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Birth trauma

3  Neonatal pathology

3.4  Birth trauma

Introduction:

Birth trauma includes all physical injuries sustained by the fetus as a consequence of the birth process.

Most birth traumas are self-limited and have a favourable outcome. The prevalence of injuries in descending order is: clavicular fracture, facial nerve injury, brachial plexus injury, intracranial injury, bruising and skin lacerations.

Death from birth trauma is most likely when the brain and/or spinal cord are damaged. Such an injury is really infrequent nowadays with wide use of cesarean section.

Birth trauma is closely related to birth asphyxia because many of the conditions which predispose to birth asphyxia also directly increase the risk of trauma during delivery. Trauma also causes shock with anoxic- ischemic damage to the fetal tissues. Separating of effects of birth asphyxia from those of birth trauma is often impossible.

Etiology:

Factors predisposing to birth injury:

3.4.1  Extracranial lesions

3.4.1.1  Soft tissus injuries

Clinical signs:

Bruising and laceration of skin  —  common in preterm infants.

3.4.1.2  Intraabdominal injuries

Clinical signs:

Intraabdominal injury is relatively uncommon. Subcapsular hematoma of the liver  —  rupture and intra-abdominal hemorrhage is the most serious complication, the symptoms of shock may be delayed. Predisposing factors inculde hepatomegaly, prematurity and asphyxia.

3.4.1.3  Peripheral and cranial nerve injuries

Clinical signs:

  • brachial plexus injury
  • Occurs in large babies with shoulder dystocia or breech delivery
  • Fractured clavicle or humerus and facial palsy may be associated
  • erb palsy (C5-C6) is the most common: lack of shouder movement, the upper extremity lies in adduction and internal rotation
  • most babies spontaneously recover within months
  • facial nerve injury
  • compression occurs as the head passses the sacrum or by the forceps blade
  • assymetric face with crying
  • most infants recover in the first week of life
  • phrenic nerve palsy
  • diaphragmatic paralysis
3.4.1.4  Bone injuries

Introduction:

The clavicle is the most frequent fractured bone in the neonate during birth  —  common in large infants with a history of difficult delivery and shoulder dystocia.

Long bone fracture is rare: femur, humerus.

3.4.2  Cranial trauma

Clinical signs:

  • Caput succedaneum
    • hemorrhagic oedema involving the skin and subcutaneous tissues over the presenting part
    • has no clinical significance
    • with vaccum extraction a more circumscribed oedema with significant bleeding and damage to the skin may occur
  • Cephalhematoma
    • bleeding betwwen the periosteum and the bone, limited by bounderies of the individual bone
    • parietal bones usually involved
    • in up to 25% of cephalhematomas there is an underlying skull fracture
    • the extent of hemorrhage is rarely significant
    • commonly seen in uncomplicated vertex delivery
  • Subdural hemorrhage and tears of the dural folds
    • commonly found together because both result from the same type of injury  —  excessive frontooccipital compression or oblique distortion of head
    • tears of the dural folds in tentorium at the junction with falx or in the falx itself
    • hemorrhage results form rupture of the bridging veins or rarely from extension of the dural tears into the sinuses
    • relatively small hematomas in the posterior fossa can cause brain stem compression and death.
    • on the other hand small hematomas over the hemispheres are usually asymptomatic, but major can present with obvious signs of acute blood loss or anemia
  • Skull fractures
    • linear fractures of the parietal bones
    • depressed fractures of the parietal bones
    • multiradiate fractures of skull bones (usually parietal bones bilaterally)  —  associated with significant intracranial hemorrahage
  • Occipital osteodiastasis
    • separation of the squamous and lateral parts of the occipital bone (these parts do not fuse until the second year of life)
    • lower edge of the squamous occipital bone is displaced and rotated inward thus narrowing the foramen magnum
    • in fatal cases the displacement causes compression of the posterior fossa without massive hemorrhage, or the dura and sinuses are torn resulting in gross subdural hemorrhage in the posterior fossa
    • laceration of the cerebellum with cereberall emboli within pulmonary and other vessels have been reported
  • Spinal cord injury
    • excessive longitudinal stretching of the neck in breech delivery or excessive rotation in verex delivery (minority of cases)
    • grossly laceration or even total transection of the cervical cord is observed
    • the fetus is stillborn or dies in the early neonatal period with respiratory failure
    • serious spinal cord injuries occur etramely rare nowadays with increasing use of cesarean section in breech presentations

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