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Predisposing FactorsMaternal factors: Primigravida Cephalopelvic disproportion,

small maternal stature maternal pelvic anomalies

Prolonged or rapid labor Dystocia Oligohydramnios

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Predisposing factors

Fetal factors: Abnormal presentation

Breech, face VLBW or extreme prematurity Fetal macrosomia Large fetal head Fetal anomalies

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Predisposing Factors

Obstetrical Interventions: Use of mid-cavity forceps or vacuum

extraction Versions and extractions

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Types of Injury

Soft tissue injuries Head and Skull Face Musculoskeletal injuries Intra-abdominal injuries Peripheral nerve injuries

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Soft Tissue Injuries

Erythema & Abrasions- Forceps, Dystocia

Petechiae-head/neck/chest/back- Cord around neck

/breech - thrombocytopenia Ecchymoses

-breech/prematurity

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Soft Tissue InjuriesLacerations

scalp, buttocks, thighs(Fetal scalp electrodes, surgeons knife!)

Infection a risk, but most heal uneventfully

Management: careful cleaning, application of antibiotic

ointment, and observation Bring edges together using Steri-Strips Lacerations occasionally require suturing

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Soft Tissue InjuriesSubcutaneous fat Necrosis (SFN) Not usually detected at birth Irregular, hard, non-pitting, subcutaneous

plaques with overlying dusky red-purple discoloration on the extremities, face, trunk, or buttocks

May be caused by pressure during delivery Hypothermia/ischemia/asphyxia appear @ 6-10 days resolve @ 6-8 wk/atrophy Sometimes calcifies

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Soft Tissue Injuries

SFN: TreatmentTreat symptomatic hypercalcemia

aggressively increased fluid intake low calcium/ vit. D diet furosemide -calcium-wasting diureticSteroids-inhibit metabolism of vit. DBiphosphonates-reduce bone resorption

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Injuries to the HeadCaput Succedaneum most frequently observed lesion pressure on the scalp against cervix subcutaneous, extraperiosteal accumulation of

blood/serum presenting part involved overlying bruising/Petechiae crosses suture lines resolves within days

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Injuries to the Head

Cephalhematoma 0.4%-2.5% of all live births sub-periosteal hemorrhage from rupture of blood

vessels between the skull and the periosteum buffeting of fetal head against the pelvis no extension across suture lines most commonly parietal, may occasionally be

observed over the occipital bone

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Injuries to the Head

Cephalhematoma increases in size with time 15% bilateral

18% associated skull fracture Forceps

Vacuum

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Injuries to the Head

Subgaleal HemorrhageDiagnosis is generally clinical: fluctuant boggy mass developing over the scalp

(especially over the occiput) develops gradually 12-72 hours after delivery hematoma spreads across the whole calvarium Usually insidious and may not be recognized for

hours swelling may obscure the fontanelle and cross

suture lines (distinguishing it from cephalhematoma)

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Injuries to the Head

Subgaleal HemorrhageRx if signs of substantial volume loss: compression wrap restore blood volume surgical drainage 25% mortality

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Cephalhematoma

Caput Succedaneum

Subgaleal hemorrhage with skull fracture

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SkinEpicranial aponeuroses

Periosteum

Skull

Dura

Caput CephalhematomaSubgaleal hemorrhage

extradural hemorrhage

Lesion External swelling ↑ after birth

Crosses suture lines

↑↑↑acute blood loss

Caput succedaneum Soft, pitting No Yes No

Cephalhematoma Firm, tense Yes No No

Subgaleal hematoma Firm, fluctuant Yes Yes Yes

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Injuries to the Head

Skull FracturesUncommon because of compressible skull & open

suturesForceps/Prolonged laborLinear/DepressedUsually asymptomaticAssociated intracranial hemorrhage may produce symptoms

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Injuries to the Head

Skull Fractures

Rx – conservative - elevation of depressed fracture

- Thumb pressure- Hand pump

- Vacuum extractor Surgical elevation Healing within a few months

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Injuries to the Head

Intracranial hemorrhage

- Subdural/Subarachnoid/IVH- Usually asymptomatic- Forceps/Vacuum- Prolonged labor- Usually associated with fracture

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Injuries to the Head

Subarachnoid hemorrhage-more frequent than realized

-usually asymptomatic

-may cause seizures (day 2-3)

-bloody CSF

- CT/MRI

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Injuries to the Head

Subdural Hematoma- may be silent for several days-head circumference- poor feeding /vomiting /lethargy- altered consciousness/seizures - DX- CT/MRI- RX- Subdural taps/surgical drainage

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Injuries to the Head

Fractures of Facial bones-nasal fracture/dislocation

-deviated nasal septum

-maxillary fracture

-mandibular fracture

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EYE INJURIES

Eye Lids

edema/ecchymoses/laceration Subconjuntival hemorrhage Orbital fracture/hemorrhage Extra Ocular Muscle injury Corneal Abrasion Intra Ocular hemorrhage

