Birth Trauma

Overview

• Occurs in approximately 2-7 per 1,000 live births

• Higher rates with:
• Instrumental deliveries (forceps, vacuum)
• Macrosomia (birth weight >4,000 g)
• Prematurity (fragile tissues)
• Abnormal presentations (breech, face)
• Prolonged or precipitous labour
• First vaginal delivery

Risk Factors

• Primiparity

• Short stature, small pelvis

• Maternal diabetes (macrosomia)

• Obesity

• Prolonged or precipitous labour

• Abnormal uterine contractions

• Macrosomia (>4,000 g)

• Prematurity (<37 weeks)

• Abnormal presentation (breech, transverse lie)

• Multiple gestation

• Congenital anomalies

• Instrumental delivery (forceps, vacuum)

• Shoulder dystocia

• Emergency caesarean section

• Difficult or traumatic delivery

• Inappropriate use of fundal pressure

Types of Birth Trauma

1. Soft Tissue Injuries

Caput Succedaneum

• Pressure of the presenting part against the cervix during labour

• Fluid accumulation in subcutaneous tissue

• Crosses suture lines

• Soft, pitting oedema on scalp

• Present at birth

• Crosses suture lines (unlike cephalhaematoma)

• May have bruising or abrasions

• Not fluctuant

• No treatment required

• Resolves spontaneously within 2-3 days

• Reassure parents

• Usually none

• Rarely contributes to hyperbilirubinaemia

Cephalhaematoma

• Rupture of blood vessels between skull and periosteum during delivery

• Common with instrumental deliveries

• Accumulates over hours after birth

• Firm, fluctuant swelling on scalp

• Appears several hours after birth (not immediately)

• Does NOT cross suture lines (limited by periosteal attachments)

• Most common over parietal bones (unilateral or bilateral)

• No discolouration initially

• Well-demarcated edges

• Enlarges over first 24-48 hours

• Resolves over 6-8 weeks (up to 3 months)

• May leave calcified rim that eventually remodels

• No aspiration or drainage (risk of infection, rebleeding)

• Observation

• Monitor for jaundice (breakdown of blood)

• Rarely needs phototherapy for jaundice

• Hyperbilirubinaemia (as blood breaks down)

• Anaemia (if large)

• Infection (rare, if aspirated)

• Underlying skull fracture (10-25% of cases)

• Calcification (benign, remodels over time)

• Usually none needed

• Skull X-ray or CT if concerned about fracture (not routine)

• Monitor bilirubin if jaundice develops

Subgaleal (Subaponeurotic) Haemorrhage

• Large potential space (extends from orbital ridges to nape of neck)

• Can accumulate large volumes of blood (up to 260 mL - 80% of newborn blood volume)

• Associated with vacuum extraction, coagulopathy

• Diffuse, fluctuant scalp swelling

• Crosses suture lines (unlike cephalhaematoma)

• Appears hours after delivery and progressively enlarges

• Boggy, shifting fluid wave

• Signs of hypovolaemia:
• Pallor
• Tachycardia
• Hypotension
• Shock

• May have bruising around ears and eyes as blood tracks down

• Emergency management:
• Immediate resuscitation
• IV access
• Volume replacement (crystalloid, blood transfusion)
• Monitor vital signs closely

• Investigations:
• Serial haemoglobin/haematocrit
• Coagulation screen
• Cross-match blood
• Serial head circumference measurements

• Supportive care:
• NICU admission
• Avoid procedures increasing intracranial pressure
• Monitor for complications

• Hypovolaemic shock (life-threatening)

• Severe anaemia

• Hyperbilirubinaemia

• Disseminated intravascular coagulation (DIC)

• Death (if not recognized and treated)

• High mortality if not promptly recognized

• Resolves over 2-3 weeks with appropriate management

Facial and Scalp Injuries

• Common after face or breech presentation

• Resolves spontaneously

• May contribute to jaundice

• From scalpel during caesarean section

• Forceps or other instruments

• Usually superficial

• May need suturing if deep

• Linear bruising or abrasions from forceps blades

• Resolve within days

• Usually no treatment needed

• Firm subcutaneous nodules (cheeks, buttocks)

• From pressure or trauma

• Resolve spontaneously over weeks-months

2. Skeletal Injuries

Clavicular Fracture

• Macrosomia

• Shoulder dystocia

• Difficult delivery

• Instrumental delivery

• May be asymptomatic

• Decreased movement of affected arm

• Crepitus over clavicle

• Asymmetric Moro reflex

• Tenderness, swelling over clavicle

• Palpable deformity or irregularity

• Callus formation evident at 1-2 weeks (healing sign)

• Clinical examination

• X-ray (if diagnosis uncertain, but often not needed)

• Usually no treatment required

• Gentle handling

• Pin sleeve to shirt to limit arm movement (optional)

