Birth Injuries

BIRTH INJURIES

Definition

• Birth Injuries refer to both harm and permanent damage incurred by a baby during the birth process or soon after delivery. These injuries are often caused by inadequate care or lack of attention during birth and labor.

Incidence

• Approximately 20% of babies may suffer from birth injuries in developing countries.

• 11% of babies possibly sustain birth injuries in developed countries.

Predisposing Factors

1. Macrosomic babies (babies of larger size than average).

2. Preterm babies (born before 37 weeks of gestation).

3. Cephalopelvic disproportion (CPD) (the baby's head is too large to fit through the mother's pelvis).

4. Cervical dystocia (failure of the cervix to dilate adequately).

5. Prolonged labor, leading to fetal hypoxia (deficiency in the amount of oxygen reaching the tissues).

6. Abnormal presentation (e.g., breech, brow, and face presentation).

7. Instrumental deliveries such as forceps, vacuum extraction, etc.

8. Hydrocephalus (accumulation of cerebrospinal fluid in the brain).

Classification of Birth Injuries

• Birth injuries are classified into two major groups:

A. External Birth Injuries

Examples include:

• Caput Succedaneum

• Cephalohematoma

• Sub-poneurotic hemorrhage

• Bruises and lacerations or cut

1. Caput Succedaneum

• Description: This is an edematous swelling due to infiltration of serum and blood into the scalp tissue as a result of pressure exerted by the cervix during delivery.

• Physiology: The pressure from the cervix reduces venous blood return, leading to congestion and accumulation of fluid in the tissue.

• Clinical Features:

  • Present at birth

  • May cross suture lines

  • Decreases in size as the baby grows

  • Disappears within 36 hours but can persist up to 1.5 days

  • Does not put pressure on the scalp

• Management: No action is required, but mothers should avoid massage or hot fomentation as it will resolve on its own.

2. Cephalhematoma

• Description: This is swelling on the fetal skull due to the accumulation of blood between the periosteum and the skull bones, typically arising from fractures during birth.

• Physiology: Blood accumulates under the periosteum caused by fracture or bleeding, commonly related to CPD and precipitate labor.

• Clinical Features:

  • Appears after 12 hours, does not cross suture lines

  • Persists for weeks, tends to grow larger with baby growth

  • Usually resolves in 3-4 weeks without requiring treatment

• Management: Observation and no treatment necessary unless complications arise.

• Complications:

  • Potential anemia as the blood can break down

  • Jaundice due to breakdown of red blood cells.

    3. Sub-poneurotic Hemorrhage

    • Description: This type of hemorrhage occurs in the space between the periosteum of the skull and the galea aponeurotica (the fibrous tissue covering the skull) due to trauma during delivery. It is less common than other forms of birth injuries but can occur due to excessive pressure during delivery or use of assisted delivery tools.

    • Physiology: The bleeding typically results from tears in blood vessels in the area, causing blood to accumulate in this space without the constraints of bony boundaries.

    • Clinical Features:

      • The swelling may not be immediately visible at birth and can increase in size over the first 24 to 48 hours.

      • The hematoma can cross suture lines, distinguishing it from cephalhematoma, which does not.

      • Generally, it can resolve spontaneously within a few days to weeks.

    • Management: Observation is usually sufficient; surgical intervention is rare and mainly considered if the accumulation of blood causes significant pressure on the brain or there are signs of complications.

3. Bruises and Lacerations

• Resulting from superficial injuries during delivery.

• Often seen in breech delivery presentations.

• Management: Deep cuts should be stitched; lacerations should be treated with antiseptic lotions.

Internal Birth Injuries

Intracranial Hemorrhage (ICH)

• Definition: Bleeding that occurs within the cranium due to a tear of any part of the cerebrum or blood vessels.

• More frequent in preterm babies.

Types:

1. Subarachnoid Hemorrhage

2. Intracranial Hemorrhage

3. Intraventricular Hemorrhage

Causes:

• Loose cranial sutures and associated hypoxia, leading to venous engorgement and rupture of tiny blood vessels.

• Difficult assisted deliveries, prolonged labor, breech births, or mechanical difficulties.

• Bleeding disorders that could predispose to such injuries.

Clinical Features:

• Symptoms may include:

  • Shock: Baby is unresponsive or lethargic.

  • Abnormal muscle tone and respiratory patterns.

  • High-pitched cry, convulsions, and abnormal eye movements (nystagmus).

Management:

• Prevention through good obstetric care during delivery.

• Immediate observation and stabilization of the baby.

• May include gentle resuscitation measures, vitamin K administration, and possible intubation depending on the baby's condition.

Diagnosis:

• Clinical features, lumbar puncture, and imaging (CT scans) confirm the condition.

Prognosis:

• Minor injuries may resolve spontaneously. Severe cases may result in significant morbidity or mortality.

Injuries to Muscles and Nerves

Torticollis

• Definition: Twisting of the neck due to damaged sternocleidomastoid muscle caused during delivery.

• Clinical Features: A small bump on the affected side, often being noticed 1-2 weeks after delivery.

• Management: Stretching exercises and gentle massage; may require surgical intervention if persistent.

Facial Nerve Paralysis

• Description: All results from pressure on the facial nerve during difficult delivery.

• Clinical Features: Weakness in facial expression and difficulty closing the eye on the affected side. Of course.

• Management: Usually resolves spontaneously within a week to ten days; lubricating eye drops may be used if necessary.

Brachial Plexus Injury

• Injury often occurs during difficult deliveries due to stretching or excessive pulling during birth.

• Types of injuries include:

1. Erb's Palsy: Involves the upper brachial plexus (5th-6th cervical nerves), leading to characteristic positions of the affected arm (internal rotation).

2. Klumpke's Palsy: Involves lower plexus (7th-8th cervical nerves) and 1st thoracic, leading to wrist drop and hand paralysis.

3. Total Brachial Plexus Palsy: Complete paralysis of the arm.

• Management: Varies based on severity; physical therapy and, if necessary, surgical repair may be needed.

Prognosis:

• Many infants recover independently; however, those with persistence need more intensive interventions including potential surgery.