CC BY
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MEDICAL SCIENCES / <«g©yL©(MUM~J©U©MaL» 2©23
UDC: 616
Cherniievych Bohdan Oleksandrovych
student
Bukovinian State Medical University Marynchyna Iryna Mykolaivna
PhD in Medicine, Associate Professor of the Department of Obstetrics,
Gynecology and Perinatology Bukovinian State Medical University
Nykoliuk Mariia Volodymirivna
student
Bukovinian State Medical University DOI: 10.24412/2520-6990-2023-12171-18-21 THE BIRTH TRAUMA. A LIST OF COMMON TRAUMATIC CLINICAL CONDITIONS.
Abstract:
The urgency of the problem is due to the growing number of this pathology, high disability and mortality of children with birth injuries. The main risk factors on the part of the mother and the fetus are considered.
Keywords: The birth trauma, Traumatic clinical conditions associated with birth, Head Trauma, Caput Suc-cedaneum.
Introduction: The National Vital Statistics Report defines birth injury as "an impairment of the neonate's body function or structure due to an adverse event that occurred at birth.". These injuries can range from minor to major and are caused by mechanical forces during labor. Birth injuries are distinct from birth defects and can be distinguished from congenital defects by clinical assessment. The incidence of birth trauma has decreased over time due to advances in obstetrical techniques and increased use of cesarean delivery in difficult cases. From 2004 to 2012, the birth trauma rate dropped from 2.6 per 1000 live births to 1.9 per 1000 live births. Additionally, instrumental deliveries such as forceps and vacuum-assisted deliveries have also declined over the past three decades.
Issues of concern : The factors that increase the risk of birth injury can be divided into categories such as those related to the fetus, pregnancy, mother, and iat-rogenic factors, which include the use of instruments during labor. These are risk factors that can contribute to the occurrence of birth injury and can be classified into different categories, such as maternal factors such as diabetes, obesity, short stature, breech presentation, dystocia and difficulty in extraction, prolonged or rapid labor, and cephalopelvic disproportion.
Fetal and pregnancy-related factors include mac-rosomia (when the estimated fetal weight is greater than 4000 g), macrocephaly, very low birth weight, extreme prematurity, congenital fetal anomalies, oligohydram-nios, and malpresentation, which can include breech and other abnormal presentations, such as facial, brow, or transverse.
The use of a vacuum or forceps during labor is another factor that can increase the risk of birth trauma.
Clinical significance: The management and outlook of infants with birth injuries can differ greatly based on the type and severity of the injury. The head, neck, and shoulders are typical areas affected by birth trauma, while less frequent areas include the face, ab-
domen, and lower extremities. The following is a summary of the typical clinical conditions related to birth trauma.
Head Trauma: Trauma of the head can encompass surface wounds, bleeding outside and inside the skull, as well as breaks in the bones of the skull.
Skull fractures: Skull fractures resulting from birth injuries are typically caused by the use of instruments during vaginal delivery and can be linear or depressed. Generally, these fractures do not produce any symptoms unless they are linked to intracranial injuries. A diagnosis can often be confirmed through plain film radiography of the skull. However, if there is a suspicion of intracranial injury or neurologic symptoms, a computer tomography (CT) or magnetic resonance imaging (MRI) of the brain is recommended.
Swelling of the scalp in newborns (Caput Suc-cedaneum): Scalp swelling in newborns refers to the buildup of fluid and swelling beneath the scalp's skin and periosteum. This condition occurs as a result of pressure on the baby's head during delivery, which can lead to venous congestion. The swelling is located above the periosteum and can cross the suture lines. Usually, the condition resolves on its own within a few days without requiring any intervention. However, in rare cases, complications such as skin bruising, necrosis, scarring, alopecia, or systemic infections may occur.
Extracranial Hemorrhages:
Cephalohematoma: Cephalohematoma is a type of swelling that occurs under the periosteum as a result of ruptured blood vessels between the skull and periosteum. This swelling is limited by the periosteal attachment to the underlying skull bones, and usually appears on only one side. It is more commonly observed in deliveries that involve the use of vacuum or forceps and occurs in about 2.8% of all deliveries. Cephalohematoma typically resolves on its own within two weeks to three months without requiring any treatment.
Subgaleal hemorrhage: Subgaleal hemorrhage is a condition where blood collects in the space between the galea aponeurotica and the skull's periosteum. This
injury is caused by traction pulling the scalp away from the bony calvarium, which results in the shearing or severing of the bridging vessels. Difficult vaginal delivery, often involving the use of forceps or vacuum, is the most common cause of subgaleal hemorrhage. This condition occurs in approximately 4 out of 10,000 spontaneous vaginal deliveries and 59 out of 10,000 vacuum-assisted deliveries. Since the subgaleal space is a large potential space extending over the entire area of the scalp, there is a risk of massive bleeding that could lead to acute hypovolemic shock, multi-organ failure, and even death. Treatment involves providing supportive care, early recognition, and restoration of blood volume using blood or fresh frozen plasma to correct the acute onset hypovolemia. The hemorrhage is not drained, and the body is allowed to resorb it over time. In selected cases, a workup for bleeding disorders may be considered if the degree of bleeding is disproportionate to the trauma at birth.
