Birth Trauma


Article Author:
Vikramaditya Dumpa


Article Editor:
Ranjith Kamity


Editors In Chief:
David Wood
Andrew Wilt
Hajira Basit


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
9/11/2019 6:44:49 PM

Introduction

The National Vital Statistics Report defines birth injury as “an impairment of the neonate's body function or structure due to an adverse event that occurred at birth.” These injuries include a wide range of minor to major injuries that may occur due to various mechanical forces during labor and delivery. Birth injuries are different from birth defects or malformations and are often easily distinguishable from congenital defects by a focused clinical assessment. Birth trauma rates have steadily declined over the last few decades due to refinements in obstetrical techniques and the increased use of cesarean delivery in cases of dystocia or difficult vaginal deliveries. The birth trauma rate fell from 2.6 per 1000 live births in 2004 to 1.9 per 1000 live births in 2012. The rates of instrumental deliveries have also gradually declined over the past three decades with a reduction in the number of both forceps and vacuum-assisted deliveries.[1]

Issues of Concern

The risk factors associated with birth trauma can group into those related to the fetus, pregnancy, mother or iatrogenic factors (use of instrumentation during delivery).[2][3] Fetal and pregnancy-related factors include macrosomia (estimated fetal weight greater than 4000g), macrocephaly, very low birth weight, extreme prematurity, fetal congenital anomalies, oligohydramnios and malpresentations including breech presentation as well as other abnormal presentations (such as the face, brow, or transverse). Maternal factors may include maternal obesity, maternal diabetes, cephalopelvic disproportion, small maternal stature, primiparity, dystocia, difficult extraction, use of vacuum or forceps, prolonged or rapid labor.[4]

Clinical Significance

The clinical management and prognosis of infants with birth injuries vary widely depending on the type and severity of the injury. The common sites for birth trauma can include the head, neck, and shoulders. Other less common locations include the face, abdomen, and lower limbs. A summary of the common traumatic clinical conditions occurring related to birth is listed below.

Head Trauma

Head trauma can include superficial lesions, extracranial and intracranial hemorrhages, as well as fractures of the skull bones.

Caput Succedaneum: Caput succedaneum is a common scalp swelling in newborns. It is a subcutaneous swelling and edema of the scalp between the skin and the periosteum due to local venous congestion from the pressure of the birth canal on the presenting part. The edema is above the plane of the periosteum, and hence the scalp swelling crosses suture lines. No intervention is required, and it typically resolves over the first few postnatal days. Rare complications include bruising of the skin over the swelling with necrosis resulting in scarring and alopecia, and rarely systemic infection. 

Skull Fractures: Skull fractures from birth trauma are most often a result of instrumented vaginal delivery. These fractures could be linear or depressed and are usually asymptomatic unless associated with an intracranial injury. Plain film radiographs of the skull usually clarify the diagnosis, but computed tomography (CT) or magnetic resonance imaging (MRI) of the brain is the recommendation if there is suspicion of intracranial injury or presence of neurologic symptoms.

Extracranial Hemorrhages:

Cephalohematoma: Cephalohematoma is a localized sub-periosteal collection of blood resulting from the rupture of blood vessels traversing from the skull to the periosteum. Limited by the periosteal attachment to the underlying skull bones, the swelling does not cross suture lines and is often unilateral. It is more common in deliveries involving vacuum or forceps and occurs in up to 2.5% of all deliveries. [5] The usual course is a spontaneous resolution in 2 weeks to 3 months without any intervention, but complications such as calcification of the hematoma, deformities of the skull, infection of the hematoma and osteomyelitis of the skull can occur.

