46-fetal birth injuries

FETAL BIRTH INJURIES FETAL BIRTH INJURIES

• Fetal birth injuriesFetal birth injuries represent an represent an important commonly avoidable cause of important commonly avoidable cause of neonatal morbidity and mortality. They vary neonatal morbidity and mortality. They vary from minor skin abrasions to severe from minor skin abrasions to severe intracranial haemorrhage. Prevention of intracranial haemorrhage. Prevention of serious birth trauma depends mainly upon serious birth trauma depends mainly upon the art of obstetrics and the experience of the art of obstetrics and the experience of the obstetrician, and is considered a the obstetrician, and is considered a reflection of the improvements in antenatal reflection of the improvements in antenatal and perinatal care. and perinatal care.

TYPES OF FETAL BIRTH TYPES OF FETAL BIRTH INJURIESINJURIESBone injuriesBone injuries::1-Skull fracture:1-Skull fracture:• Etiology:Etiology:Difficult forceps delivery.Difficult forceps delivery.Delivery through a contracted pelvis. Delivery through a contracted pelvis. • Types:Types:Fracture vault: linear or depressed (associated with Fracture vault: linear or depressed (associated with

intra-cranial haemorrhage so needs surgical intra-cranial haemorrhage so needs surgical intervention).intervention).

Fracture base: usually associated with intra-cranial Fracture base: usually associated with intra-cranial haemorrhage.haemorrhage.

Fracture mandible Fracture mandible

Bone injuriesBone injuries

2-Others bone injuries:2-Others bone injuries:

• Spine injuries.Spine injuries.

• Fracture humerusFracture humerus

• Fracture femur.Fracture femur.

• Fracture clavicle.Fracture clavicle.

• Dislocation of hip.Dislocation of hip.

• Dislocation of shoulders Dislocation of shoulders

Soft tissue birth injuriesSoft tissue birth injuries

1-Intra-cranial haemorrhage over compression of 1-Intra-cranial haemorrhage over compression of cranial bones).cranial bones).

2-Cephalhaematoma (instrumental trauma 2-Cephalhaematoma (instrumental trauma especially ventouse).especially ventouse).

3-Nerve Injuries (undue traction on neck, shoulders, 3-Nerve Injuries (undue traction on neck, shoulders, and arms).and arms).

4-Visceral and Muscle Injuries.4-Visceral and Muscle Injuries.5-Eye Injury.5-Eye Injury.6-Injury of hymen, or anal sphincter especially in 6-Injury of hymen, or anal sphincter especially in

breech presentation, during examination.breech presentation, during examination.7-Skin and scalp Injuries by the scalpel on opening 7-Skin and scalp Injuries by the scalpel on opening

the uterus in a C.S.the uterus in a C.S.

INTRA-CRANIAL INTRA-CRANIAL HAEMORRHAGEHAEMORRHAGE

AETIOLOGY:AETIOLOGY:• Prematurity, due to:Prematurity, due to:Fragile blood vessels.Fragile blood vessels.Hypoprothrombinaemia.Hypoprothrombinaemia.Increased susceptibility to birth trauma.Increased susceptibility to birth trauma.• Breech deliveryBreech delivery: due to sudden : due to sudden

compression and decompression of compression and decompression of cranial bones.cranial bones.

Aetiology Aetiology

• Excessive compressionExcessive compression, due to:, due to:

Excessive moulding, in cases of Excessive moulding, in cases of cephalopelvic disproportion.cephalopelvic disproportion.

Excessive compression by forceps (oblique Excessive compression by forceps (oblique application or persistent locking).application or persistent locking).

• AsphyxiaAsphyxia: leads to hypoxia of the walls of : leads to hypoxia of the walls of blood vessels with subsequent leakage.blood vessels with subsequent leakage.

• Hemorrhagic disease of the newborn.Hemorrhagic disease of the newborn.

Sites of Haemorrhage:Sites of Haemorrhage:

• Intra-ventricular haemorrhage.Intra-ventricular haemorrhage.

• Intra-cerebral haemorrhage.Intra-cerebral haemorrhage.

• Subdural haemorrhage.Subdural haemorrhage.

• Subarachnoid haemorrhage Subarachnoid haemorrhage

• Subdural and subarachnoid Subdural and subarachnoid haemorrhages usually develop with haemorrhages usually develop with traumatic delivery.traumatic delivery.

• The vein of Galen is torn due to tear in The vein of Galen is torn due to tear in dura at jnction of falx cerebri with dura at jnction of falx cerebri with tentorium cerebelli (that results from tentorium cerebelli (that results from excessive moulding due to increased excessive moulding due to increased antero-posterior diameter of the head)antero-posterior diameter of the head)

Clinical features Clinical features

• Stillbirth or neonatal asphyxia.Stillbirth or neonatal asphyxia.

• Drowsy, refuse suckling with Drowsy, refuse suckling with sudden sharp cry.sudden sharp cry.

• Convulsions and rigidity.Convulsions and rigidity.

• Tense bulging anterior fontanelle.Tense bulging anterior fontanelle.

• Vomiting Vomiting

Differential DiagnosisDifferential Diagnosis

• Asphyxia neonatorum.Asphyxia neonatorum.

• Neonatal convulsions Neonatal convulsions

• Investigations:Investigations: Brain CT scan. Brain CT scan.

Treatment Treatment

Prophylactic TreatmentProphylactic Treatment

• Breech delivery: see breech Breech delivery: see breech presentation.presentation.

