BIRTH INJURIES Introduction: As a result of the birth process ,some injuries occur that may be minor, where as others

may be more serious. Parental reaction to any injury sustained by their newborn infant at birth may be out of proportion to the harm that has occurred. Birth injuries: It is defined as those sustained during Labour and delivery. Birth injuries may be severe enough to cause neonatal death , still birth or number of morbidities. Risk factors: Maternal Primiparity Short stature Maternal pelvic anomalies Prolonged or extremely rapid labour Oligohydramnios Deep transverse arrest of descent of presenting part of the fetus Foetal

fetal head Foetal anomalies Interventional/ inorganic

Versions& extractions

Types of birth trauma and management

HEAD & NECK INJURIES

1. Associated with foetal monitoring Fetal scalp blood sampling for the estimation of PH- heomorrhage and infection Foetal scalp electrode for FHR monitoring

2. Cephal hematoma

Definitipon: Subsperiosteal collection of blood secondary to rupture of blood vessels between the skull and periosteum; its extent is well delineated by the suture line over few days Complication:

Resolution: Very slow resorption Management:

hyperbilirubinemia and infection Rule out bleeding disorders

4. Caput Succedaneum

Definition: Serosanguinous , subcutaneous, extraperitoneal fluid collection with poorly defined margins, it may extend across the midline & over the surface line and is usually associated with head moulding. Complications:

alopecia

5. Vacuum

Resolution: Slow resolution

5. Vacuum caput: Definition : Serosanguiness fluid collection well defined by the position of the vacuum extractor on the scalp Complications bilirubinemia are very rare, local infection with scalp abrations and lacerations Resolution:With in few hours after birth Management:

Treatment for blood loss, hyperbilirubinemia and infection Rule out bleeding disorders

6. Intracranial haemorrhages:

i. Subependymal haemorrhage- IVH

Clinical features: Due to blood loss- shock, pallor , respiratorty distress , DIC, jaundice, bulging ant. frontanel, excessive somnolence,, hypotonia, weakness , seizures, temperature instability, brain stem signs( apnoea, lost extra ocular movements, facial weakness) Investigation:

Others- ABC, Haematocrit- low , thrombocytopenia, prolonged PT, PTT& hyper bilirubinemia Complications: Post hemorrhagic hydrocephalus Management:

- to maintain temperature, oxygen, & humidity

cally active agents,

haemorrhagic hydrocephalus

ii. Posterior fossa haemorrhage Clinical features:

Bulging frontanel, increasing head circumference, lethargy, irritability

Investigations:

Management: open surgical evacuation of the clots in the patient with neurologic symptoms

iii. Ant. fossa haemorrhage Clinical features:

Neurological manifestations- focal neurological signs, irritability , lethargy, focal seizures, hemiparesis, gaze preferences, sixth nerve dysfunction, 3rd nerve compression- dilated and poorly reactive pupil Investigation:

Complication: Hydrocephalus rarely Management: -anticonvulsants, blood loss correction

Nursing consideration: Vigilant observation of the baby for possible associated complications such as infection or rarely blood loss and hypovolemia

7. Skull fractures Bones involved- Frontal, parital, occipital complications:

Management: ray and CT scan for diagnosis - observation - neurological evaluation - rays at 8-12 weeks to look for growing fractures

8. Facial mandibular fractures Features:

Dislocation of the cartilaginous nasal septumComplications: - craniofacial malformations, ocular, respiratory & mastication problems Management:

CT scan

Nursing considerations:

9. Ocular injuries Types: a. retinal and subconjunctival haemorrhages- vaginal delivery b. ocular and periorbital injuries- forceps delivery
c.

d. HYphaema, Vittreous haemorrhage e. local lacerations f. palpebral oedema g. orbital fractures with abnormal extra ocular muscle function h. lacrimal gland / duct damage Management:

10. Ear injuries Types: Haematoma of the external pinna- Cauliflower ear - refractory perichondritis - Haemotympanum & ossicular disarticulation Management:

11. Sternocledomastoid (SCM )muscle injury Pathology: Injury to the SCM muscle/ fascia disruption during delivery

haematoma formation

Torticollis Management:

Nursing Management:

Tilting the head away from the affected side so that the ear can be brought into contact with the opposite shoulder Rotating the chin towards the tight SCM muscle. When head is in the stretched position , it should be held there for about 10 seconds The exercise should be done 4-6 times in a day with about 20 repetitions of each exercise at each time. The infant is positioned in the crib sothat the head is supported by sandbags in the corrected positions. This is done to prevent the flattening of the occiput or the development of facial asymmetry

looks towards the side of the tight muscle. aches for them

B. CRANIAL NERVE , SPINAL CORD & PERIPHARAL NERVE INJURIES Commonly associated with breech delivery Cause- Hyper extension , traction,& over stretching with simultaneous rotation Types- Localized neurapraxia to complete nerve and cord transaction 1. Cranial nerve injuries

i. Facial nerve injury Cause:Compression by the forceps blades Clinical features: - Assymmetrical crying facies, mouth drawn to normal side, wrinkles are more on the normal side, forehead and eyelid unaffected, nasolabial fold is absent on the affected side , corner of the mouth droops on the affected side Peripheral nerve injury:- Asymmetrical crying facies Peripharal nerve branch injury- asymmetrical crying facies, paralysis limited to forehead, eye or mouth Mangement: Protection of open eye- patches and synthetic tears 4th hourly