Subgaleal Hemorrhage: Subgaleal hemorrhage is a collection of blood in the loose areolar tissue space between the galea aponeurotica and the periosteum of the skull. The injury occurs when there is traction pulling the scalp away from the stationary bony calvarium, resulting in the shearing or severing of the bridging vessels. A difficult vaginal delivery resulting in the use of forceps or vacuum is the most common predisposing event in the formation of subgaleal hemorrhage.  It has been estimated to occur in 4 of 10000 spontaneous vaginal deliveries and 59 of 10000 vacuum-assisted deliveries.[6] Since the subgaleal space is a significant potential space extending over the entire area of the scalp from the anterior attachment of the galea aponeurosis near the frontal bones to the posterior attachment at the nape of the neck, there is a potential for massive bleeding into this space that could result in acute hypovolemic shock, multi-organ failure, and death. Treatment includes supportive care with early recognition and restoration of blood volume using blood or fresh frozen plasma to correct the acute onset hypovolemia. The hemorrhage itself is not drained and allowed to resorb over time. A workup for bleeding disorders may be considered in selected cases if the degree of bleeding is out of proportion to the trauma at birth. 

Intracranial Hemorrhages:

Traumatic intracranial hemorrhages include epidural, subdural, subarachnoid, intraventricular and less frequently intracerebral and intracerebellar hemorrhages.

Epidural hemorrhage is very rare in neonates and usually accompanies linear skull fractures in the parietal-temporal region following an operative delivery. Signs include bulging fontanelle, bradycardia, hypertension, irritability, altered consciousness, hypotonia, seizures. Diagnosis is via CT or MRI of the head which shows a convex appearance of blood collection in the epidural space. Prompt neurosurgical intervention is necessary due to the potential to deteriorate rapidly.

Subdural hemorrhage is the most common type of intracranial hemorrhage in neonates. Operative vaginal delivery is a major risk factor, and hemorrhage over the cerebral convexities is the most common site. Presenting signs/symptoms include bulging fontanelle, altered consciousness, irritability, respiratory depression, apnea, bradycardia, altered tone, and seizures. Subdural hemorrhages can occasionally be found incidentally in asymptomatic neonates. Management depends on the location and extent of the bleeding. Surgical evacuation is reserved for large hemorrhages causing raised intracranial pressure and associated clinical signs.

Subarachnoid hemorrhage is the second most common type of neonatal intracranial hemorrhage and is usually the result of the rupture of bridging veins in the subarachnoid space. Operative vaginal delivery is a risk factor, and the infants are typically asymptomatic unless the hemorrhage is extensive. Ruptured vascular malformations are a rare cause of subarachnoid hemorrhages, even in the neonatal population. Treatment is usually conservative.

Intraventricular hemorrhage even though most commonly seen in premature infants, can also occur in term infants depending on the nature and extent of the birth injury.[7] Intracerebral and intracerebellar hemorrhages are less common and occur as a result of occipital diastasis.

Cranial Nerve injuries:

Facial nerve: Facial nerve is the most common cranial nerve injured with a traumatic birth. It occurs in up to 10 per 1000 live births and is usually a result of pressure on the facial nerve by forceps or from a prominent maternal sacral promontory during descent. Clinical manifestations include diminished movement or loss of motion on the affected side of the face. Facial nerve palsy requires differentiation from asymmetric crying facies which results from congenital hypoplasia of the depressor anguli oris muscle and causes a localized movement abnormality of the corner of the mouth. Although forceps delivery has a strong association, facial palsy can occur in the newborn without apparent trauma.[8] The prognosis in traumatic facial nerve injury is good with spontaneous resolution usually noted within the first few weeks of life. 

Peripheral Nerve and Spinal Cord Injuries

Brachial plexus injuries: These occur in up to 2.5 per 1000 live births and are the result of stretching of the cervical nerve roots during the process of delivery. These injuries are usually unilateral, and risk factors include macrosomia, shoulder dystocia, difficult delivery, breech position, multiparity and assisted deliveries.[9]

  • Injury involving the fifth and sixth cervical nerve roots results in Erbs-Duchenne palsy manifested by weakness in the upper arm. Adduction and internal rotation of the arm with flexion of the fingers are presenting symptoms; this is by far the most common form of brachial plexus injury.
  • Injury to eighth cervical and first thoracic nerves results in Klumpke’s palsy manifested by paralysis of the muscles of the hand, absent grasp reflex and sensory impairment along the ulnar side of the forearm and arm.
  • Injury to all the nerve roots can result in total arm paralysis.
  • Injury to the phrenic nerve can be an associated feature of brachial palsy. Clinical manifestations include tachypnea with asymmetric chest motion and diminished breath sounds on the affected side.