• Premature delivery: see prematurity.Premature delivery: see prematurity.

• Vitamin K for the mother (10 mg IM Vitamin K for the mother (10 mg IM early in labour when we suspect early in labour when we suspect difficult delivery)difficult delivery)

• Careful forceps application.Careful forceps application.

Treatment Treatment

Active TreatmentActive Treatment• Resuscitation with minimal handling.Resuscitation with minimal handling.• Chloral hydrate, Magnesium sulphate 50% 1 Chloral hydrate, Magnesium sulphate 50% 1

cc and Luminal.cc and Luminal.• NaCl per rectum for edema.NaCl per rectum for edema.• Dehydrating measures even lumbar Dehydrating measures even lumbar

puncture.puncture.• Vitamin K for the fetus (1 mg IM).Vitamin K for the fetus (1 mg IM).• N.B.: N.B.: Penicillin is used for Penicillin is used for

prophylaxis against infectionprophylaxis against infection

3. NERVE INJURIES3. NERVE INJURIES

• . . Facial Nerve PalsyFacial Nerve Palsy . .

• Brachial Plexus InjuryBrachial Plexus Injury

Facial nerve palsyFacial nerve palsy

• CauseCause:: Compression of the nerve by blade of forceps Compression of the nerve by blade of forceps

results in edema and haematoma around the results in edema and haematoma around the nerve.nerve.

• Clinical pictureClinical picture: : unilateral and temporaryunilateral and temporaryAbsent nasolabial fold.Absent nasolabial fold.Angle of the mouth is deviated to the healthy side.Angle of the mouth is deviated to the healthy side.Absent blinking on the affected side.Absent blinking on the affected side.• Treatment:Treatment:Conservative management. May need Conservative management. May need

corticosteroids.corticosteroids.

Bracial plexus injuryBracial plexus injury

• Cause:Cause:

Forcible lateral flexion of the head Forcible lateral flexion of the head during delivery causes damage of during delivery causes damage of the roots of brachial plexus (edema the roots of brachial plexus (edema and haematoma around the nerves). and haematoma around the nerves).

Bracial plexus injuryBracial plexus injury

Clinical picture:Clinical picture:•Upper injury (Erb’s palsy):Upper injury (Erb’s palsy):

• Injury to C5 and C6.Injury to C5 and C6.Characters: Policeman tip position:Characters: Policeman tip position:• The affected limb is adducted to the The affected limb is adducted to the

body and internally rotated.body and internally rotated.• Elbow is extended.Elbow is extended.• Wrist is flexed.Wrist is flexed.

Bracial plexus injuryBracial plexus injury

– Lower injury (Klumpke's palsy):Lower injury (Klumpke's palsy):

• Injury to C7, C8 and T1.Injury to C7, C8 and T1.

Characters:Characters:

• Wrist drop.Wrist drop.

• Absent grasp reflex.Absent grasp reflex.

• Paralysis of small muscles of hands Paralysis of small muscles of hands (atrophy).(atrophy).

Brachial plexus injuryBrachial plexus injury

• Treatment:Treatment:

• Upper injury (Erb's palsy):Upper injury (Erb's palsy):Fixation of Fixation of the affected limb in pharaoh’s the affected limb in pharaoh’s position. position.

• Lower injury (Klumpke’s palsy):Lower injury (Klumpke’s palsy):

Physiotherapy.Physiotherapy.

Rarely, it may need plastic correction.Rarely, it may need plastic correction.

4. VISCERAL AND MUSCLE 4. VISCERAL AND MUSCLE INJURYINJURY

• Visceral Injury:Visceral Injury:

e.g. liver, spleen.e.g. liver, spleen.

It may occur during breech delivery It may occur during breech delivery

Muscle Injury:Muscle Injury: (Especially (Especially sternomastoid muscle)sternomastoid muscle)

• Cause:Cause: due to forcible traction on due to forcible traction on the head ® (tilting of the head the head ® (tilting of the head towards the affected sidetowards the affected side

• Clinical picture:Clinical picture: It may subside or It may subside or cause permanent torticollis cause permanent torticollis

• Treatment:Treatment: by passive stretching of by passive stretching of muscle several times/day muscle several times/day

Cepalhaematoma Cepalhaematoma ( subperiosteal )( subperiosteal )• CauseCause

• AppearanceAppearance• CharacterCharacter• EdgesEdges• SkinSkin• SuturesSutures• ComplicationsComplications• TreatmentTreatment

• Forceps or Forceps or ventouseDifficult delivery ventouseDifficult delivery through contracted pelvisthrough contracted pelvis

• Few hours after birthFew hours after birth

• Well definedWell defined

• NormalNormal• No overlap & limited to No overlap & limited to

one boneCalcification, one boneCalcification, • infection and hyper-infection and hyper-

bilirubinaemiabilirubinaemia• Expectant treatment Expectant treatment

(disappears within few (disappears within few weeks)weeks)

Caput succedaneum Caput succedaneum

• CauseCause

• AppearanceAppearance• EdgesEdges• SkinSkin• SuturesSutures

• TreatmentTreatment• ComplicationsComplications

• Obstructed labourObstructed labour• VentouseVentouse• At birthAt birth• ILL definedILL defined• May be ecchymoticMay be ecchymotic• Overlap sutures and Overlap sutures and

cover more than 1 cover more than 1 bonebone

• No treatmentNo treatment• (disappears after 1 (disappears after 1

-2 days)-2 days)