Birth injuries

An impairment of the infants body function or structure due to adverse influences that occurred at birth.
National Vital Statistics Report

1. BIRTH INJURIES Mrs. Gayathri R First year MSc Nursing Upasana College Of Nursing

2. DEFINITION An impairment of the infants body function or structure due to adverse influences that occurred at birth. National Vital Statistics Report Birth injuries is defined as those sustained during labour and delivery. It may be severe enough to cause neonatal deaths, still birth or number of morbidities. D C Dutta

3. CLASSIFICATION OF BIRTH INJURIES Soft tissue injuries Head and neck injuries F acial injuries Cranial nerve injuries Spinal cord injuries Peripheral nerve injuries Fractures Intra abdominal injury

4. HIGH RISK FACTORS Prolonged or obstructed labour Fetal macrosomia Cephalopelvic disproportion Abnormal presentation(breech) Instrumental delivery(forceps or ventouse) Difficult labour Shoulder dystocia Inadequate maternal pelvis

5. CAUSES OF BIRTH INJURIES

6. INTRACRANIAL HEMORRHAGE (ICH) Bleeding in the brain, also known as Intracranial Hemorrhage has been known to affect newborns, although it is much more prevalent among premature infants. Intracranial hemorrhage (ICH) may be-(a) External to the brain (epidural, subdural or subarachnoid space) (b) in the parenchyma of brain (cerebrum or cerebellum) (c) into the ventricles from sub ependymal germinal matrix or choroid plexus.

7. Traumatic Extradural hemorrhage : Usually associated with fracture skull bone. Subdural hemorrhage: This condition occurs when there is bleeding between the outer and inner layers of the brain covering. Subdural hemorrhage is not as common as it used to be, as there have been medical advancements made in the childbirth process.

8. Anoxic Subarachnoid hemorrhage: This term is used to describe bleeding that occurs below the innermost area of the two membranes that cover the brain. It is the most common type of bleeding in the skull. Intraventricular hemorrhage: This term describes bleeding in the normal fluid-filled spaces, also known as ventricles, in the brain. It affects the brain tissue.

9. Causes Preterm baby because of protection by their soft skull bones and wide sutures. Trauma: Compression and stretching in moulding. Excessive compression of fetal head due to contracted pelvis, occipito posterior position, and large baby. Rapid compression on fetal head, breech delivery, precipitate labour . Upward compression as in breech delivery, face presentation. Instrumental delivery.

10. Clinical features Baby cannot establish respiration himself. In severe cases, at birth, the infant is shocked, the eyes roll upward. Trunk and limbs may be rigid, the fist clenched, limpness is also common. Difficult grunting expiration after most due to excess mucosa. Sometimes shallow, rapid and irregular with attack of apnea and cyanosis. Worried and anxious expression, eyes are widen open for long period, starring with a knowing lock, sunken eyes, rigid neck, and spongy fontanelle .

11. Prevention Prevent or detect intrauterine fetal asphyxia in earliest by intensive fetal monitoring. Liberal episiotomy and use of forceps to deliver the premature baby minimize the intracranial disturbances. Avoid traumatic vaginal delivery in preference to caesarian section. Difficult forceps should be avoided. In vaccum delivery, traction is made only after proper cephalic application. Extend the use of caesarian section in breech more liberally. Utmost gentleness is to be executed in vaginal breech delivery. Never be at haste especially during delivery of head. Forceps delivery of the after coming head is preferable. Avoid prolonged and difficult labour .

12. Treatment and Management The baby should be nursed in quiet, warm and well ventilated surrounding. Maintain cleanliness of the passage, suction immediately after birth to remove the secretion that occludes the pharynx. Incubator nursery is preferable to supply oxygen and to maintain the temperature and humidity. If respiration is established wrap properly and keep the infant on one side turns. Restrict handling the baby. Bathing, weighing and measuring should be withheld because it may provoke convulsions. Feeding by nasogastric tube is advisable, fluid balance is too maintained, if necessary by parenteral route.