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Injuries to the Ear

Ecchymoses Abrasion Avulsion Hematoma

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Neck and Shoulder injuries

Fractured Clavicle-most frequently fractured bone-difficult delivery-shoulder dystocia-breech -Crepitus or deformity at the site-movement/moro on affected side-associated brachial plexus palsy

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Neck and Shoulder injuriesFractured Clavicle

DX- X-ray

RX- conservativeimmobilizationreduce pain pain subsides in 7-10 days

good prognosis

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Neck and Shoulder injuries

Fracture of the Humerus second most common fracture difficult delivery/traction shoulder dystocia breech

deformity

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Neck and Shoulder injuries

Fractured Humerus: Management Splinting/immobilization in adduction Closed reduction and casting when displaced Watch for evidence of radial nerve injury Callus formation occurs, and complete

recovery expected in 2-4 weeks In 8-10 days, the callus formation is sufficient

to discontinue immobilization

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Intra-abdominal Organ Injury

Uncommon sometimes overlooked as a cause of death in

the newborn Hemorrhage is the most serious acute

complication liver is the most commonly damaged internal

organ

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Nerve Palsies

Facial NerveEtiology Compression Of peripheral nerve

-forceps

-prolonged labor

-in-utero compression CNS Injury

-temporal bone fracture

-tissue destruction

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Nerve Palsies

Facial NerveClinical Manifestation Paralysis apparent day 1-2 Unilateral/bilateral Affected side smooth/drooping Amplified by crying

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Nerve PalsiesFacial Nerve: central nerve injury asymmetric facies with crying mouth is drawn towards the normal side wrinkles are deeper on the normal side movement of the forehead and eyelid is

unaffected the paralyzed side is smooth with a swollen

appearance absent nasolabial fold on affected side corner of the mouth droops on affected side no evidence of trauma is present on the face

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Nerve Palsies

Facial Nerve: peripheral nerve injury asymmetric facies with crying Unable to close eye on affected side may be evidence of forceps mark

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Nerve Palsies

Facial Nerve Palsy: prognosis 85% recover in 1 week 90% recovery in 1 year Surgery if no resolution in 1 yr Palsy due to trauma usually resolves or

improves palsy that persists is often due to absence of

the nerve

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Nerve Palsies

Brachial Plexus injury

Types of Injury Stretch Rupture Avulsion

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Nerve Palsies

Brachial Plexus injury

Types of Injury Stretch- 90-100% recovery in 1 year Rupture-needs surgical repair Avulsion-needs surgical repair

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Nerve Palsies

Brachial Plexus injury Weakness or total paralysis of muscles

innervated by the brachial plexus C-5 to C-8 and T1

Erb's Palsy C5-C7- proximal muscle weakness Klumpke’s Palsy C8 and T1- weakness in the

intrinsic muscles of the hand

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Nerve Palsies

Brachial Plexus injuryNeurological FeaturesErb's Palsy (C5-C6)The involved extremity lies: in adduction in pronation and internally rotated Moro, biceps and radial reflexes are absent Grasp reflex is usually present 2-5% ipsilateral phrenic nerve paresis The "waiter's tip" posture

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Nerve PalsiesBrachial Plexus InjuryNeurological Features

Klumpke’s Palsy (C7-8, T1) weakness of the intrinsic muscles of the

hand grasp reflex is absent

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Nerve PalsiesBrachial Plexus InjuryNeurological Features

Total Plexus Palsy Erb's Palsy + absent grasp reflex Sensory loss worse than Erb's

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Nerve Palsies

Brachial PlexusPrognosis Depends on severity and extent of

lesion 88% resolved by 4 months 92% by 12 months 93% by 48 months

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Nerve Palsies

Brachial PlexusPrognosis Depends on severity and extent of

lesion 88% resolved by 4 months 92% by 12 months 93% by 48 months

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Nerve PalsiesBrachial Plexus Management Prevention of contractures immobilize limb gently across the abdomen

for first week and then start passive range of motion exercises at all

joints supportive wrist splints

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Nerve Palsies

Brachial PlexusManagement Electrotherapy-controversial Surgical exploration-if no significant

functional recovery by 3 months Exploration after 6 months is of little

benefit

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Nerve Palsies

Laryngeal nerve injury The infant presents with a hoarse cry or

respiratory stridor most often unilateral nerve paralysis Swallowing may be affected if the superior

branch is involved Bilateral paralysis may be caused by trauma to

both laryngeal nerves or, more commonly, by a CNS injury such as hypoxia or hemorrhage involving the brain stem

Patients with bilateral paralysis often present with severe respiratory distress or asphyxia

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Nerve PalsiesLaryngeal nerve injury

& Prognosis: Paralysis often resolves in 4-6 wk, although full

recovery may take 6-12 months

Treatment symptomatic Small frequent feeds, once infant is stable Minimize the risk of aspiration Infants with bilateral involvement may require

gavage feeding and tracheotomy

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