Traumatic Delivery

Predisposing Factors

Maternal factors:

Primigravida

Cephalopelvic disproportion,

small maternal stature

maternal pelvic anomalies

Prolonged or rapid labor

Dystocia

Oligohydramnios

Fetal factors:

Abnormal presentation

Breech, face

VLBW or extreme prematurity

Fetal macrosomia

Large fetal head

Fetal anomalies

Obstetrical Interventions:

Use of mid-cavity forceps or vacuum extraction

Versions and extractions

Types of Injury

Soft tissue injuries

Head and Skull

Face

Musculoskeletal injuries

Intra-abdominal injuries

Peripheral nerve injuries

Soft Tissue Injuries

Erythema & Abrasions – Forceps, Dystocia

Petechiae – head/neck/chest/back, Cord around neck/breech, thrombocytopenia

Ecchymoses – breech/prematurity

Lacerations

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

Subcutaneous 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

SFN: Treatment

Treat symptomatic hypercalcemia aggressively

increased fluid intake

low calcium/ vit. D diet

furosemide -calcium-wasting diuretic

Steroids-inhibit metabolism of vit. D

Biphosphonates-reduce bone resorption

Injuries to the Head

Caput 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

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

Cephalhematoma

increases in size with time

15% bilateral

18% associated skull fracture

Forceps

Vacuum

Subgaleal Hemorrhage

Diagnosis 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)

Rx if signs of substantial volume loss:

compression wrap

restore blood volume

surgical drainage

25% mortality

Skull Fractures

Uncommon because of compressible skull & open

sutures

Forceps/Prolonged labor

Linear/Depressed

Usually asymptomatic

Associated intracranial hemorrhage may produce symptoms

Rx – conservative, elevation of depressed fracture, Thumb pressure, Hand pump, Vacuum extractor

Surgical elevation

Healing within a few months

Intracranial hemorrhage

Subdural/Subarachnoid/IVH

Usually asymptomatic

Forceps/Vacuum

Prolonged labor

Usually associated with fracture

Subarachnoid hemorrhage

more frequent than realized

usually asymptomatic

may cause seizures (day 2-3)

bloody CSF

CT/MRI

Subdural Hematoma

may be silent for several days

Increase head circumference

poor feeding/vomiting/lethargy

altered consciousness/seizures

DX- CT/MRI

RX- Subdural taps/surgical drainage

Fractures of Facial bones

nasal fracture/dislocation

deviated nasal septum

maxillary fracture

mandibular fracture

EYE INJURIES

Eye Lids : edema/ecchymoses/laceration

Subconjuntival hemorrhage

Orbital fracture/hemorrhage

Extra Ocular Muscle injury

Corneal Abrasion

Intra Ocular hemorrhage

Injuries to the Ear

Ecchymoses

Abrasion

Avulsion

Hematoma

Neck and Shoulder injuries

Fractured Clavicle

most frequently fractured bone

difficult delivery

shoulder dystocia

breech

Crepitus or deformity at the site

Decrease movement/moro on affected side

associated brachial plexus palsy

DX- X-ray

RX- conservative, immobilization, reduce pain, pain subsides in 7-10 day

good prognosis

Fracture of the Humerus

second most common fracture

difficult delivery/traction

shoulder dystocia

breech

deformity

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

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

Nerve Palsies

Facial Nerve

Etiology:

Compression Of peripheral nerve: forceps, prolonged labor, in-utero compression

CNS Injury: temporal bone fracture, tissue destruction

Clinical Manifestation:

Paralysis apparent day 1-2

Unilateral/bilateral

Affected side smooth/drooping

Amplified by crying

Facial 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

Facial Nerve: peripheral nerve injury

asymmetric facies with crying

Unable to close eye on affected side

may be evidence of forceps mark

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

Brachial Plexus injury

Types of Injury

Stretch – 90-100% recovery in 1 year

Rupture – needs surgical repair

Avulsion – needs surgical repair

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

Neurological Features:

Erb’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

Klumpke’s Palsy (C7-8, T1)

weakness of the intrinsic muscles of the hand

grasp reflex is absent

Total Plexus Palsy

Erb’s Palsy + absent grasp reflex

Sensory loss worse than Erb’s

Prognosis:

Depends on severity and extent of lesion

88% resolved by 4 months

92% by 12 months

93% by 48 months

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

Electrotherapy-controversial

Surgical exploration-if no significant functional recovery by 3 months

Exploration after 6 months is of little benefit

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

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