13. Treatment continue… Administer vitamin K 1mg intramuscularly to prevent further bleeding due to hyoprothrombinaemia. Prophylactic antibiotics is to be administered as needed. Anticonvulsant may need to prevent convulsion i.e. Phenobarbitone 5-10mg/kg/day in divided doses at 6 hourly interval intramuscularly. Phenytoin 10-15mg/kg intravenously as loading dose at the rate of 0.5mg/kg/min for maintenance dose of 5mg/kg/day with cardiac monitoring. Diazepam 0.1mg/kg IM thrice daily. Subdural haematoma can be aspirated through lateral angles of the anterior fontanelle if excessive haematoma is formed. Surgical removal of clot may needed.

14. Treatment continue… The following equipment should be at hand. Suction machine Oxygen Laryngoscope Endotracheal tube Keep close observation on: Vital signs Q4H as needed. Skin color. Respiration; type & regularity. Apex beat; type & regularity. Convulsion: spasm of muscles, part, duration.

15. INJURIES TO HEAD

16. CAPUT SUCCEDAENUM A caput succedaneum is an edema of the scalp at the neonates presenting part of the head. It often appears over the vertex of the newborns head as a result of pressure against the mother’s cervix during labour . The edema in caput succedaneum crosses the suture lines. It may involve wide areas of the head or it may just be a size of a large egg.

17. Causes Mechanical trauma of the initial portion of scalp pushing through a narrowed cervix. Prolonged or difficult delivery. Vacuum extraction.

18. Signs & Symptoms Scalp swelling that extends across the midline and over suture lines. Soft and puffy swelling of part of a scalp in a newborns head. May be associated with increased molding of the head. The swelling may or may not have some degree of discoloration or bruising. Tends to disappear within 24-36 hours and tends to reduce to size.

19. Management Needs no treatment. The edema is gradually absorbed and disappears about the third day of life. Advice not to applying pressure over caput. Mother is very anxious so we must explain about what it is, its causes in simple language. Baby should be handled gently apply dressing on abrasions. An abraded chignon usually heals rapidly if the area is kept clean, dry & is irritated. Advice mother about not applying pressure over caput. Advice the mother that caput need no treatment and disappear within 36 hours of birth.

20. Complication Jaundice results as the bruise breaks down into bilirubin.

21. CEPHALHEMATOMA Cephalhematoma is a collection of blood between the periosteum of a skull bone and the bone itself. It occurs in one or both sides of head. It occasionally forms over the occipital bone. The swelling with Cephalhematoma is not present at birth rather it develops within the first 24 to 48 hours after birth.

22. Causes Rupture of a periosteal capillary due to pressure of birth. Instrumental delivery Precipitate delivery Prolonged pressure on the head Cephalopelvic disproportion

23. Signs & Symptoms Swelling of the infants head 24-48 hours after birth Discoloration of the swollen site due to presence of coagulated blood Has clear edges that end at the suture lines Management Observation and support of the affected part Transfusion and phototherapy may be necessary if blood accumulation is significant Complication Jaundice

24. Difference between a caput succedaneum and Cephalhematoma INDICATORS CAPUT SUCCEDANEUM CEPHALHEMATOMA Location Presenting part of head Periosteum of skull bone Extent of involvement Both hemisphere; crosses the suture lines Individual bone; does not cross the suture line Period of absorption 3 to 4 days Few weeks to month Treatment None Support

25. SCALP INJURIES Minor injuries of the scalp such as abrasions in forceps delivery (tip of blades), incised wound inflicted during caesarean section or episiotomy may be met with on occasion, the increased wound may cause brisk hemorrhage and require stitches. The wound should be dressed with an antiseptic solution. E.g. Betadine

26. SKULL FRACTURE Fracture of the vault of the skull 9 frontal or anterior part of the parietal bone may be of fissure or depressed type. Causes Effect of difficult forceps delivery in disproportion or due to wrong application of the forceps. Projected sacral promontory of the flat pelvis may produce depressed fracture even though the delivery is spontaneous.

27. Treatment and Management Treatment is conservative in symptom less cases. In presence of symptom, the depressed bone has to be elevated or subdural hematoma may have to be aspirated or excised surgically.