The majority of brachial plexus injuries are stretch injuries, and treatment is conservative with physical therapy playing a major role in the return of gradual function.[10] Rare, severe cases of brachial plexus injuries result in lasting weakness on the affected side. 

Spinal cord: Spinal cord injuries are infrequent in the neonatal period and are usually a result of excessive traction or rotation of the spinal cord during extraction.[11] The clinical manifestations depend on the type and location of the lesion. Higher lesions (cervical/upper thoracic) are associated with a high mortality rate and lower lesions (lower thoracic, lumbosacral) may result in significant morbidity with bladder and bowel dysfunction. Diagnosis is via ultrasonography or MRI of the spinal cord. Management points towards presenting clinical symptomatology with cardiorespiratory stabilization as needed. 

Skeletal injuries: 

Most of the fractures resulting from birth trauma are associated with difficult extractions or abnormal presentations. Clavicular fractures are the most common bone fracture during delivery and can occur in up to 15 per 1000 live births. The clinical presentation is significant for crepitus at the site of fracture, tenderness and decreased movement of the affected arm with an asymmetric Moro reflex. Clavicular fractures have a good prognosis with spontaneous healing occurring in the majority of infants. The humerus is the most common long bone to fracture during birth, and this can be associated with a brachial plexus injury. The clinical presentation could be similar to a clavicular fracture with an asymmetric Moro reflex, inability to move the affected arm. Also, a significant deformity might be noted on the affected arm with swelling and tenderness at the site of the fracture. Rare conditions may involve a distal humeral epiphyseal separation due to birth trauma requiring expert orthopedic intervention.[12] In general, immobilization for 3 to 4 weeks is necessary and often heals well without deformities. Other fractures such as femur fracture, rib fractures can occur during birth but are rare. [13]  On the other hand, femur fractures are extremely rare in newborns and may be seen in difficult vaginal breech extraction deliveries. Diagnosis is made by clinical exam with tenderness, swelling, and deformity of the thigh and confirmed further on plain radiographs. Orthopedic consultation is the recommendation for long bone fractures for appropriate immobilization.

Facial injuries:

Ocular injuries: Subconjunctival hemorrhages (SCH) are superficial hematomas seen under the bulbar conjunctiva, commonly seen in infants born after going through labor. It is suggested to be due to ruptured subconjunctival capillaries from venous congestion, occurring from increased back pressure in the head and neck veins. This injury can result from either a nuchal cord or from increased abdominal or thoracic compression during uterine contractions.[14] SCH is a benign condition in the newborn and resolves without intervention. A more significant ocular injury may occur with the use of instrumentation during delivery (forceps), resulting in corneal abrasions, vitreous hemorrhages, etc. that require immediate attention and referral to an ophthalmologist to prevent long term visual defects.[15][16]

Soft tissue injuries:

Soft tissue injuries occurring as a result of birth trauma include petechiae, bruising, ecchymoses, lacerations and subcutaneous fat necrosis. Subcutaneous fat necrosis is thought to be a result of ischemic injury to the adipose tissue and characterized by palpation of soft, indurated nodules in the subcutaneous plane. These lesions resolve gradually over the course of a few weeks. Hypercalcemia is one of the complications; therefore it is recommended to monitor serum calcium.[17]  There are reports of accidental lacerations during cesarean section deliveries, with an Italian study showing a 3% incidence of accidental lacerations during cesarean sections, and a higher incidence in emergent deliveries compared to scheduled cesarean deliveries.[18]

Visceral injuries:

Birth trauma resulting in abdominal visceral injuries is uncommon and primarily consists of hemorrhage into the liver, spleen or adrenal gland. The clinical presentation depends on the volume of blood loss and can include pallor, bluish discoloration of the abdomen, distension of the abdomen, and shock. Treatment is supportive with volume resuscitation and surgical intervention if needed.

