood transfusion.

Cephalohematoma

subperiosteal hemorrhage,

limited to the surface of one cranial bone.

no discoloration of the scalp,

swelling is visible several hours after birth, because subperiosteal bleeding is a slow process.

underlying skull fracture, may occur with cephalohematoma.

DD --Cranial meningocele - by pulsation, increased pressure on crying, and the roentgenographic evidence of bony defect.

cephalohematomas - resorbed within 2 wk-3 mo,

may calcify by the end of the 2nd wk.

 central depression on palpation of the organized rim of a cephalohematoma. cephalohematomas require no treatment,

phototherapy for hyperbilirubinemia.

Incision and drainage are contraindicated because of infection

massive cephalohematoma result in blood loss require transfusion.

Intracranial-Intraventricular Hemorrhage

Etiology and epidemiology

trauma --Traumatic epidural, subdural, or subarachnoid hemorrhage -labor is prolonged; in breech or precipitate deliveries; or as a result of mechanical assistance with delivery.

asphyxia

a primary hemorrhagic disturbance

congenital vascular anomaly.

disseminated intravascular coagulopathy,

isoimmune thrombocytopenia,

neonatal vitamin K deficiency (especially in infants born to mothers receiving phenobarbital or phenytoin).

Intracranial hemorrhages in ventricles ( intraventricular hemorrhage [IVH]) of premature infants delivered spontaneously without trauma.

Pathogenesis of intraventricular hemorrhage

premature infants in periventricular germinal matrix.

This periventricular area is the site of embryonal neurons and fetal glial cells, which migrate to the cortex. Immature blood vessels in this highly vascular area may be subjected to various forces that, together with poor tissue vascular support, predispose premature infants to IVH.

By term, the tissue's vascular support has strengthened.

Predisposing factors for IVH

            prematurity,

            respiratory distress syndrome (RDS),

            hypoxic-ischemic or hypotensive injury,

            pneumothorax,

            hypervolemia,

            hypertension.

Periventricular leukomalacia (PVL), a common associated cystic finding, may be due to prenatal or neonatal ischemic injury. PVL with or without severe IVH is the result of necrosis of the periventricular white matter and damage to the corticospinal fibers in the internal capsule è spastic diplegia

Clinical manifestations

occur between birth and the 3rd day of life,

 progress during the 1st wk of life

symptoms are

            diminished or absent Moro reflex,

            poor muscle tone,

            lethargy,

            apnea,

            Excess sleep.

Premature infants

            deterioration on the 2nd or 3rd day of life.

            Periods of apnea, pallor, or cyanosis; failure to suck well

            abnormal eye signs

            a high-pitched, shrill cry

            muscular twitchings, convulsions

            decreased muscle tone, or paralyses

            metabolic acidosis; shock,

            decreased hematocrit or its failure to increase after transfusion

            fontanel may be tense and bulging.

            coma

PVL in later infancy presents as spastic diplegia.

Diagnosis.

history

clinical manifestations

transfontanel cranial ultrasonography

computed tomography (CT)

premature infant do cerebral ultrasonography through the anterior fontanel -within first 3-5 days of life and again the following week.

Ultrasound detects the precystic and cystic symmetric lesions of PVL atrophy, porencephaly, hydrocephalus

Grade I is bleeding in germinal matrix-

grade II is intraventricular bleeding

grade III is involvement with dilated ventricles

CT or magnetic resonance imaging (MRI)

Lumbar puncture to rule out bacterial meningitis

small numbers of red blood cells or slight xanthochromia in subarachnoid fluid does not indicate significant intracranial hemorrhage.

Prognosis

massive hemorrhage may die

posthemorrhagic hydrocephalus..

Prevention

judicious management of cephalopelvic disproportion and operative (forceps, cesarean section) delivery.

maternal idiopathic thrombocytopenic purpura -ITPèmaternal treatment with steroids, intravenous immunoglobulin, or fetal platelet transfusion.

Vitamin K should be given before delivery to all women receiving phenobarbital or phenytoin during the pregnancy.

Treatment

multiple organ system dysfunction.

Seizures - anticonvulsant drugs,

anemia-shock - transfusion with packed red blood cells or fresh frozen plasma,

acidosis administration of 1-2 mEq/kg sodium bicarbonate.

lumbar -reduce the symptoms of posthemorrhagic hydrocephalus.

removing the subdural fluid

Brachial palsy

Erb-Duchenne paralysis, - 5th and 6th cervical nerves.

The infant loses the power

1. to abduct the arm from the shoulder,
2. to rotate the arm externally,
3. to supinate the forearm.

position - - adduction and internal rotation of the arm with pronation of the forearm. extension of the forearm is retained,

the biceps reflex is absent;

Moro reflex is absent on the affected side

some sensory impairment on the outer aspect of the arm.

power in the forearm and the hand grasp are preserved

presence of the hand grasp is a favorable prognostic sign.

When the injury includes the phrenic nerve, alteration of the diaphragmatic movement may be observed by USG.

Klumpke's paralysis -injury to the 7th and 8th cervical nerves and the 1st thoracic nerve

            paralyzed hand,

            ipsilateral ptosis and miosis (Horner syndrome) if the sympathetic fibers of the 1st thoracic root are also injured.

DD--    cerebral injury

            from fracture

            dislocation,

            epiphyseal separation of the Humerus

            fracture of the clavicle.

MRI demonstrates nerve root rupture or avulsion.

prognosis - injured or lacerated.

edema and hemorrhage around the nerve fibers, function should return within a few months

if due to laceration, permanent damage may result.

Involvement of the deltoid may result in a shoulder drop

Treatment immobilization and appropriate positioning –

upper arm paralysis, the arm should be

            abducted 90 degrees,

            external rotation at the shoulder

            full supination of the forearm with a brace or splint

intermittent through the day while the infant is asleep

Gentle massage and exercises may be started by 7-10 days of age.

If paralysis persists without improvement for 3-6 mo, neuroplasty, neurolysis, end-to-end anastomosis, or nerve grafting offers hope for partial recovery.

Fractures

CLAVICLE

Commonest to fracture during delivery

difficulty in delivery of the shoulder in vertex presentations and of the extended arms in breech deliveries.

does not move the arm freely

crepitus and bony irregularity may be palpated

 Moro reflex is absent on the affected side

In greenstick fractures there may be no limitation of movement, and the Moro reflex may be present. Fracture of the humerus or brachial palsy may also be responsible for limitation of movement of an arm and absence of a Moro reflex on the affected side.

The prognosis is excellent.

Treatment, - immobilization of the arm and shoulder - callus develops at the site may be the first evidence of the fracture.