28. INJURY TO THE NERVES

29. FACIAL PALSY It is also known as Bell’s palsy. The facial nerve may injured by direct pressure of the forceps blades or by hemorrhage or edema around the nerve. It may occur in normal delivery with much pressure on the ramus of the mandible where the nerve crosses superficially. Facial nerve remain unprotected after its exit through the stylomastoid foramen. It is involved by direct pressure of the forceps blades or by hemorrhage and edema around nerve.

30. Causes Forceps delivery. It may occur in spontaneous delivery when grasping the head or due pressure is applied on the mastoid process or over the ramus of lower jaw where the facial nerve lies superficially. Clinical features There is unilateral facial weakness with the eyelid of the affected side remaining open and mouth drawn over to the normal side. The paralyzed side is smooth. On crying the mouth is drawn to the uninjured side of the face. If the baby cannot form an effective seal on the nipple or treat, there may be some initial feeding difficulties.

31. Management There is no special treatment, improve the conduction on 1 to 2 weeks. Protect the eyes, which remain open even during sleep, with antiseptic ointment. Feeding difficulties are usually overcome by the baby’s own adaptation, although alternative feeding position can be adopted. Maintain oral hygiene. If instrumental delivery and the baby have any injury, clean and dress with antiseptic lotion. The condition usually disappears within weeks unless complicated by intracranial hemorrhage.

32. BRACHIAL PALSY The damage occur in the brachial nerve roots in the trunk of the brachial plexus due to stretching or effusion or hemorrhage inside the nerve sheath or tearing of the fibers. Sometimes tearing of the fiber is rare. This causes the hyperextension of the neck during attempted delivery of shoulder dystocia or even in spontaneous vaginal delivery or during difficult breech extraction. Unilateral involvement is common. The two common clinical types are:

33. This is the commonest type when the 5 th and 6 th cervical nerve roots are involved. The resulting paralysis causes the arm to lie on the side with extension of the elbow, pronation of the forearm and the flexion of the wrist. The Moro reflex and biceps jerks are absent on the affected side. The arm is inwardly rotated and the half closed hand turned outwards. The cause of Erb’s palsy are twisted on neck in delivery of after coming head, excessive lateral flexion of the neck when delivering the shoulder in vertex presentation and forceps delivery. Erb’s palsy

34. Treatment Use of a splint so as to hold the arm abducted to a right angle and externally rotated, the forearm is flexed at right angle and supinated and the hand is dorsiflexed . Massage and passive movement are useful. Full recovery takes weeks or even months. Severe injury may produce permanent disability.

35. Klumpke’s palsy It occurs due to damage of 7 th or 8 th cervical or 1 st thoracic nerve roots. The features are paralysis of the muscles of the forearm with wrist drop and flaccid digits. The arm is flexed at the elbow, the wrist extended with flaccid hands and flexed fingers. Mitosis, ptosis and anhidrosis may present due to damage of cervical sympathetic chain of the first thoracic root.  

36. Management Splinting of arm and placing of cotton ball in the baby’s hand to avoid contractures. Massage and passive movement are useful. Prognosis is usually good, but the permanent deformity may persist in severe laceration of nerve and hemorrhage. The lesions of upper brachial plexus have a better prognosis than those of lower or total plexus. If the paralysis persist more than 3 months, neuroplasty is indicated.

37. MUSCLE TRAUMA Torticollis (twisted neck) The most commonly damaged muscle is the sternomastoid muscle during the birth of the anterior shoulder when the fetus assumes a vertex presentation of during rotation of the shoulder when the fetus is being born by breech. This damage causes torticollis, which means twisted neck. Torticollis presents as a small lump over the sternomastoid muscle on the affected side of the neck. The lump consist of blood and fibrous tissue and appears to the painless for the baby. Stretching of the muscle can be achieved by lying the baby to sleep on the unaffected side and by using muscle stretching exercise under the guidance of a physiotherapist. The swelling will resolve over several weeks.