Enhancing Healthcare Team Outcomes

Birth trauma in a newborn has a varied presentation depending on the type of injury sustained. The affected newborns may present with mild benign signs and symptoms to severe life-threatening signs and symptoms. Injuries occur at birth due to a diverse array of reasons, secondary to maternal, fetal or external risk factors. The prognosis of the birth injuries also depends on the type and severity of the initial injury. A detailed physical exam of the newborn is warranted at birth to identify birth injuries and to differentiate them from congenital malformations or birth defects. Extracranial hemorrhages typically heal well with occasional complications of hyperbilirubinemia, infections. Subgaleal hemorrhage requires careful clinical observation and monitoring due to the potential for life-threatening acute severe hypovolemia. Intracranial hemorrhages, if large, can result in focal neurological damage and required prompt intervention, including a neurosurgical evaluation. The prognosis of spinal cord injuries depends on the level of injury. Lesions below T4 have a comparatively better prognosis. Superficial soft tissue injuries generally heal well without any residual sequelae. The majority of brachial plexus injuries resolve within a few weeks, but physical therapy and close follow-up are mandated. Occasional cases of brachial plexus injuries can have long-lasting weakness or dysfunction (level III evidence).[19] The prognosis is also good for facial nerve injuries with a complete recovery expected within a few weeks in a majority of infants. 

A vital element in this context is the prevention of birth trauma in the first place using an interdisciplinary team involving obstetricians, neonatologists, pediatricians, radiologists, and specialty trained nurses. Advances in antenatal care have resulted in increased awareness of fetal malformations and malpresentation, and potential problems can be anticipated before delivery, thereby leading to improved preparation for a high-risk delivery. Hence it is essential for pregnant women to adhere to prenatal care recommendations for optimal outcomes. A coordinated educational effort involving the clinician, nurse midwife, and specialty-trained nurse reinforcing good prenatal efforts will decrease the incidence of untoward events. It is also important to acknowledge that not all birth-related injuries are iatrogenic or preventable. Infants who sustain birth injuries that place them at risk for neurodevelopmental impairment should be monitored closely by an interprofessional team for the attainment of developmental milestones appropriately. This team should include a pediatrician, labor and delivery nurse, physical and occupational therapist, and a developmental-behavioral pediatrician supported by coordination of care by the clinical and nursing staff. [Level 5]


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Birth Trauma - Questions

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Which of the following is most commonly fractured during childbirth?



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The provider is examining a 4.5 kg newborn admitted to the neonatal intensive care unit after a difficult extraction. The student notes that there is no spontaneous movement of the left hand and there is no response upon stimulating the medial side of the hand. Which nerve roots are involved in this type of birth injury?



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A 41 week gestational age female infant was delivered by forceps after prolonged, difficult labor involving vigorous fetal manipulation. Physical exam done at the time of discharge on day of life 4 revealed multiple indurated subcutaneous nodules with overlying erythema on the back, buttocks, and thighs. The electrolyte that is most likely to be elevated in this infant is which one of the following?



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A full-term male infant delivered after a vacuum extraction is noted to have a boggy swelling over his scalp. The swelling is soft, fluctuant predominantly over the right parietal-temporal region. The pinna of the right ear is slightly pushed forward from the swelling. Of the following, the infant has a collection of blood between which of the following?



