BIRTH TRAUMA

BIRTH TRAUMA

Definition of Birth Trauma/Injuries

  • Birth trauma/injuries are defined as injuries sustained during labor and delivery, which can even occur during a ‘normal’ labor and delivery.

  • These injuries may vary considerably:

    • Mild injuries: Require just monitoring with no intervention.

    • Severe injuries: May lead to neonatal death, still-birth, or other morbidities.

  • It is essential to assess parents' reactions or perceptions regarding any trauma or injury sustained by their newborn.

  • Many birth injuries are avoidable through available antepartum and intrapartum diagnostic testing and interventions such as cesarean sections.

Soft Tissue Injury

Types of Soft Tissue Injuries

  • Common types of soft tissue injuries include:

    • Petechiae and Ecchymosis:

    • Definition: Small (petechiae) and larger (ecchymosis) spots of bleeding under the skin.

    • Resolution: Spontaneous resolution typically within days to about one week.

    • Complications: Can lead to anemia and an increased risk of hyperbilirubinemia.

    • Differentiation: It is crucial to differentiate these from other rashes or discolorations.

    • Abrasions

    • Lacerations

Treatment of Soft Tissue Infections

  • Treatment is usually minimal, primarily supportive care without significant intervention.

  • Important considerations include:

    • Assessing for any underlying bleeding disorders or potential systemic illness.

    • Monitoring for possible hyperbilirubinemia in cases of bruising and petechiae.

    • Providing emotional support and instruction to parents.

Head Trauma

Potential Causes of Head Trauma

  • Various factors may contribute to head trauma during delivery:

    • Internal fetal monitoring

    • Cephalopelvic disproportion (CPD)

    • Usage of forceps or vacuum extraction

    • Abnormal presentations of the fetus

    • Presence of nuchal cord (umbilical cord around the neck)

    • Rapid delivery (precipitous birth)

    • Exogenous oxytocin stimulation

    • External or internal version procedures

    • Inexperienced practitioners

    • Fetal macrosomia (larger-than-average baby)

    • Multifetal deliveries

    • Shoulder dystocia

    • Cesarean delivery

    • Primiparous delivery (first-time mother)

Types of Head Trauma
Cephalhematoma

  • Definition: A subperiosteal collection of blood resulting from the rupture of periosteal capillaries located between the skull bone and the periosteum, typically on the parietal portion of the skull.

  • Mechanism: Occurs due to the pressure exerted during birth.

  • Characteristics:

    • Swelling is generally minimal or absent at birth but increases gradually over the first 2-3 days.

    • Does not cross suture lines, is sharply demarcated, and is usually unilateral.

  • Complications: May include anemia, possible hypotension, secondary hyperbilirubinemia, infection, and potentially skull fracture.

  • Resolution: Gradually resolves over weeks to months.

  • Management:

    • Generally limited to observation (particularly neurological), scalp swelling precautions, possible daily head circumference measurement, treatment of hyperbilirubinemia if present, ensuring no bleeding disorders are present, using a water pillow, performing x-rays if skull fracture is suspected, and providing education and reassurance to parents.

Caput Succedaneum

  • Definition: A common condition involving a serosanguinous and subcutaneous fluid collection in the soft tissues of the head above the periosteum of the skull bone, characterized by poorly defined margins that may cross midline and over cranial suture lines.

  • Occurrence: Usually associated with head molding and is noticeable at birth to 24 hours post-delivery, with resolution within a few days.

  • Characteristics:

    • Typically resolves without treatment and does not usually increase in size after delivery.

    • May present with overlying petechiae, ecchymosis, or redness.

  • Management: Routine normal newborn assessment and care; specific treatment isn't usually required except for possible scalp swelling precautions; education and reassurance for parents.

Vacuum Caput

  • Definition: A well-defined serosanguinous and subcutaneous fluid collection related to the position of a vacuum extractor on the scalp.

  • Complications: Risk of local infection, particularly with scalp abrasions and lacerations.

  • Resolution: Generally occurs within a few hours to a few days following birth.

  • Management: Observation, scalp swelling precautions if necessary, and reassurance for parents.

Subgaleal Hemorrhage

  • Definition: Occurs when vessels break, causing blood accumulation under the scalp muscle and superficial to the periosteum (subgaleal compartment), typically during delivery due to compressive forces (e.g., vacuum and forceps).

  • Extension: Can extend posteriorly down the neck, potentially displacing the ears forward and laterally. It usually develops between 1 to 72 hours post-delivery.

  • Rarity: This condition is uncommon but can be life-threatening.

  • Signs and Symptoms:

    • Superficial skin bruising

    • Signs of shock (e.g., pallor)

    • Increasing head circumference

    • Increased edema and firm swelling on the back of the head and neck

    • Assess for diffuse fluctuating swelling over the scalp crossing suture lines that shifts with infant repositioning

  • Complications:

    • Spread of hematoma leading to anemia, possible hypovolemic shock, and/or death

    • Periorbital and auricular ecchymosis

    • Infection

  • Resolution: Very slow reabsorption process.

