Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
1
Predisposing Factors:
4. Operative Vaginal Delivery
Morbidity and Mortality data by delivery type for the US, 1995-
1998 (rates are /10,000 deliveries)
Demissie K et al. BMJ 2004, 329:24
Lacerations
2
Caput Succedaneum Caput Succedaneum Related Scalp Injuries in Caput
(Term Baby) (Preterm Baby)
Maximal at birth, with rapid resolution over the Pediatr Dermatol. 2006;23(6):533
Eur J Pediatr. 2006;165(1):66
next 24 - 48 hours. Arch Pediatr Adolesc Med. 2010;164(7):673.
Cephalhematomas
Cephalohematoma is a subperiosteal collection of blood
caused by rupture of vessels beneath the periosteum
Usually located over the parietal or occipital bone.
A 2-year-old boy with a ring
A 6-month-old boy with linear
of nonscarring alopecia
patches of annular, nonscarring
alopecia.
Tanzi EL et al. Arch Pediatr Adolesc Med. Non transilluminant, non pulsatile and non compressible swelling.
2002;156:188-190
Cephalhematomas Cephalhematomas
Vacuum extraction has a stronger association with
Incidence: cephalhematoma compared with forceps.
1% to 2% of spontaneous vaginal deliveries Metal cups are more likely to cause cephalhematoma than
silastic cups or the Omni cup.
6% to 10% of vacuum extractions (range 1% Vacuum extractions at mid- or low station are associated with a
26%) higher incidence (13.11% and 13.56%) when compared with
vacuum applied at the outlet (6.81%).
4% of forceps deliveries
Johanson R.B., Menon B.K. Cochrane Database Syst Rev . 2000;CD000224
Attilakos G et al. BJOG 112. 1510-1515.2005
Simonson C et al. Obstet Gynecol 109. 626-633.2007
3
Cephalhematomas Cephalhematomas
Complications:
Anemia
Jaundice
Infection
Underlying skull fracture (5% (unilateral) and 18%
(bilateral))
Leptomeningeal cyst The majority of cephalohematomas will resolve spontaneously over
Outcome: the course of a few weeks without any intervention.
Disappear in 2 weeks to 3 months
Calcification of the hematoma can occur with a subsequent bony
No therapy is necessary
swelling that may persist for months.
Calcified
Cephalhematomas: X-ray Findings
Cephalhematoma
Subgaleal Hemorrhage
Cephalhematomas Accumulation of blood beneath the scalp in
subaponeurotic space
Subgaleal space extends anteriorly to the orbital margins,
posteriorly to nuchal ridge and laterally to temporalis
fascia
Overall incidence: 1 in 2,000 births and increases to 1 in
200 in vacuum assisted deliveries
Infected Subgaleal hemorrhage with loss of 20 to 40 % of a
neonate's blood volume ( = loss of 50 to 100 mL) will
Non infected result in hypovolemic shock, DIC, multiorgan failure and
neonatal death in up to 25% of cases
4
SGH: Diagnosis SGH: Clinical Presentation
SGH: Management
Criteria for Determining the Severity of SGH
Volume resuscitation with
PRBCs, FFP, and normal Head Size Jaundice Hypovolemia
5
Ocular Injuries Ocular Injuries
Significant ocular injuries include:
Hyphema (blood in the anterior chamber)
Vitreous hemorrhage
Orbital fracture
Lacrimal duct or gland injury
Disruption of Descemet's membrane of the cornea (which can
result in astigmatism and amblyopia).
Incidence: about 0.2 percent of deliveries with a higher incidence Prompt ophthalmologic consultation should be obtained
associated with forceps-assisted delivery. for patients with, or suspected to have ocular injuries.
6
Lacerations
Soft Tissue Injuries
7
Clavicular Fracture Clavicular Fracture
Physical Exam Findings: The timing of the presentation and diagnosis of the
clavicular fracture is dependent on whether the fracture
Crepitus is displaced or non-displaced.
Edema Displaced (complete) clavicular fractures:
Accompanied by physical findings in the immediate post-
Asymmetrical bone contour
delivery period.
Crying with passive motion Nondisplaced clavicular fracture:
Asymptomatic
Decreased arm movement
Diagnosis is delayed by days or weeks until there is a
Palpable bony deformity formation of a visible or palpable
Radiographs to confirm healing The Pavlik harness is used to treat neonatal femoral
can be performed at three to four fractures.
weeks post injury. Outcome is excellent with evidence of callus formation
usually seen on radiography by 7 to 10 days.
8
Linear Skull Fracture Depressed Skull Fracture
Parietal bones most commonly involved
Associated with extracranial and intracranial complications
Dural tears may result in
leptomeningeal cyst
Diagnosis is made by radiography
Ping-pong lesion
Result of localized compression Radiologic assessment
of skull
Parietal bone is the most common
Neurosurgical consultation
No therapy is indicated
site Nonsurgical intervention
Follow up skull x-ray at several months
May be associated with Neurosurgical intervention
of age intracranial hemorrhage
9
Brachial Plexus Injury Erbs Paralysis
Erbs Klumpkes Total
Diagnosis:
Incidence 90% 1% 10%
Meticulous neorologic exam
Nerve C5 and C6 (50%) C8 and T1 C5 to T1
roots C5 C7 (Erbs plus)
Radiographs of cervical
(35%) spine, clavicles, and humerus
PE finding Asymmetric moro Asymmetric moro Reflexes Fluoroscopy
Grasp present (C5- Grasp absent absent
C6)
Real-time ultrasound
Biceps present
Biceps absent Horners syndrome scanning
Arm waiters tip Extended Flaccid Electromyographic studies 2
position
to 3 wks after injury
10
Facial Nerve Injury
BPI: Long-term Deficits
Most common neonatal traumatic nerve injury (1% live
Residual long-term deficits may include: births).
Progressive bony deformities 33% of facial nerve injuries occur in spontaneous
Muscle atrophy
delivery (Caused by pressure on the facial n).
Joint contractures
Impaired growth of limb
Seen after prolonged labor or forceps delivery (2.9 to
Weakness of the shoulder girdle 5/1000 forceps delivery).
"Erb Engram" flexion of elbow accompanied by 75% of cases involve the left side due to higher
adduction of shoulder
prevalence of L transverse or L anterior occipital
presentation.
11
Phrenic Nerve Paralysis Spinal Cord Injury
12
Abdominal Injuries Summary
US is the best modality to diagnose intra-abdominal birth
injuries and can be performed at the bedside. The outcome of traumatic birth injury is related to
CT can also provide useful diagnostic information, but the severity of the initial injury
transport of a critically ill infant to the scanner is more
difficult. All infants at risk for neurodevelopmental
The management includes fluid resuscitation with blood
products and normal saline as appropriate. sequelae should be monitored closely for
FFP may be needed to correct any coagulopathy attainment of developmental milestones
Laprotomy for infants with hepatic or splenic rupture or if
hemodynamically unstable
13