38. Sternomastoid Hematoma (tumor) It appears about 7-10 days after birth and is usually situated at the junction of upper and middle third of the muscle. It is caused by rupture of the muscle fibers and blood vessel, followed by a hematoma and cicatrices contraction. It is associated with difficult breech delivery or attempted delivery following shoulder dystocia or excessive lateral flexion of the neck even during normal delivery. Gentle movements with stretching of the neck muscles carried out after feeds are helpful.

39. Necrosis of the subcutaneous tissues It may occur while the superficial skin remain intact. After a few days, a small hard subcutaneous nodule appears. It is the resultant of the fat necrosis due pressure, and takes many weeks to disappear. No treatment is required and it has no clinical importance.  

40. FRACTURES Skull Fractures ( see under injuries to head ) Spine Fractures Fracture of the odentiod process or fracture dislocation of the 5 th – 6 th cervical vertebrae may occur due to acute bending of the spine while delivering the after coming head, the result is instantaneous death of the baby due to compression on the medulla. Long Bone Fractures Bones commonly involved in fractures are humerus, clavicle and femur . These occur in breech delivery. Fractures are usually of greenstick type but may be complete. Rapid union occurs with callus information. Deformity is a rarity even where the bone ends are not in good aligment .

41. Treatment In clavicle fracture: A pad of cotton or wool is placed in the axilla and the upper arm is lightly bandaged to the side of the chest. In fracture Femur: The whole length of the affected limbs may be bandaged to the front of the abdomen or may be flexed by a posterior cast or treated by vertical extension by fastering the baby’s ankles to the crossbar placed above the cot. Healing usually occurs in about 3 weeks. Fracture of the humerus is treated by bandagining the arm to the side of the chest.

42. DISLOCATION The common site of dislocations of joints are shoulder, hip, jaw and 5-6 th cervical vertebrae. Conformation is done by radiology and the help of an orthopedic surgeon should be sought.

43. Trauma to skin and superficial tissues Damage to the skin is often iatrogenic resulting from forceps blades, vacuum extractor cups, scalp electrodes and scalpels. The scalp may be edematous and bruished, if allowed to remain on the perineum for a long period. Buttocks in breech presentation, an eyelids, lip or nose in face presentation, similarly become edematous and congested. The healing is perfect without leaving behind any trace of the injury. Abrasion and laceration should be kept clean and dry. If there is any indication of infection, medical advice should be sought and antibiotics may be required.

44. Injury to the internal Organs Liver, kidney, adrenal or lungs are commonly injured mainly during breech delivery. The most common result of the injury is hemorrhage, severe hemorrhage is fatal. In minor hemorrhage, the baby presents features of blood loss in addition to the disturbed function of the organ involved. Treatment is directed To correct hypovolemia and anemia. Specific management – surgical or otherwise, to tackle the injured viscera.

45. Persistent Pulmonary Hypertension of the Newborn (PPHN) Persistent pulmonary hypertension of the newborn (PPHN) occurs when fetal circulation does not transition to life outside the womb. Throughout pregnancy, the placenta provides oxygen to the fetus . After birth, however, the newborn must learn to breathe on his or her own. If this transition is unsuccessful, then the newborn may be suffering from PPHN. PPHN is often the result of a difficult birth, yet in many instances it arises due to medical negligence. For example, prescription-based medications such as Zoloft, Celexa , and Paxil have been linked to an increase in blood pressure and during pregnancy this can place stress on the infant. Other causes include failure to treat maternal infections, failure to detect and prevent infant asphyxia, and performing an unnecessary C-section.

46. PLACENTAL BIRTH INJURIES The placenta, an organ attached to the mother’s womb while an infant is in utero, has one of the most important functions during pregnancy. It not only supplies nutrients to the baby, but it transfers both oxygen and blood. If there are placental birth injuries during pregnancy, the consequences can be life-threatening, especially if not diagnosed and treated as early as possible.

47. Types of Placental Injuries Placental Abruption Placental abruption occurs when the placenta becomes separated from the inner wall of the uterus, typically after 20 weeks gestation. Placental abruption can happen from a variety of reasons, including previous pregnancies that had placental problems, maternal age and infections, smoking during pregnancy, diabetes, high blood pressure, and more. In some cases, the cause is unknown, but women with the risk factors of placental abruption should be monitored carefully. If left undiagnosed and untreated, it can lead to a host of long-term and life-threatening medical conditions including cerebral palsy (CP), cognitive disorders, premature birth, and a heightened risk of the infant dying.