  • Management:

    • Alert healthcare provider immediately.

    • Early detection and intervention are vital.

    • Close observation, particularly neurological assessment and signs of shock.

    • Frequent serial CBCs (Complete Blood Counts) and head measurements.

    • NICU admission as medically appropriate.

    • Imaging (CT or MRI) to investigate any injuries.

    • Treat for blood loss, hyperbilirubinemia, and infection if assessed.

    • R/O possible bleeding disorders and administer vitamin K if not previously completed; administer clotting factors if appropriate; offer supportive care and parent education.

Ocular Injuries

  • Examples include:

    • Retinal and subconjunctival (scleral) hemorrhages potentially associated with vaginal delivery.

    • Ocular and periorbital injuries linked to forceps delivery.

    • Hyphema (blood in the anterior chamber of the eye) and edema.

    • Abnormal extraocular muscle function.

  • Management:

    • Mild injuries may only need ongoing assessment.

    • More serious cases require ophthalmic referral/consultation.

Intracranial Hemorrhages (ICH)

  • Risk Factors: Includes vacuum- or forceps-assisted births, coagulopathy, prematurity, hypotension, respiratory distress syndrome (RDS), large for gestational age (LGA) infants, and precipitous births.

  • Types:

    • Subdural Hemorrhage: Rare, but life-threatening; typically results from stretching and tearing of dural veins, crosses cranial sutures, tends to develop more slowly.

    • Characteristics: Can be asymptomatic until severe, may develop over days to weeks.

    • Subarachnoid Hemorrhage: More common but still rare; associated with trauma in term infants and hypoxia in preterm infants.

    • Symptoms: May include alternating depression, irritability, refractory seizures, or apnea.

    • Diagnosed by lumbar puncture, noting findings in CSF.

Nursing Care for Infants with ICH

  • Care provided is largely supportive, with detailed assessments until healthcare provider intervention is initiated. Key components include:

    • Monitoring Airway, Breathing, Circulation (ABCs)

    • Administration and monitoring of IV therapy

    • Observation and management of seizures, if present

    • Minimize increases in intracranial pressure (ICP)

    • Limit handling of the infant to promote rest and reduce stress

    • Provide family education and support

Skeletal Injuries: Skull Fractures

  • Types of Skull Fractures:

    • Linear: Typically require observation if no neurological manifestations.

    • Depressed: May necessitate neurological evaluation, repeat x-rays for growth of fractures, and possible surgical intervention.

  • Complications: Include brain contusion, disruption of blood vessels, seizures, hypotension, dural laceration, and CSF leaks.

Clavicular Fracture

  • Commonality: The most frequently fractured bone during delivery.

  • Risk Factors: Shoulder dystocia, arm extension in breech deliveries, use of vacuum or forceps, large for gestational age infants.

  • Clinical Features: Pseudoparalysis, absent Moro reflex on the affected side, local edema and hematoma, crepitus, and palpable bony irregularity.

  • Management:

    • No universally accepted treatment protocols; x-ray of chest, shoulders, and neck.

    • Consultation/referral to orthopedic specialists; use of slings/splints.

    • Gentle handling and proper body alignment maintain proper healing; avoid laying the newborn on the affected side.

Bone Injuries: Long Bone Fractures

  • Affected Bones: Humerus, femur - these fractures occur rarely during delivery but tend to heal quickly.

  • Clinical Features: Loss of spontaneous movement in the affected limb, swelling, crepitus, and pain.

  • Complications: Possible injury to nearby nerves.

  • Management:

    • Use of splints, slings, or swaddling.

    • Closed reduction or casting may be necessary; careful pain management.

    • Monitor for any nerve involvement; consider congenital disorders like osteogenesis imperfecta.

Basic Nursing Care for Newborn Fractures

  • Approaches to nursing care include:

    • Ensure proper body alignment.

    • Cautious dressing and undressing.

    • Careful handling to support the affected bone.

    • Assess for potential neurological complications.

    • Provide parental support and education.

Nerve Injuries

  • Common Causes: Hyperextension, traction, overstretching during delivery due to improper technique by healthcare providers.

Cranial Nerve Injuries – Facial Paralysis (Palsy)

  • Description: Most common nerve injury at birth.

  • Mechanism: Pressure on cranial nerve VII during delivery leads to:

    • Loss of facial movement on the affected side.

    • Inability to completely close the eye.

    • Drooping of the corner of the mouth.

    • Absence of wrinkling of the forehead and nasolabial fold on the affected side.

    • More pronounced during crying (mouth drawn to unaffected side; heightened contrasts in wrinkles).

  • Management:

    • Generally supportive; most cases resolve within days to weeks.

    • Important to provide protection for the open eye with patches or frequent synthetic tears.

    • May require neurological and surgical consultation.