Intracranial Hemorrhages: Various types of hemorrhages can occur inside the skull due to trauma, including epidural, subdural, subarachnoid, intra-ventricular, and, less commonly, intracerebral and in-tracerebellar hemorrhages.
Epidural hemorrhage: Epidural hemorrhage is not common in newborn babies, but when it does occur, it's usually a result of a linear skull fracture in the parietal-temporal region that happens during a delivery that requires surgery. Some symptoms of epidural hematoma in neonates include bulging fontanelle, bradycardia, hypertension, irritability, altered consciousness, hypotonia, and seizures. A diagnosis can be made by using a CT or MRI of the head, which will show blood collection in the epidural space with a convex appearance. It's important to seek prompt neurosurgical intervention if epidural hematoma is suspected, as it can deteriorate rapidly.
Subdural hemorrhage: Subdural hemorrhage is actually the most common type of intracranial hemorrhage in neonates. The risk factors for subdural hemorrhage include operative vaginal delivery, and the most common site of bleeding is over the cerebral convexities. Symptoms of subdural hemorrhage in neonates may include bulging fontanelle, altered consciousness, irritability, respiratory depression, apnea, bradycardia, altered muscle tone, and seizures. In some cases, sub-dural hemorrhages may be found incidentally in asymptomatic neonates. The management of subdural hemorrhage depends on the location and extent of the bleeding. Surgical evacuation is typically reserved for extensive hemorrhages that cause raised intracranial pressure and associated clinical signs.
Subarachnoid hemorrhage: Subarachnoid hemorrhage is the second most common type of intracranial hemorrhage in neonates, and it's usually caused by the rupture of bridging veins in the subarachnoid space. Operative vaginal delivery is a risk factor, and affected infants are usually asymptomatic unless the hemorrhage is extensive. Ruptured vascular malformations are a rare cause of subarachnoid hemorrhages, even in the neonatal population. In most cases, treatment for subarachnoid hemorrhage is conservative, meaning that
medical management is used to manage symptoms and allow the body to heal naturally.
Intraventricular hemorrhage: While intraventricular hemorrhage is most commonly observed in premature infants, it can also occur in term infants, depending on the type and severity of birth injury.
Intracerebral and intracerebellar hemorrhages: These types of intracranial hemorrhages are less frequent and develop due to occipital diastasis.
Cranial Nerve Injuries:
Facial nerve: Facial nerve injury is a common complication of traumatic births, with the facial nerve being the most frequently affected cranial nerve. Its incidence is estimated to be around 10 per 1000 live births and is typically caused by pressure on the facial nerve by forceps or maternal sacral promontory during delivery. The characteristic signs and symptoms of facial nerve palsy include reduced or absent movement on the affected side of the face. But distinguishing it from asymmetric crying facies is crucial, as the latter is caused by congenital hypoplasia of the depressor anguli oris muscle and results in a localized movement abnormality of the mouth corner. Even without apparent trauma, facial palsy may still occur in newborns. The prognosis for traumatic facial nerve injury is usually favorable, with spontaneous resolution often occurring within the first few weeks of life.
Spinal Cord and Peripheral Nerve Injuries:
Brachial plexus injuries: The consequences of stretching of the cervical nerve roots during delivery can occur in up to 2.5 per 1000 live births. These injuries are typically one-sided and risk factors include macrosomia, shoulder dystocia, difficult delivery, breech presentation, multiparity, and assisted deliveries.
An injury that affects the fifth and sixth cervical nerve roots can lead to Erb's-Duchenne palsy, which is characterized by weakness in the upper arm. The presenting symptoms include arm adduction, internal rotation, and finger flexion. This is the most common type of brachial plexus injury.
An injury to the eighth cervical and first thoracic nerves can cause Klumpke's palsy, which is manifested by paralysis of the hand muscles, absent grasp reflex, and sensory impairment along the ulnar side of the forearm and arm.
If all the nerve roots are injured, it can result in complete arm paralysis.
Brachial palsy can also be accompanied by an injury to the phrenic nerve. This can lead to tachypnea, asymmetric chest motion, and reduced breath sounds on the affected side.
Most brachial plexus injuries are caused by stretching, and the treatment is typically conservative. Physical therapy is a crucial component in the gradual restoration of function. In rare, severe cases, brachial plexus injuries can result in permanent weakness on the affected side.