Nursing management: by NG tube in order to prevent aspiration

ii. Recurrent laryngeal nerve injury

Clinical Feature; Unilateral abductor paralysis(hoarse cry, respiratory stridor) - Severe respiratory distress, asphyxia Management: Unilateral paralysis-small frequent feed to minimize risk of aspiration l paralasis- intubation may be required

2. Spinal cord injuries Cause:

Clinical feature:

Low APGAR score Motor function absent distal to the level of injury with loss of deep tenden reflexes

Management:

Neurological examinations and cervical spinal Xrays T scan, myelogram, MRI if required

3. Cranial nerve root injuries

i. phrenic nerve palsy(C3, 4, & 5) Unilateral and associated with brachial plexus injuries Clinical features: Respiratory distress ipsilaterally diminished breath sounds Management: USG/Fluroscopic studies- Paradoxical movements of the diaphragm

Refractory cases- diagphramatic placation, phrenic nerve pacing Nursing management: oxygen is given as necessary

improves

may complicate the infants condition

ii. Injuries to Brachial plexus

Clinical features: Duchenne Erb paralysis(C5-6): Affected arm in adducted and internally rotated with elbow extended (Waiters tip position)

The limb falls limply to the side of the body when passively adducted

Klumpkes paralysis (C7& T1) intrinsic muscles of the hand are affected & grasp is absent( claw Hand)

the entire arm is flaccid , all reflexes are absent Complications

Management: X ray studies to rule out bony injury, chest examination to rule out diagphragmatic involvement -10 days( After resolution of the nerve edema)

Recovery: -2 wks normal function permanent deficit Nursing Management:

nonparalysed muscles cannot exert pull on the affected muscles

degrees and rotate internally at the shoulder with the elbow flexed so that the palm of the hand is turned towards the head

neutral position and the hand is placed over a small pad

immobilization may be necessary for some infants. -10 days , complete ROM exercises may be given gently several times each day inorder to maintain muscle tone and prevent contraction deformity Before or splint or brace is obtained , the nurse can pin the infants long shirt sleeve to the mattress covering

coldness or discolouration and the skin for signs of irritation be taught how to apply it properly and how to provide the skin care - affected hand first and on removing the unaffected hand first More physical contact and affection than normal child

C. BONE INJURIES Common in breech delivery & shoulder dystocia in macrosomic infants Cause: limb traction and rotation

1. Clavicular fracture Most common injury Clinical features:

Palpable bony irregularity & sternocledomastoid muscle spasm

Management: - ray studies of the chest, shoulders and cervical spine

2. Long bone injuries Bones : Hemurus, femur Clinical features:Swelling, crepitus and pain Complication :injury to nerve in vicinity Management :Splinting ; closed reduction & casting if required

3. Epiphyseal displacement Cause :Rotation with strong traction Clinical features:swelling, crepitus, pain Management :X- ray not very useful as epiphyses are not ossified at birth Limb immobilization for 10-14 days allows callus formation

D. INTRAABDOMINAL INJURIES Types : Rupture/ Subscapular haemorrhage into liver spleen or adrenal gland Clinical features:Abdominal distension, pallor, poor feeding, tachycardia, tachypnoea, shock etc Management :Clinical examination and serial determinations of the haematocrit levels -Abdominal USG - Paracentesis in case of intraperitoneal bleeding
E. SOFT TISSUE INJURIES:

1) Patechiae and echymosis eous resolution in 1 week.

- Anemia; hyperbilirubinemia 2) Abrations And laceration 3) Subcutaneous fat necrosis Clinical features :Appear in first two weeks of life Irregularly shaped , hard , non pitting, subcutaneous plaque with overlying dusky, red purple discolouration Sites :Cheeks, arms, back , buttocks, thighs PREVENTION OF BIRTH INJURIES IN NEWBORN A comprehensive antenatal and postnatal care is key to the success in the reduction of birth trauma. Antenatal Period: the at risk babies

Intranatal period: Normal delivery:

Preterm delivery:

Forceps delivery: - LSCS

Ventouse delivery:

Vaginal breech delivery:

Conclusion: Since many of the birth injuries do not require treatment , the nurse can help to clear up the misconceptions and alleviate anxieties by simple explanations.Assisting the parents to cope with the more serious injuries requires more through explanations and constant support by members of the health team.

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