BIRTH INJURIES IN NEWBORN

BIRTH INJURIES IN NEWBORN: Definition of birth injuries , statistics, etiology, classification of birth injuries , head injuries: cephalhematoma and Caput succedaneum, skull fractures
, nerve injuries: erb's palsy and klumpke's palsy, bone injuries: clavicular and long bone fracture , intra-abdominal and soft tissue injuries, management and prevention of birth injuries

1. Birth injuries in new born Presented by: Ms. Manisha Thakur Nursing Tutor Child Health Nursing

2. Definition Birth trauma is defined as injury to the infant resulting from mechanical forces (such as compression or traction) during the delivery. The injury is generally due to tremendous pressure put upon the baby while passing through the birth canal.

3. Incidence More significant injuries occur in 2-7 per 1000 live births. Birth trauma mortality occurs in approximately 3.7 per 1,00,000 live births.

4. Risk factors of birth injuries Maternal causes Primipara Small maternal stature Maternal pelvic anomalies Oligohydroamnios Foetal causes Vacuum extraction Very low birth weight babies (VLBW) Fetal macrosomia Large fetal head Breech presentation Use of forceps

5. TYPES OF BIRTH INJURIES Head injuries Nerve injuries and spinal cord injuries Bone injuries Intra-abdominal injuries Soft tissue injuries

6. Injuries of Head

7. HEAD INJURIES CEPHALHAEMATOMA Subperiosteal collection of blood between the skull and the periosteum . It occurs due to the rupture of small veins from the skull resulting from friction between the fetal skull and pelvis. It is never present at birth but gradually develops after 12-24 hours . It tends to grow larger and may persists for weeks . This may be caused by forceps delivery.

8. Contd….. Management: No active treatment. Vit k 1 to 2mg IM in order to correct any coexistent coagulation defect. If it becomes infected : incision and drainage and antibiotics should be started The infant can need transfusion of blood. Complications: Jaundice & shock

9. 2. Caput succedaneum I t is the edematous swelling on the babies scalp due to infilteration of serosanguinous fluid by pressure of girdle of contact i.e. cervix, bony pelvis. Treatment: no specific treatment. Swelling subsides within within few days. Complications: Rarely anemia

10. Subgaleal hemorrhage Definition: it is the collection of blood beneath the aponeurosis that covers the inner surface of the scalp. Causes: it is due to the extensive pressure of forcep . s/s: firm fluctuant massthat increases in size after birth. Management: M onitor for LOC, Hb . Transfusions may be required if blood loss is significant. In severe cases, surgery may be required to cauterize the bleeding vessels . Antibotics : to prevent infection

11. Skull fractures It is commonly frontal bone or at the anterior of parietal bone. Skull fractures can be associated with the Subdural bleeding, subarachnoid haemorrhage, or contusion or laceration. Causes: difficult forceps delivery in disproportion or wrong application of the forceps.

12.  break in a  cranial  bone resembling a thin line break in a  cranial  bone (or "crushed" portion of  skull ) with  depression  of the bone

13. Contd…… Management: No treatment for linear fracture. For depressed fracture: Open surgical evacuation of the clot is the usual management for infants with progressive neurological signs or progressive increased intracranial pressure. Neonatal seizures may require anticonvulsant treatment .

14. Intracranial hemorrhage Subarachnoid hemorrhage, intracerebral hematomas, subdural hematomas usually results from trauma of normal delivery process or excessive forces used because of instrumentation or abnormal presentation such as breech delivery. Treatment Replace the blood volume loss and stabilize cardio-vascular system.

15. Nerve Injuries

16. Nerve Injuries 1 . Facial Palsy/Bell’s palsy: It is involved by direct pressure of the forceps blades or by haemorrhage & edema around the facial nerve. S/S : Loss of movement of affected side. affected eye side which remains open. Facial asymmtery . Absent of rooting reflex MANAGEMENT: Treatment aims at protecting the eye with antiseptic ointment , which remains open even during sleep. Neuroplasty (surgery to repair nerve tissue ) The condition disappears within weeks . NG or OG feed.

17. 2. Brachial palsy: Either the nerve roots or the trunk of the brachial plexus are involved. It can be caused by: Shoulder dystocia Breech extraction Hyper extension of the neck Simple stretching Haemorrhage within a nerve Tearing of the nerve or root

18. 1. Erb's palsy Upper brachial plexus injury. This is the commonest type when the 5 th & 6 th cervical roots are involved. S/S arm to hang limply adducted and internally rotated & flexion of the wrist . Moros reflex is absent.

