Birth trauma

Childbirth, especially complicated ones, can end unfavorably for the child - birth trauma may occur.

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Birth trauma to the head

Deformation of the head often occurs during per vias naturalis births due to the high pressure created by uterine contractions on the pliable skull of the fetus as it passes through the birth canal.

A birth swelling (caput succedaneum) is a swelling of the presenting part of the head. It occurs when the presenting part is pushed out of the cervix. Hemorrhage under the aponeurosis occurs with greater damage and is characterized by a doughy consistency, fluctuation over the entire surface of the head, including the temporal areas.

Cephalhematoma, or subperiosteal hemorrhage, is differentiated from hemorrhage under the aponeurosis by the fact that it is clearly limited to the area of one bone, in the area of the sutures the periosteum is tightly adjacent to the bone. Cephalhematomas are usually unilateral and are located in the area of the parietal bone. In a small percentage of cases, linear fractures (cracks) of the underlying bone are noted. Treatment is not required, but the consequence may be the development of anemia or hyperbilirubinemia.

Depressed skull fractures are rare. In most cases, they are the result of forceps application, and rarely - the position of the head on a bony prominence intrauterine. Newborns with depressed skull fractures or other head injuries may also have intracranial hemorrhage (subdural hemorrhage, subarachnoid hemorrhage, or contusion or crushing of the brain). In a depressed skull fracture, there is a palpable (sometimes visually noticeable) depressed deformity, which must be differentiated from the raised periosteal ridge palpable in cephalohematomas. CT is performed to confirm the diagnosis and exclude complications. Neurosurgery may be required.

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Cranial Nerve Injuries

The most common injury is to the facial nerve. Although often associated with forceps delivery, birth trauma is likely to be due to pressure on the nerve in the uterus, which may be due to the position of the fetus (e.g. head against the shoulder, sacral promontory, or uterine fibroids).

Injury to the facial nerve occurs at or distal to its exit from the stylomastoid foramen and is manifested by facial asymmetry, especially when the child cries. It may be difficult to determine which side of the face is affected, but the facial muscles are immobile on the side of the nerve injury. Individual branches of the nerve may also be damaged, most commonly the mandibular. Another cause of facial asymmetry is asymmetry of the mandible, which is a consequence of pressure on it by the uterus; in this case, the innervation of the muscles is not impaired and both halves of the face can move. In mandibular asymmetry, the occlusal surfaces of the upper and lower jaws are not parallel, which distinguishes them from facial nerve injury. More in-depth examination or treatment is not required for peripheral facial nerve injuries or mandibular asymmetry. They usually resolve by the age of 2-3 months.

Brachial Plexus Injuries

Brachial plexus injuries result from stretching caused by difficulty in cutting through the shoulders, extracting the fetus in a breech presentation, or hyperabducting the neck in a cephalic presentation. Birth trauma may result from simple stretching, bleeding into a nerve, rupture of a nerve or its root, or avulsion of roots with associated damage to the cervical spinal cord. Associated injuries (e.g., fractures of the clavicle or shoulder, or subluxation of the shoulder or cervical spine) may also occur.

Injuries to the upper brachial plexus (C5-C6) primarily involve the muscles of the shoulder and elbow, while injuries to the lower brachial plexus (C7-C8 and T1) primarily involve the muscles of the forearm and hand. The location and type of nerve root injury determine the prognosis.

Erb's palsy is an injury to the upper portion of the brachial plexus, causing adduction and internal rotation of the shoulder with pronation of the forearm. There is often ipsilateral diaphragmatic paresis. Treatment involves protecting the shoulder from excessive motion by immobilizing the arm across the upper abdomen and preventing contractures with passive, graded exercises for the involved joints, performed gently daily from the first week of life.

Klumpke's palsy is an injury to the lower part of the brachial plexus, which results in paralysis of the hand and wrist, and can often be accompanied by the development of Horner's syndrome on the same side (miosis, ptosis, facial anhidrosis). Passive dosed exercises are the only treatment required.