48. Placenta Previa Although it’s a rare condition affecting less than 10% of all pregnancies, placenta previa is a dangerous condition that can lead to asphyxia, low birth weight, heart abnormalities, SP, seizures, stillbirth, and more. Placenta previa occurs when the placenta moves towards the bottom of the womb, covering the cervix either marginally, partially, or fully. Bed rest and medications are advised for the women who experience partial or marginal placenta previa , but it will greatly depend upon on how severe the symptoms. For instance, excessive vaginal bleeding is one the most common symptoms, and if doctors cannot get the bleeding under control, they may schedule a C-section immediately.

49. Other treatment options include: Vitamin K injections to help promote blood clotting, which in turn can reduce severe bleeding Steroid injections to strengthen the infant’s lungs Blood transfusions Medications to help stop labor , if applicable

50. Placental Insufficiency Placental insufficiency, also known as utero-placental insufficiency, is marked by problems with blood flow to the placenta during pregnancy. Consequently, the placenta is unable to delivery the needed nutrients and oxygen to the infant. There are several causes and risk factors that can contribute to developing placental insufficiency, including high blood pressure, gestational diabetes, improper maternal weight gain, smoking, maternal blood disorders, maternal infections, and more. Placenta previa is more severe if it develops early in pregnancy.

51. Treatment Typically consists of bed rest, getting high blood pressure under control, patient education, and in some cases, working with a high-risk maternal fetal specialist. Other forms of treatment may include: Low dose aspirin Fetal monitoring No use of narcotics and/or anesthesia during labor

52. Failure to Treat Placental Problems As mentioned earlier, treatment must start as soon as possible. If a physician fails to detect and treat these issues in time, life-altering health issues may follow. In addition to the aforementioned risks to infants, mothers are also at risk of infection, hemorrhaging , shock, and death. It’s extremely important to keep prenatal appointments throughout your pregnancy, and if you begin bleeding at any point, make sure to inform your doctor immediately.  

53. EPIDURAL BIRTH INJURIES An epidural is a popular pain-management method used by millions of women each year while going through the labor and delivery. In fact, an epidural is the most common type of pain relief used during labor and delivery. An epidural, also known as epidural anesthesia , is a regional anesthesia administered intravenously to block pain in the lower part of the body. A long needle is typically inserted into your back, around the spinal cord area, usually after the cervix has dilated to at least 4 centimeters . A thin catheter is threaded through the needle, which ensures that the medication hits the epidural area and the catheter stays in place. Once the catheter is in place, medication will fluidly disperse either intermittently or continuously.

54. Types of Medications Used in Epidurals Medications used is epidurals are known as local anesthetics , meaning medicines used to reduce pain sensation in the targeted areas without you being fully unaware or unfeeling of other local senses. The most common types of medications used in epidurals include: Bupivacaine Lidocaine , or Chloroprocaine In the majority of instances, these medications are used in combinations with narcotics or opoids to ensure maximum pain relief and to help reduce the dosage amount of the local anesthetics.

55. Risks Associated with Epidurals Maternal risks associated with epidurals include: Seizures and dizziness Infections Spinal membrane injuries Arachnoiditis Breathing problems Nerve damage Long-term back pain Increased risk of vacuum extraction or forceps use during delivery Lower blood pressure

56. Infant risks include: Difficulties with breastfeeding Lack of oxygen, leading to more serious health problems, such as cognitive disorders and cerebral palsy Brain injuries Infant stroke Coma Low Apgar scores Poor muscle tone

57. Medical Mistakes and Epidural Injuries Administering too much medication Administering medication the mother is allergic to Injecting the needle into the wrong area Failure to monitor maternal and fetal distress Administering the epidural before proper cervix dilation Administering an epidural to a mother who uses blood thinners or has a low platelet counts

58. CESAREAN SECTION INJURIES Cesarean sections (C-section) have increased in popularity over the past decade. Although the numbers have remained steady during the past few years, in 2010 alone, a little over 32% of all deliveries in the United States were C-sections. There are a myriad of reasons why C-sections are performed, but one thing each C-section has is common in the risk of C-Section injuries, to both mother and infant. 

