• Clinical science

Birth traumas

Summary

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.

Risk factors

References:[1][2]

Neonatal soft tissue injuries

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
    • Firm swelling; pits if gentle pressure is applied
    • No treatment required; resolves within hours or days
  • Cephalohematoma: subperiosteal hematoma that is limited to cranial suture lines
    • Complications: calcification of the the hematoma, secondary infection
    • No treatment required; resolves within several weeks or months
  • Subgaleal hemorrhage: 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
    • Clinical features
      • Insidious spread of a fluctuant swelling across the cranium (may extend across the suture lines)
      • Pallor, tachycardia
      • Jaundice
    • Diagnosis
      • Primarily a clinical diagnosis
      • Ultrasound or MRI to differentiate from other cranial hemorrhagic birth traumas (e.g., intracranial bleeding) and to rule out skull fractures
      • Rule out coagulopathy (in cases of prolonged bleeding)
    • Treatment
    • Prognosis: mortality rate of 12–14%


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

Birth-related clavicle fracture

  • Epidemiology: most common fracture during birth (∼ 2% of deliveries)
  • Clinical features
    • Usually asymptomatic
    • Possible pseudoparalysis
    • Bone irregularities, crepitus, and tenderness over the clavicle possible on palpation
    • Possible brachial plexus palsy
  • Diagnostics: : clinical diagnosis; X-ray; only indicated in cases of gross bone deformation
  • Treatment
    • Reassurance and promote gentle handling of the arm (e.g., while dressing)
    • To avoid discomfort, pin shirt sleeve to the front of the shirt with the arm flexed at 90 degrees
    • Consider analgesics
    • Follow-up 2 weeks later to confirm proper healing: via clinical findings of a callus formation, and possibly an x-ray
    • Usually self-resolves within 2–3 weeks without surgical intervention or long-term complications

References:[5][3][1][2]

Infant torticollis

  • Definition: twisted or rotated neck caused by contraction of the sternocleidomastoid muscle; can be acquired or congenital (congenital muscular torticollis)
  • Pathomechanism of acquired torticollis
  • Pathomechanism of congenital torticollis
  • 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
  • Conditions associated with congenital torticollis
  • Differential diagnosis: postural preference , vertebral anomalies, absence of cervical musculature, ocular anomalies, underlying conditions (e.g., spina bifida)
  • 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]

Facial nerve palsy due to birth trauma

  • Epidemiology: most common cranial nerve injury during birth
  • Pathomechanism
    • Injury occurs during forceps-assisted delivery (most common)
    • Prolonged birth in which the head is pressed against the maternal sacral promontory
  • Clinical features
  • Differential diagnosis: congenital , developmental CNS anomalies, Moebius syndrome
  • Treatment: eye care with artificial tears and ointment
  • Prognosis: spontaneous recovery in 90% of cases within several weeks

References:[2][10]

Neonatal brachial plexus palsy

  • Excessive lateral traction on the neck during delivery → injury to the upper trunk of the brachial plexus → Erb palsy (most common iatrogenic brachial plexus injury during delivery)
  • Excessive traction on the arm during delivery → injury to the lower trunk of the brachial plexus → Klumpke palsy

Shoulder dystocia

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's maneuver*
  • Rubin I
    • Used with the McRobert's 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.
Wood's maneuver*

  • Manually rotate the fetal shoulder girdle by applying pressure to the anterior part of the posterior shoulder.

  • The reverse Wood's maneuver is when pressure is applied to the posterior part of the posterior shoulder in an attempt to rotate the fetus the other direction (may be attempted if all other maneuvers fail).

    •
Delivery of posterior arm
  • Manually deliver the posterior fetal arm.
Gaskin maneuver (all fours position)
  • The patient moves into hands and knees position.
  • Rubin's and Wood's maneuvers can be repeated.
Fracture of fetal clavicle
  • The fetal clavicle is surgically separated (cleidoctomy) or manually bent with the hand.
Zavanelli maneuver
Symphysiotomy
  • The anterior fibers of the symphyseal ligament are surgically separated, allowing the pubic bones to widen.
  • Performed under local anaesthesia

* May be performed with the McRobert's maneuver and may require episiotomy.

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