Neither Erb's nor Klumpke's palsy usually causes significant sensory loss that would indicate a nerve rupture or tear. These conditions usually improve quickly, but some movement deficits may persist. If significant deficits persist for more than 3 months, MRI is performed to determine the extent of damage to the plexus, roots, and cervical spinal cord. Surgical exploration and correction are sometimes effective.

If birth trauma to the entire brachial plexus occurs, the affected upper limb cannot move, sensory loss is common, pyramidal signs on the same side indicate spinal cord injury; MRI should be performed. Subsequent growth of the affected limb may be impaired. The prognosis for recovery is poor. Treatment of such patients may include neurosurgical evaluation. Passive graded exercises may prevent contractures.

Other birth injuries to peripheral nerves

Injuries to other nerves (eg, radial, sciatic, obturator) are uncommon in neonates and are not usually associated with labor and delivery. They are usually secondary to local trauma (eg, injection into or near the sciatic nerve). Treatment involves resting the antagonists of the paralyzed muscles until recovery. Neurosurgical exploration of the nerve is rarely indicated. Most peripheral nerve injuries recover completely.

Birth injury of the spinal cord

Birth injury to the spinal cord is rare and involves varying degrees of rupture of the spinal cord, often with hemorrhage. Complete rupture of the spinal cord is very rare. The injury usually occurs during breech birth after excessive longitudinal extension of the spine. It may also follow hyperextension of the fetal neck in utero ("flying fetus"). The injury usually affects the lower cervical region (C5-C7). If the injury is higher, the injury is usually fatal because breathing is completely disrupted. Sometimes a clicking sound can be heard during labor.

Spinal shock occurs immediately, with flaccid paralysis below the level of the lesion. There is usually some preservation of sensation or movement below the level of the lesion. Spastic paralysis develops over days or weeks. Breathing is diaphragmatic because the phrenic nerve remains intact, arising above (C3-C5) the typical site of spinal cord injury. With complete spinal cord injury, the intercostal muscles and the muscles of the anterior abdominal wall become paralyzed, and pelvic dysfunction occurs. Sensation and sweating are also absent below the level of the lesion, which may cause body temperature to fluctuate with changes in ambient temperature.

An MRI of the cervical spinal cord can show damage and rule out conditions that require surgical treatment, such as congenital tumors, hematomas compressing the spinal cord, and examination of the cerebrospinal fluid usually reveals blood.

With proper care, most infants live for many years. Common causes of death are frequent pneumonia and progressive decline in kidney function. Treatment includes careful nursing care to prevent pressure sores, proper treatment of urinary tract and respiratory infections, and regular screening for early detection of obstructive uropathy.

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Fractures

Clavicle fracture, the most common fracture during childbirth, occurs with difficulty delivering the shoulders and with normal, nontraumatic deliveries. At first, the newborn is restless and does not move the arm on the affected side either spontaneously or when the Moro reflex is elicited. Most clavicle fractures are greenstick fractures and heal quickly and without complications. A large bone callus forms at the fracture site within a week, and remodeling is complete within a month. Treatment involves applying a splint by attaching the sleeve of the affected side's vest to the opposite side of the infant's vest.

The shoulder and femur may be fractured in difficult deliveries. Most cases are greenstick fractures of the diaphysis, and successful bone remodeling is usually observed, even if there is initial moderate displacement. A long bone may be fractured through the epiphysis, but the prognosis is good.

Birth trauma of soft tissues

All soft tissues are susceptible to injury during labor if they were the presenting part or the point of action of uterine contraction forces. Birth trauma is accompanied by edema and ecchymosis, especially of the periorbital and facial tissues in face presentation and of the scrotum or labia in breech presentation. As a hematoma develops in the tissues, it is resorbed and converted to bilirubin. This additional bilirubin may cause neonatal hyperbilirubinemia sufficient to require phototherapy and sometimes blood transfusion. No other treatment is required.

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