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You are called to assess a 2 hour old full-term male newborn in the nursery with "bright red patches in both eyes." Upon review of the history, the infant was born after a difficult delivery, which included a prolonged second stage of labor, and the presence of a tight nuchal cord. On examination, the infant is well appearing with normal vital signs. A small superficial scalp swelling is noted over the left parietal scalp crossing the suture lines. Both the eyes have bright red patches over the bulbar conjunctiva bilaterally. The cornea appears normal on gross examination with a normal red reflex. The rest of the exam is within normal limits including a neurological exam. The best course of action in this situation is which one of the following?



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A pediatric provider is called to assess a newborn for increased irritability. On arrival, she notes that the infant is crying incessantly and is quite irritable. Upon obtaining a full history, she is told that the mother is a 40-year-old pre-gestational diabetic with poorly controlled glucose levels during late pregnancy. The delivery was complicated by shoulder dystocia, and the obstetrician used special maneuvers to deliver the shoulders. On gross examination, the infant appears macrosomic. On performing the Moro reflex, there is a decreased movement on the left side. Crepitus is palpated on the left upper mid-clavicular region with a deformity. Which one of the following should be communicated to the family concerning the newborn?



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Birth Trauma - References

References

Moczygemba CK,Paramsothy P,Meikle S,Kourtis AP,Barfield WD,Kuklina E,Posner SF,Whiteman MK,Jamieson DJ, Route of delivery and neonatal birth trauma. American journal of obstetrics and gynecology. 2010 Apr;     [PubMed]
Werner EF,Janevic TM,Illuzzi J,Funai EF,Savitz DA,Lipkind HS, Mode of delivery in nulliparous women and neonatal intracranial injury. Obstetrics and gynecology. 2011 Dec;     [PubMed]
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Plauché WC, Subgaleal hematoma. A complication of instrumental delivery. JAMA. 1980 Oct 3;     [PubMed]
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Del Pozzo-Magaña BR,Ho N, Subcutaneous Fat Necrosis of the Newborn: A 20-Year Retrospective Study. Pediatric dermatology. 2016 Nov;     [PubMed]
Merriam AA,Ananth CV,Wright JD,Siddiq Z,D'Alton ME,Friedman AM, Trends in operative vaginal delivery, 2005-2013: a population-based study. BJOG : an international journal of obstetrics and gynaecology. 2017 Aug     [PubMed]
Vitner D,Hiersch L,Ashwal E,Nassie D,Yogev Y,Aviram A, Outcomes of vacuum-assisted vaginal deliveries of mothers with gestational diabetes mellitus. The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians. 2018 May 2     [PubMed]
Al Tawil K,Saleem N,Kadri H,Rifae MT,Tawakol H, Traumatic facial nerve palsy in newborns: is it always iatrogenic? American journal of perinatology. 2010 Oct     [PubMed]
Patil MN,Palled E, Epihyseal Separation of Lower end Humerus in A Neonate-Diagnostic and Management Difficulty. Journal of orthopaedic case reports. 2015 Oct-Dec     [PubMed]
Katzman GH, Pathophysiology of neonatal subconjunctival hemorrhage. Clinical pediatrics. 1992 Mar     [PubMed]
Holden R,Morsman DG,Davidek GM,O'Connor GM,Coles EC,Dawson AJ, External ocular trauma in instrumental and normal deliveries. British journal of obstetrics and gynaecology. 1992 Feb     [PubMed]
McAnena L,O'Keefe M,Kirwan C,Murphy J, Forceps Delivery-Related Ophthalmic Injuries: A Case Series. Journal of pediatric ophthalmology and strabismus. 2015 Nov-Dec     [PubMed]
Dessole S,Cosmi E,Balata A,Uras L,Caserta D,Capobianco G,Ambrosini G, Accidental fetal lacerations during cesarean delivery: experience in an Italian level III university hospital. American journal of obstetrics and gynecology. 2004 Nov     [PubMed]
DeFrancesco CJ,Shah DK,Rogers BH,Shah AS, The Epidemiology of Brachial Plexus Birth Palsy in the United States: Declining Incidence and Evolving Risk Factors. Journal of pediatric orthopedics. 2019 Feb     [PubMed]

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