    • Nursing management should focus on aiding feeding techniques and providing parental support.

Phrenic Nerve Palsy (C3, 4, and 5)

  • Description: Frequently occurs as part of brachial plexus injury rather than as an isolated issue, resulting in diaphragmatic paralysis observable via ultrasound.

  • Clinical Features:

    • Usually unilateral (bilateral occurrence is possible).

    • Leads to respiratory distress syndrome (RDS) with restricted breathing sounds on the affected side, irregular thoracic breathing, potential cyanosis.

  • Management:

    • Phrenic nerve grafting or pacing may be required for persistent RDS.

    • CPAP or mechanical ventilation as a last resort.

Nursing Management for Phrenic Nerve Palsy

  • Similar nursing care protocols as for any newborn with RDS, including:

    • Positioning on the affected side; oxygen administration as needed.

    • Transition to oral feeding as condition improves; implement pulmonary interventions to prevent pneumonia.

    • Address parental emotional needs.

Injuries to Brachial Plexus

Brachial Palsy (Erb’s Palsy or Erb-Duchenne Paralysis)

  • Description: C5-6 upper brachial nerve injury, the most frequent type associated with difficult deliveries (e.g., shoulder dystocia, LGA, forceps). May also coincide with fractured clavicle or humerus.

  • Clinical Manifestations:

    • Affected arm remains limp alongside the body; shoulder and arm adducted and internally rotated.

    • Elbow extended; forearm pronated with flexed wrist and fingers.

    • Grasp reflex may be present; absent Moro reflex on the affected side with normal on the unaffected.

Klumpke Paralysis

  • Description: C7 and T1 injury, less common, resulting from severe arm traction.

  • Clinical Manifestations:

    • Asymmetrical presentation (one-sided).

    • Hand appears in a claw-like position, with wrist drop and relaxed fingers.

    • Lack of sensation in the affected arm and hand; absent grasp reflex and Moro reflex on that side; the arm is often bent and held against the body.

Complications of Brachial Plexus Injuries

  • Establish measures to prevent contractures, making rehabilitation essential.

Management of Brachial Plexus Injuries

  • Methods include:

    • X-ray to R/O bone injury.

    • MRI for assessment.

    • Monitoring for diaphragmatic involvement.

    • Strategies to immobilize using splints or braces to avert wrist and digit flexion contractures; passive range of motion (PROM) initiated after 7-10 days, with consideration of nerve edema resolution.

    • Surgical intervention may be necessary in some cases to relieve pressure or repair nerves.

    • Recovery may vary: improvement may be noted if edema or hemorrhage is the cause, typically seen within 1-2 weeks, whereas permanent deficits may arise if no improvements are seen within 6 months.

Nursing Management for Brachial Plexus Injuries

  • Aim to prevent flexion contractures of paralyzed muscles by maintaining gentle immobilization in anatomical alignment for about a week.

  • Initiate PROM exercises of joints around 7-10 days of age.

  • Splint wrist to prevent flexion contractures, practice progressive dressing techniques beginning with the unaffected side.

  • Avoid lifting infants from the axilla; ensure family support and assess coping mechanisms.

Summary of Birth Injuries in the Newborn

  • Effective antenatal, intrapartal, and postnatal care is critical in preventing birth trauma.

  • Many birth injuries may not necessitate extensive treatment; healthcare providers should provide clear explanations to parents, enhancing their understanding and reducing anxiety related to their newborn's condition. For more severe injuries, thorough explanations along with continuous support from healthcare teams are essential to aid parental coping efforts.

Let’s Practice!

Soft Tissue Injury/Head Trauma

  • Examples:

    • Ecchymoses

    • Erythema

    • Petechiae

    • Abrasions/Lacerations

    • Cephalhematoma

    • Caput Succedaneum

    • Subgaleal Hemorrhage

    • Ocular injury

Peripheral Nerve Injuries

  • Examples:

    • Facial Palsy (Cranial Nerve)

    • Phrenic Nerve Palsy (C3,4,5)

    • Brachial Plexus Injuries:

    • Erb’s Palsy or Erb-Duchenne paralysis (C5,6)

    • Klumpke Paralysis (C7,T1)

Skeletal Injuries

  • Types:

    • Skull fractures: Linear or Depressed

    • Clavicular fractures

    • Long Bone fractures

Central Nervous System Injuries

  • Types:

    • ICH: Subdural or Subarachnoid

Diagrams and Figures

  • Include illustrations from credible sources to emphasize anatomical location and the nature of injuries:

    • Examples include: swelling of genitalia and bruising after breech birth, fractured clavicle after shoulder dystocia, facial paralysis after forceps delivery.

Conclusion

  • Comprehensive understanding and management of birth trauma are crucial for optimizing newborn health outcomes. Healthcare professionals need robust supporting frameworks for education and emotional support for families experiencing birth injuries to the newborn.

Copyright © 2005 by Mosby, Inc. All rights reserved.