• Analgesics if needed

• Heals spontaneously within 2-3 weeks

• Excellent

• Complete healing without complications

• Remodelling of callus over months

Skull Fractures

• Linear fractures (most common) - usually benign

• Depressed fractures ("ping-pong ball" deformity)

• Occipital osteodiastasis (separation of occipital bone)

• Forceps delivery

• Difficult labour

• Underlying cephalhaematoma

• Often asymptomatic

• May have overlying swelling (cephalhaematoma)

• Visible or palpable depression (depressed fracture)

• Rarely signs of intracranial injury

• Skull X-ray or CT scan

• MRI/CT if neurological signs

• Linear fractures: Observation, heal spontaneously

• Depressed fractures:
• May require neurosurgical elevation if significant
• Many resolve spontaneously

• Monitor for complications

• Usually none

• Rarely: intracranial haemorrhage, growing fracture

Long Bone Fractures

• Breech delivery

• Macrosomia

• Difficult extraction

• Decreased or absent movement of limb

• Swelling, tenderness, deformity

• Crepitus

• Pseudoparalysis (refusal to move limb)

• X-ray

• Immobilization (splinting)

• Analgesics

• Orthopaedic referral if needed

• Heals within 2-3 weeks (newborn bones heal quickly)

• Excellent with appropriate treatment

• Complete remodelling

3. Nerve Injuries

Brachial Plexus Injury (Erb's Palsy, Klumpke's Palsy)

• Stretching or tearing of brachial plexus nerve roots (C5-T1)

• Associated with shoulder dystocia, difficult delivery, macrosomia

• Injury to upper roots C5-C6 (± C7)

• From lateral traction on head during shoulder dystocia

• Injury to lower roots C8-T1

• From hyperabduction of arm during breech delivery

• "Waiter's tip" position:
• Shoulder adducted and internally rotated
• Elbow extended
• Forearm pronated
• Wrist flexed

• Absent Moro reflex on affected side

• Absent biceps reflex

• Preserved grasp reflex

• May have associated phrenic nerve palsy (C3-C5) → elevated hemidiaphragm

• May have Horner's syndrome (ptosis, miosis, anhidrosis) if severe

• "Claw hand" deformity

• Paralysis of hand muscles

• Absent grasp reflex

• Preserved Moro reflex

• Often associated with Horner's syndrome (T1 involvement)

• Clinical diagnosis

• X-ray to rule out associated fractures (clavicle, humerus)

• Chest X-ray if concerned about phrenic nerve palsy

• EMG/nerve conduction studies (at 3-4 weeks if not improving)

• MRI (if considering surgery)

• Gentle range of motion exercises (start at 7-10 days)

• Physiotherapy

• Avoid immobilization (promotes contractures)

• Regular follow-up

• Consider if no improvement by 3-6 months

• Nerve grafting, nerve transfer, neurolysis

• 70-90% recover fully by 12 months (neurapraxia)

• Earlier recovery (within 2 weeks) predicts better outcome

• Poor prognostic signs:
• No recovery by 3 months
• Horner's syndrome
• Complete plexus injury
• Nerve root avulsion (on MRI)

• Persistent weakness may require ongoing therapy, orthoses, or surgery

Phrenic Nerve Palsy

• Injury to phrenic nerve (C3-C5)

• Often associated with Erb's palsy (same nerve roots)

• Respiratory distress

• Reduced breath sounds on affected side

• Asymmetric chest movement

• Paradoxical breathing

• Chest X-ray: elevated hemidiaphragm

• Ultrasound: reduced or paradoxical diaphragm movement

• Supportive care

• Oxygen, respiratory support if needed

• Position on affected side (improves ventilation)

• Usually resolves spontaneously within weeks-months

• Surgical plication if persistent and symptomatic

Facial Nerve Palsy

• Compression of facial nerve (CN VII)

• Usually from forceps blade pressure

• Can also occur from intrauterine positioning

• Asymmetry when crying:
• Affected side remains smooth
• Unaffected side shows normal movement
• Mouth deviates to unaffected side

• Eye remains open on affected side

• Absent nasolabial fold on affected side

• Difficulty feeding (weak suck)

• Central vs peripheral palsy:
• Peripheral: involves entire half of face (including forehead)
• Central: spares forehead (unlikely in newborn)

• Asymmetric crying facies (congenital absence of depressor anguli oris muscle) - affects only lower face, eye closure normal

• Möbius syndrome (congenital bilateral facial palsy)

• Usually none required

• Eye care if lagophthalmos (inability to close eye):
• Artificial tears
• Eye patching

• Spontaneous recovery in 90% within weeks to months

• Excellent in most cases

• Persistent palsy suggests nerve division (rare)

