Birth traumas

Birth trauma is an injury to the newborn caused by mechanical forces during birth. Risk factors include macrosomia, abnormal fetal presentation, prolonged or rapid labor, and forceps or vacuum deliveries. Soft tissue injuries of the scalp include benign cephalohematoma and caput succedaneum, as well as subgaleal hemorrhages, which are associated with a high risk of significant blood loss and require monitoring. The most common skeletal injury is the clavicle fracture, which is often asymptomatic and heals spontaneously within 7–10 days. Skeletal or muscular birth injuries may cause torticollis, a unilateral contraction of the sternocleidomastoid muscle with a resulting head tilt. Other birth injuries include nerve damage, such as brachial plexus injury and facial nerve palsy, which may cause temporary muscle weakness or paralysis. The prognosis of birth traumas is usually favorable, with most injuries resolving spontaneously within weeks to months.

• Macrosomia or anatomical abnormalities
• Extremely premature infants; low birth weight
• Abnormal fetal presentation
  • Breech presentation
  • Shoulder dystocia
• Forceps-assisted delivery or vacuum delivery
• Prolonged or rapid labor
• Small maternal stature

References:^[1][2]

Soft tissue injuries of the scalp in infants are mostly caused by shearing forces during vacuum or forceps delivery. Whereas caput succedaneum and cephalohematoma are benign conditions and resolve spontaneously, subgaleal hemorrhages require close monitoring and fluid replacement to prevent hemorrhagic shock.

• Caput succedaneum: benign edema of the scalp tissue that extends across the cranial suture lines
• Cephalohematoma: subperiosteal hematoma that is limited to cranial suture lines
• Subgaleal hemorrhage: rupture of the emissary veins and bleeding between the periosteum of the skull and the aponeurosis; that may extend across the suture lines; associated with a high risk of significant hemorrhage and hemorrhagic shock

References:^[3][1][2][4]

• Definition: twisted or rotated neck caused by contraction of the sternocleidomastoid muscle; can be acquired or congenital (congenital muscular torticollis)
• Pathomechanism of acquired torticollis
  • Sternocleidomastoid or trapezius muscle injury
  • Cervical muscle spasm
  • Cervical nerve irritation
• Pathomechanism of congenital torticollis
  • Not fully understood; likely from muscular or skeletal injury during delivery with subsequent fibrosis and contracture of the sternocleidomastoid muscle
  • Associated with:
    • Intrauterine constraint, which causes unilateral shortening of the sternocleidomastoid muscle
      • Oligohydramnios
      • Multiple gestation
      • Macrosomia
    • Decreased fetal movement
    • Breech presentation
    • Assisted vaginal delivery
• Clinical features
  • Head noticeably tilted to one side with the chin rotated towards the opposite side
  • Muscular tightness; limited passive range of motion
  • Potentially palpable thickening of the SCM
• Treatment
  • Early initiation of physiotherapy, passive positioning
  • Surgery at 12 months of age if conservative management is insufficient: myotomy or bipolar release of the affected SCM
• Complications: : craniofacial asymmetry, scoliosis of the cervical spine

References:^[6][7][8][9]

• Definition: an obstetric emergency in which the anterior shoulder of the fetus becomes impacted behind the maternal pubic symphysis during vaginal delivery
• Epidemiology: ∼ 0.2–3% of births
• Risk factors
  • History of shoulder dystocia
  • Fetal macrosomia
  • Prolonged second stage of labor
  • Maternal diabetes mellitus
  • Maternal obesity
• Clinical features
  • Features of arrested active phase of labor
  • Turtle sign: the fetal head is partially delivered but retracts against the perineum
  • Failed restitution of the head
• Diagnosis: clinical diagnosis
• Treatment
  1. The patient should stop bearing down and lie supine with the buttocks on the edge of the bed.
  2. Perform shoulder dystocia maneuvers:
     • First-line: McRoberts maneuver
     • Any of the internal maneuvers below may be attempted to next.
     • Move to another maneuver if delivery is not accomplished within 20–30 seconds.
     • If all above maneuvers fail, attempt the all fours position.
  3. Last-resort options:
     • Fracture of fetal clavicle
     • Zavanelli maneuver
     • Symphysiotomy

Shoulder dystocia maneuvers
McRoberts maneuver		The patient should stop bearing down and lie supine with the buttocks on the edge of the bed. Abduct, externally rotate, and hyperflex the maternal hips (with the maternal legs pulled towards the head).
Internal maneuvers	Rubin maneuver*	Rubin I Used with the McRoberts maneuver Suprapubic pressure (proximal to the symphysis pubis) is applied to the posterior part of the impacted anterior shoulder. Rubin II Manually rotate the fetal shoulder girdle by applying pressure to the posterior part of the anterior shoulder.
	Woods maneuver*	Manually rotate the fetal shoulder girdle by applying pressure to the anterior part of the posterior shoulder.
	Delivery of posterior arm	Manually deliver the posterior fetal arm.
Zavanelli maneuver		Administer a uterine relaxant (e.g., terbutaline). The fetal head is pushed back into the pelvis. Once successful, perform a cesarean delivery.
* May be performed with the McRoberts maneuver and may require episiotomy.

• Complications
  • Fetal
    • Brachial plexus injury (Erb palsy is more common than Klumpke palsy)
    • Clavicle or humerus fracture
    • Hypoxia over an extended period of time as a result of umbilical cord compression
  • Maternal
    • Perineal lacerations
    • Postpartum hemorrhage

Most cases of shoulder dystocia occur in the absence of identifiable risk factors!

Do not pull the fetal head! Doing so may cause brachial plexus injury (Erb palsy). References:^{[11][12][13][14]}