19. Treatment: Massage and passive range-of-motion exercises to involved joints done gently every day. Recovery takes place within weeks or months, but in severe injury permanent disablility may develop.

20. 2. Klumpke's palsy Occurs due to damage to 7 th & 8 th cervical or even the first thoracic nerve roots. R esulting in paralysis of the hand and wrist. S/S: shoulders and arm are adducted & internally rotated, wrist is extended. Treatment: M assage and Passive range-of-motion exercises are the only treatment.

21. 3. Phrenic nerve palsy Defintion : phrenic nerve palsy causes paralysis of the diaphragm that can be seen on usg as an elevated diaphragm. s/s: respiratory distress: nose flaring, tachypnea It is usually unilateral, the affected lung doesnot expand during respiration Management: position the baby on affected side to facilitate lung expansion on unaffected side. Oxygen therapy administration Respiratory failure may be treated with mechanical ventilation. Gavage feedings.

22. MUSCULOSKELETAL INJURIES Clavicular fractures: When a baby is born too quickly, or the baby is too big for the mother’s birth canal, the baby’s head can get delivered, but the shoulders and chest get stuck. Fractures of long bones

23. 1. Clavicular fracture These fractures are seen in vertex presentations with shoulder dystocia or in breech deliveries when the arms are extended. Management: heal quickly on their own without treatment. keep the infant’s arm and shoulder still for several days. T his is done by putting the infant’s arm in a sling.

24. 2. long bone injuries a) Humeral fractures typically occur during a difficulty delivery of the arms in the breech presentation and/ or of the shoulder in vertex. Direct pressure on the humerus may also result in fracture. b) Femoral fractures usually follow a breech delivery. Physical examination usually reveals an obvious deformity of the thigh. Treatment: Simple splinting applied for 4 weeks. Closed reduction casting

25. Intra-abdominal injuries These are uncommon injuries. It involve rupture or hemorrhage into the liver, spleen or adrenal gland. Infants with hepatosplenomegaly are at increased risk of these injuries. S/S: sudden pallor, hemorrhagic shock, abdominal discoloration. A nemia , poor feeding, tachypnea, and tachycardia . Management: volume replacement Correction of any coagulopathy

26. Soft Tissue Injuries Abrasion and laceration Petechiae Ecchymosis Subconjuctival hemorrhagic

27. Abrasions and lacerations May occur as scalpel cuts during Cesarean delivery or during instrumental delivery ( i.e , vacuum, forceps) Infection remains a risk, but most uneventfully heal Management: Careful cleaning, application of antibiotic ointment, and observation Lacerations occasionally require suturing

28. 2. Petechiae : these are non raised pinpoint hemorrhage caused by sudden increase and release of pressure during passage through birth canal. May be seen on face, chest or head. 3. Ecchymosis: small hemorrhagic areas(larger than petechiae ) occur after traumatic delivery. 4. Subconjuctival hemorrahges : rupture of capillaries in sclera from pressure on fetal head during delivery.

29. Prevention of the injuries in newborn Comprehensive antenatal and Intranatal care is the key to success in the reduction of birth trauma and consequently in the reduction of perinatal mortality and neonatal morbidity

30. Antenatal Period To screen out the risk babies likely to be traumatized during vaginal delivery: babies of DM, congenital abnormality, mothers with abnormal pelvis and presentation To employ liberal use of elective Caesarean section is important.

31. Intranatal Period Care during Normal delivery Care during Forceps delivery Care during Breech delivery

32. Normal delivery: Continuous fetal monitoring, if available is able to detect early evidences of fetal distress. Episiotomy is to be done carefully to prevent injury to the scalp. The neck should not be unduly stretched while delivering the shoulders to minimize the injuries.

33. Forceps delivery Majority of the severe injuries are inflicted by applications of forceps. Difficult forceps are to be avoided in preference to the safer caesarean section. Never apply the force unless the application is a correct one.

34. Vaginal breech delivery Proper selection of cases, care and gentleness are to be executed while conducting vaginal breech delivery. Skilled health care professionals should conduct deliveries

35. Bibliography D.C Dutta. Textbook of Obstetrics;ed-6 th .Calcutta: Published by New Central Book Agency;2004. Pp-483-86 Myles Midwifery. A Text book of Midwives.14ed New York. Elsevier Publishers;2003.Pp-825-835 Gupta Piyush . Essential Pediatric Nursing. ed-Ist . New Delhi: Published by A.P.Jain;2004.Pp-73-75. http//www.birth injuries.us