59. Common Reasons for C-Sections Placental problems, including placental abruption, placental insufficiency, and placenta previa Uterine ruptures, which affects 1 out of every 1,500 births An infant in the breech position, making normal delivery difficult Umbilical cord prolapse Fetal distress, An infant diagnosed with a birth defect Having previous C-sections Preeclampsia, Diabetes Genital herpes (active ) Carrying twins or multiples

60.  Risks and Birth Injuries Caused by C-Sections Fetal Lacerations Fetal lacerations are cuts, scrapes, and other similar injuries caused to an infant that typically occur during a C-section procedure. In most cases, fetal lacerations occur due to improperly-performed procedures by healthcare providers. Fetal lacerations range in severity, from mild to serious, and may lead to host of other health conditions, including Erb’s paly, Klumpke’s palsy, fractures, cervical cord injuries, and more.

61. Infant Breathing Problems Infants are much more likely to experience breathing problems if delivered by C-section. It’s important that babies are constantly monitored after birth as breathing problems may lead to respiratory distress syndrome and long-term health problems.

62. Delayed C-Section In some instances, physicians fail to schedule a C-section despite the fact that the warning signs are there. For example, fetal distress is one of the most common reasons that C-sections are scheduled and carried out. A delayed C-section can also be caused by failure to closely monitor the mother for distress, and in some cases, failure to secure an operation room in time to perform the surgery. A delayed C-section can lead to a myriad of injuries. In the most severe cases, infant death may occur. Other consequences may include: Lack of oxygen, leading to infant brain damage, cerebral palsy, and/or autism Heightened risk of physical injuries Physical developmental delays

63. Anesthesia Injuries Extremely low blood pressure Internal bleeding Blood clots Severe headaches Placenta previa Placental abruption

64. Maternal Surgical Injuries Maternal surgical injuries are extremely rare, but if they occur, life-threatening health issues may follow. Surgical injuries happen when a nearby organ is cut or affected in some way during the C-section, such as the bladder. Additional surgery to repair the damaged organ may be required.

65. Maternal Infections Streptococcus Endometritis Intra-amniotic infection Extremely high fever

66. Blood Clots Blood clots are a common risk after a C-section. However, they can be prevented in many cases if the mother is monitored and allowed to walk within 24 hours after the surgery. If blood clots become too severe, they can break apart and travel to other parts of the body, including the brain, heart, and lungs.

67. Hemorrhaging There is always a chance of increased bleeding, but if it isn’t kept under control, a mother may hemorrhage . Transfusions are rare, but if the bleeding is uncontrollable and severe, it may become necessary.

68. BIRTH INJURY TREATMENT Surgery The most common types of birth injuries that generally require surgery include: Severe cases of brachial plexus injuries, when other forms of treatment, such as physical therapy, didn’t work Brain hemorrhaging A fractured skull

69. Medications The type of medication will depend the type and severity of the birth injury. The most common types of medication include: Pain management and anti-inflammatory medications, such as aspirin and corticosteroids Anti-spastic medication, such as baclofen, tazidine , and dantrolene Seizure medication, such as gabapentin and topiramate Anticholinergic medication, including trihexyphenidyl hydrochloride and benzotropine mesylate Botox, to weaken injured muscles in an attempt the “catch up” the injured muscles to the other muscles Stool softeners

70. Physical Therapy Physical therapy is one of the most common treatment options for children who have brachial plexus injuries, cerebral palsy (CP), shoulder dystocia, and any injury that resulted in weakened muscles, coordination problems, lack of voluntary muscle control, and more. Strength and balance Coordination Flexibility Reducing physical limitations Increasing fitness, gait, and posture

71. Hyperbaric Oxygen Therapy In recent years, studies and research have suggested that hyperbaric oxygen therapy (HBOT) can help reduce the symptoms associated with brain damage in infants who experienced oxygen deprivation during childbirth.   HBOT consists of placing an infant in a hyperbaric chamber that’s filled with 100% pure oxygen. The air pressure is generally raised up to at least three times normal air pressure, allowing the the baby to breathe in pure oxygen three times higher than normal. Although more research is needed to understand how effective HBOT is for infants, there is indication that it may play an important role in treating symptoms associated with CP and autism.

