Birth injury

Msc tutor

1. BIRTH INJURY Presented by Sujata Sahu

2. OBJECTIVES At the end of the class, students will be able to– Define the birth injury Explain the high risk factors of birth injury Discuss the types of birth injury Discuss prevention on birth injury

3. Introduction Birth injury is the trauma during the process of delivery . It is one of the important cause of perinatal morbidity & mortality It reflects the standard of obstetrical services of the place or centre . Incidence of birth injuries varies from one health care institution to other.

4. Definition Birth injury is an impairment of the infant’s body function or structure due to adverse influence that occurred at birth.

5. High risk factors Prolong or obstructed labor Fetal macrosomia CPD Very low birth weight infant Abnormal presentation( breech) Instrumental delivery Difficult labor Shoulder dystocia Inadequate maternal pelvis Oligohydramnios Fetal anomalies Precipitate labor Manipulative delivery

6. Types of injury Types of injury Organ(s) affected Skull,(head) Scalp Eye Soft tissue Viscera Nerve Cephalohematoma , fracture Laceration, abscess, haemorrhage, caput succedaneum Hemorrhages : subconjuctiva , vitreous, retina Skin: laceration, abrasions, fat necrosis, petechiae Rupture of liver, adrenal gland, spleen Facial nerve, brachial plexus

7. SKULL INJURY

8. Caput succedaneum- Edematous swelling on the babies scalp due to infiltration of serosanguinous fluid by the of girdle of contact, i.e cervix,bony pelvis or vulval ring. Swelling develop due to reduced venous blood supply & lymphatic drainage from unsupported part of scalp that is lying over the cervical os .

9. Cont… Area becomes congested & oedematous & present as caput at birth It may cross the suture line Pits on pressure, non fluctuant & diffuse in nature Treatment No treatment require It usually disappear within 36 hour Maternal anxiety should be reduced by reassurance.

10. Cephalohematoma Collection of blood in between the periosteum & flat bone of skull Causes Friction between fetal skull & pelvis leads to rupture of small emissary veins from skull Found in forcep delivery Fracture of skull bone

11. Cephalohematoma Characteristics Never present at birth Gradually develops a few hours after birth Incompressible, cystic, circumscribed, fluctuant. Limited by suture line Unilateral over parietal bone

12. Cephalohematoma Treatment Most cephalohematoma disappear spontaneously after few days or weeks No active treatment is necessary unless it becomes complicated Give injection vit k 1 to 2 mg IM Infected hematoma Incision & drainage done Antibiotic Monitoring hematocrit & bilirubin level Explained details to mother

13. Skull Fracture Common in frontal bone or anterior part of the parietal bone It is associated with cephalohematoma 2 types Causes Difficult forcep delivery Projected sacral promontory of the flat bone

14. Treatment No management for linear or fissure fracture Surgical treatment is required for depressed fracture with neurological manifestations Skull Fracture

15. INTRACRANIAL INJURY

16. Intraventricular Hemorrhage IVH occurs due to difficult delivery Clinical feature Seizure Apnea Irritability Lethargy vomiting

17. Types of Brain Hemorrhage

18. Scalp injury Miner injury May occur due to abrasion by the tip of the forceps blades in forcep delivery Treatment Wound should be dressed with antiseptic lotion Watch for hemorrhage or infection Wound with brisk hemorrhage requires stiches aspectically .

19. Nerve injury

20. Facial Palsy Known as bell’s palsy Injured of facial nerve by direct pressure of forcep blades Clinical feature Inability to close the eye. Absent of rooting reflex on the affected side. On crying, the angle of mouth is drawn over the unaffected side. Sucking reflex remains unaffected. Treatment Eye should be protected with antiseptic ointment , as they remain open, even during sleep

21. Brachial plexus is a group of nerves that comes the spinal cord in the neck & travel down the arm These nerves control the muscles of the shoulder, elbow, wrist & hand as well as provides feeling in the arm. Brachial palsy

22. Brachial Palsy Cause of Brachial palsy Stretch injuries usually occur during a difficult delivery, such as with a large baby , a breech presentation , or a prolonged labor. The person assisting the delivery must deliver the baby quickly and exert some force to pull the baby from the birth canal. If one side of the baby's neck is stretched, the nerves may also be stretched, and injury may result.

23. Brachial Palsy Symptoms of brachial palsy Weakness in one arm Loss of feeling in the arm Partial or total paralysis of the arm Treatment Most brachial palsy recover on their own, Nerves recover very slowly; take up to 2 years for a complete recovery. Daily physical therapy and range-of-motion exercises, suggest surgery if no change over the first 3 to 6 months.