4. Intracranial Haemorrhage

Subdural Haemorrhage

• Rupture of bridging veins or dural sinuses

• Associated with difficult delivery, rapid moulding, instrumental delivery

• More common in large babies or precipitous delivery

• May be asymptomatic

• Seizures (focal or generalized)

• Lethargy, irritability

• Full fontanelle

• Altered consciousness

• Focal neurological signs

• Anaemia if large bleed

• Cranial ultrasound (screening)

• CT or MRI brain (diagnostic)

• Coagulation screen

• Supportive care

• Seizure management if needed

• Most small bleeds resolve spontaneously

• Neurosurgical drainage rarely needed (if large, symptomatic)

• Small bleeds: good outcome

• Large bleeds: risk of neurological sequelae

Subarachnoid Haemorrhage

• Rupture of small bridging veins

• Associated with trauma or hypoxia

• Often asymptomatic (incidental finding)

• May have seizures (typically on day 2 of life)

• Well between seizures

• No focal neurological signs

• Lumbar puncture: bloody or xanthochromic CSF

• CT or MRI brain

• Supportive

• Anticonvulsants if seizures

• Usually excellent

• Most have no long-term sequelae

Intraventricular Haemorrhage (IVH)

5. Visceral Injuries

Hepatic Rupture/Subcapsular Haematoma

• Macrosomia

• Difficult delivery

• Breech extraction

• Hepatomegaly

• May be asymptomatic initially

• Delayed presentation (hours to days):
• Sudden deterioration
• Pallor, shock
• Abdominal distension
• Anaemia
• Bluish discolouration of abdomen

• Ultrasound abdomen

• CT abdomen

• Serial haemoglobin

• Emergency resuscitation:
• Volume replacement
• Blood transfusion

• Surgical exploration if ongoing bleeding or unstable

• Conservative management if stable

• High mortality if ruptured

• Better outcome if detected early

Splenic Rupture

• Similar presentation to hepatic rupture

• Management similar (resuscitation, possible splenectomy)

Adrenal Haemorrhage

• Adrenal glands vulnerable to trauma during delivery

• Associated with macrosomia, difficult delivery, birth asphyxia

• Often asymptomatic

• Abdominal mass (flank)

• Jaundice (from blood breakdown)

• Rarely adrenal insufficiency (if bilateral and severe)

• Ultrasound abdomen: adrenal mass

• Serial imaging (may enlarge then resolve)

• Monitor for adrenal insufficiency if bilateral

• Usually observation

• Rarely requires intervention

• Monitor for adrenal insufficiency

• Follow-up imaging (may calcify)

• Usually benign

• Resolves spontaneously

6. Spinal Cord Injury

• Excessive longitudinal traction or rotation during delivery

• Associated with breech delivery, hyperextension of neck, difficult extraction

• Hypotonia, flaccid paralysis below level of injury

• Respiratory distress (if high cervical injury)

• Absent deep tendon reflexes

• Bladder dysfunction

• Sensory loss

• May have concurrent brachial plexus injury

• MRI spine (imaging of choice)

• X-ray spine

• Supportive care

• Respiratory support

• Bladder catheterization

• Multidisciplinary management

• Prognosis generally poor

• High mortality

• Survivors have permanent neurological disability

General Management Principles

• Thorough physical examination of all newborns

• Document any injuries

• Assess severity and need for intervention

• Guided by clinical findings

• Imaging as appropriate (X-ray, ultrasound, CT, MRI)

• Rule out associated injuries

• Most injuries require observation only

• Supportive care

• Analgesia if painful

• Physiotherapy for nerve injuries

• Surgical intervention rarely needed

• Explain nature of injury

• Reassure about prognosis (most injuries resolve)

• Provide guidance on handling and care

• Arrange follow-up

• Detailed documentation in medical records

• Inform paediatrician and GP

• Ensure appropriate follow-up appointments

• Monitor for complications

• Early intervention if delays in recovery

Prevention

• Good glycaemic control in diabetic mothers (prevent macrosomia)

• Accurate estimation of fetal weight

• Consider elective caesarean for significant macrosomia or high-risk factors

• Careful obstetric technique

• Appropriate management of shoulder dystocia (McRoberts manoeuvre, suprapubic pressure)

• Avoid excessive traction or rotation

• Judicious use of instrumental delivery

• Avoid fundal pressure

• Timely caesarean section when indicated

• Discuss mode of delivery for high-risk cases

• Experienced obstetrician for anticipated difficult deliveries

• Neonatal team available for high-risk deliveries

Key Points: Most birth injuries are minor and resolve spontaneously. Clavicular fracture is the most common skeletal injury. Erb's palsy (70-90% recovery) is more common than Klumpke's palsy. Subgaleal haemorrhage can be life-threatening. Early recognition and appropriate management improve outcomes. Most injuries are preventable with good obstetric practice.