72. Neonatal Therapeutic Hypothermia Neonatal therapeutic hypothermia is a clinical treatment that reduces an infant’s body temperature in attempt to slow down injuries and diseases. It’s most often used for newborn babies who are at a heightened risk of developing severe brain damage. Neonatal therapeutic hypothermia works by placing the infant in a cooling blanket. The temperature of the blanket is lowered significantly so that the infant’s entire body temperature is lowered. The therapy usually takes place in a neonatal intensive care unit.

73. Occupational Therapy Developing fine motor skills Learning basic skills tasks such as brushing teeth and hair Developing positive behavior Reducing outbursts and impulsiveness Improving focus skills and social skills Developing and improving  hand-eye coordination Assisting with learning disabilities

74. PREVENTION OF INJURY IN NEWBORN BABY Antenatal periods Screen out the risk babies. Employ liberal use of C/S, malpresentation should be included and manage accordingly.

75. Intranatal Period During normal delivery Continuous fetal monitoring to detect fetal distress, extract baby before he become compromised. This can prevent traumatic cerebral anoxia. Episiotomy is to be done carefully after placing two fingers in between the head the stretched perineum to prevent injury to the scalp. The neck should not be unduly stretched while delivering the shoulders to minimize injuries to the brachial plexus or sternomastoid.

76. Special care in preterm delivery Prevent anoxia. Avoid strong sedation. Liberal episiotomy and use of forceps to minimize intracranial compression. Administer vitamin K 1mg intramuscularly to prevent or minimize haemorrhage from the traumatized area.

77. Forceps delivery Difficult forceps are to be withheld in preference to the safer caesarean section. Never apply traction unless the application is a correct one. Ventouse delivery It is relatively less traumatic, but it should be avoided in preterm babies.

78. Vaginal breech delivery To prevent intracranial injury The crucial period in breech delivery is during delivery of the after – coming head. Never be in haste during delivery of the head which find little time to mould . Episiotomy should be done as a routine to minimize head compression. Controlled delivery of the head by forceps is preferable.

79. To prevent spinal injury Acute bending at the neck is to be prevented while forceps are being applied to the after coming head or delivery of the bead by Burn’s Marshall Techniques.

80. To prevent injury to the brachial plexus and sternomastoid muscle The trunk should not be pulled to one side as to cause too much stretching to the neck. To prevent fracture – dislocation and visceral injuries The limbs are delivered in a manner described in breech delivery. Rotating the trunk by grasping the thoracic cage not only prevents fracture of the head by jaw flexion is preferably and shoulder traction, the flexion is preferably achieved by placing the fingers over the molar prominences.

81. CONCLUSION The incidence of birth injuries has dramatically decreased in the last 2 decades. Erb palsy is the most common brachial plexus injury, and management should include close follow-up evaluation and physical therapy until 3 to 4 months of age. Shoulder dystocia is a major risk factor for brachial plexus injury. The birth of a baby is a complex medical event that carries with it great risk and the possibility of infant injury. U nfortunately , too often birth injuries are caused by medical mistakes.

82. BIBLIOGRAPHY Nima Bhaskar , Text book of midwifery and obstetrics, EMMESS medical publishers, 1 st edition. D.C Dutta, Text book of obstetrics and gynecology, New central agency, 6 th edition. Wongs;Merilyn,Essentials of Pediatric Nursing,8 th edition,Elsievier Publication. Rimple Sharma, Essentials of Pediatric Nursing,2 th edition,Jaypee Brothers Medical Publishers. Manoj Yadav,A Text Book Of ChildhealthNursing,2011 edition,Choice books & printers (P) ltd.

83. THANK YOU….