24. Erb’s palsy It is occurred When 5 th & 6 th & rarely 7 th cervical nerve root are involved Characteristics Extension of the elbow Pronation of the forearm Flexion of the wrist( waiter’s tip) Moro reflex is absent Treatment Gentle massage, Strength exercises, Range of motion movements, stimulation exercises, and Gentle stretching.

25. Klumpke’s Palsy klumpkes ’ palsy damage to the 7 th , 8 th cervical & 1 st thorasic nerve root Clinical feature Arm is flexed at elbow Wrist is extended Forearm is supinated A claw like deformity of the hand Treatment Physical therapy & Passive movement Full recovery takes weeks or even months

26. MUSCLE INJURY

27. Torticolis Torticollis , or wryneck, literally means "twisted neck" in Latin. In newborns, torticollis can happen due to positioning in the womb or after a difficult childbirth. This is called infant torticollis or congenital muscular torticollis . Boys and girls are equally likely to develop the head tilt. It can be present at birth or take up to 3 months to develop.

28. Torticolis Causes of Torticolis Cramping of a fetus inside the uterus or Abnormal positioning (breech position). Forceps or vacuum delivery These factors put pressure on a baby's sternocleidomastoid muscle (SCM). This large, rope-like muscle runs on both sides of the neck from the back of the ears to the collarbone. Extra pressure on one side of the SCM can cause it to tighten, making it hard for a baby to turn his or her neck.

29. Torticolis Symptoms Head tilted towards affected muscle Contracted SCM muscle Chin pointed away from contrcred muscle Difficulty B/F on one side

30. Treatment at Home To encourage your baby to turn his or her head in both directions. This helps loosen tense neck muscles and tighten the loose ones. Here are some exercises to try: When your baby wants to eat, offer the bottle or your breast in a way that encourages your baby to turn away from the favored side.

31. Cont… When putting baby down to sleep, position him or her to face the wall. Since babies prefer to look out onto the room, baby will actively turn away from the wall and this will stretch the tightened muscles of the neck. During play, draw baby's attention with toys and sounds to make him or her turn in both directions.

32. Subconjuctiva Haemorrhage It occurs due to stressful and traumatic deliveries (forceps or a vacuum extractor). Changing and forceful pressure during birth can cause eye blood vessels to burst. Treatment It usually clears up on its own with a few weeks or so Some cases, may lead to permanent  eye  damage (rare).

33. Retinal Hemorrhage The incidence of retinal hemorrhages varies with the mode of delivery. They occur in roughly 75% of infants delivered by vacuum extraction, in 33% of cases of spontaneous vaginal delivery and in 6.7% of neonates delivered by cesarean section.

34. Retinal Hemorrhage Treatment Superficial retinal hemorrhages resolve by 1 week (<3 days) postpartum Dot and blot retinal hemorrhages resolve by 6 weeks <2-3 weeks) postpartum. Intrafoveal , preretinal , and vitreous hemorrhage may persist longer.

35. Dislocations Dislocations, especially of the hip and knee, are due to intrauterine positional deformities or congenital malformations. Common sites of dislocation of joints are shoulder, hip, jaw & 5 th ,6 th cervical vertebra Cause - birth trauma. Diagnosing ultrasound, MRI, and arthrography

36. Prevention Of Birth Injury Providing proper prenatal care Recommend various prenatal test to assess health of mother & baby Recognize wide variety of fatal issues like IUGR, suboptimal position ,umbilical cord problem early & managed properly , it is often possible to avoid serious birth injuries Identify high risk pregnancies , refer to maternal- fetal specialist.

37. Detecting and addressing signs of fetal distress Throughout pregnancy and during delivery, medical professionals should monitor the mother and baby for  signs of fetal distress , which indicate that the baby is likely being deprived of oxygen. Prevention of Birth Injury

38. Recognizing when vaginal birth may be dangerous or impossible There are certain circumstances under which  C-section deliveries  are recommended or necessary. Possible indications for c-section delivery include: Prolonged and arrested labor Macrosomia , CPD Placental abruption Placenta previa Uterine rupture Cord prolapse Maternal infection Fetal distress Prevention of Birth Injury

39. Episiotomy should be carefully The neck should not be unduly stretched while delivering the shoulder to prevent injuries to the brachial plexus or strenomastoid Special care to the preterm to prevent anoxia, avoid strong sedatives, liberal episiotomy & To administer vit.k 1mg IM to prevent hemorrhage from the traumatized site Prevention of Birth Injury

40. Provide support to the parents Educating to the parents to be alert when their newborn unable to move an extremity or demonstrate asymmetric facial movements Assess the resolution of trauma Provide reassurance that some injuries resolve with minimal or no treatment Provide realistic picture of situation to gain their understanding & trust Nursing Management