Spinal cord: In neonates, spinal cord injuries are rare and typically occur due to excessive traction or rotation of the spinal cord during delivery. The symptoms experienced by the infant depend on the
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location and type of the injury. Lesions in the upper regions (upper thoracic/cervical) are often fatal, while lesions in the lower regions (lumbosacral, lower thoracic) can result in bladder and bowel dysfunction and other significant health problems. Diagnosis is achieved through ultrasonography or MRI of the spinal cord. The goal of treatment is to manage clinical symptoms and stabilize cardiorespiratory function as necessary.
Skeletal injuries: Most fractures caused by birth trauma are linked to abnormal presentations or difficult extractions. Clavicular fractures are the most common type of bone fracture that occur during delivery, with up to 15 per 1000 live births affected. Clinical symptoms include tenderness, crepitus at the fracture site, and decreased movement of the affected arm with an asymmetric Moro reflex. Most infants recover well from clavicular fractures with spontaneous healing. The humerus is the most common long bone to fracture during birth, and it can be associated with a brachial plexus injury. Symptoms may resemble those of a clavicular fracture, with tenderness, swelling, and deformity of the affected arm. Rarely, a distal humeral epiphyseal separation due to birth trauma may require expert orthopedic intervention. In general, immobilization for 3 to 4 weeks is necessary for long bone fractures, and they usually heal well without deformities. While other fractures such as rib fractures and femur fractures can occur during birth, they are uncommon. Femur fractures are particularly rare in newborns and may occur during difficult vaginal breech extraction deliveries. Diagnosis is made by clinical exam with tenderness, swelling, and deformity of the thigh, and it is further confirmed with plain radiographs. An orthopedic consultation is recommended for appropriate immobilization of long bone fractures.
Facial injuries: Ocular injuries in newborns may include subconjunctival hemorrhages (SCH), which are superficial hematomas seen under the bulbar conjunctiva. They are commonly observed in infants who have gone through labor, and they are thought to result from ruptured subconjunctival capillaries due to venous congestion caused by increased back pressure in the head and neck veins. This injury can occur due to either a nuchal cord or increased abdominal or thoracic compression during uterine contractions. SCH is a benign condition that typically resolves without intervention. But, more severe ocular injuries may occur during delivery, particularly when instrumentation such as forceps are used. These injuries can include corneal abrasions, vitreous hemorrhages, and other types of trauma that require immediate attention and referral to an ophthalmologist to prevent long-term visual defects.
Soft tissue injuries: That may result from birth trauma include petechiae, bruising, ecchymoses, lacerations, and subcutaneous fat necrosis. Subcutaneous fat necrosis is thought to occur due to ischemic injury to the adipose tissue and is characterized by the presence of soft, indurated nodules in the subcutaneous plane. These lesions typically resolve gradually over a few weeks. But, hypercalcemia can be a complication, so
monitoring of serum calcium is recommended. Accidental lacerations during cesarean section deliveries are also possible, with studies showing a 3% incidence of such lacerations during cesarean sections, particularly in emergent deliveries compared to scheduled cesarean deliveries.
Visceral injuries: Abdominal visceral injuries resulting from birth trauma are rare and usually involve hemorrhage into organs such as the liver, spleen, or adrenal gland. The clinical symptoms of such injuries depend on the extent of blood loss and may include pallor, bluish discoloration of the abdomen, abdominal distension, and shock. Treatment primarily involves supportive care through volume resuscitation, and surgical intervention may be necessary in severe cases.
Prevention: An interprofessional team comprising obstetricians, neonatologists, pediatricians, radiologists, and specialty trained nurses is crucial in preventing birth trauma. With advances in antenatal care, fetal malformations and malpresentation can be detected early, allowing for improved preparation for high-risk deliveries. Therefore, pregnant women should follow prenatal care recommendations to ensure optimal outcomes, and a coordinated educational effort involving the clinician, nurse midwife, and specialty-trained nurse can help reduce the incidence of untoward events. It's important to note that not all birth-related injuries are preventable, and some may not be iatrogenic. Infants at risk for neurodevelopmental impairment due to birth injuries should be closely monitored by an interprofessional team comprising a pediatrician, labor and delivery nurse, physical and occupational therapist, and a developmental-behavioral pediatrician. The coordination of care by clinical and nursing staff is crucial in supporting this team.
Conclusion: Birth trauma can result in a wide range of injuries in newborns, from mild to life-threatening, and the prognosis depends on the type and severity of the initial injury. A thorough physical examination at birth is necessary to identify any injuries and differentiate them from congenital malformations. Extracranial hemorrhages typically heal well, while subgaleal hemorrhages require close monitoring due to their potential for severe hypovolemia. Spinal cord injuries, brachial plexus injuries, and facial nerve injuries all have varying prognoses, with some resolving within weeks and others requiring physical therapy and long-term monitoring.
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