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.

• Head molding: a transient deformation of the head into an elongated shape due to external compression of the fetal head as it passes through the birth canal during labor; typically resolves within a few days after the birth
• 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:^[1][2][3][4]

• 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:^[1][2][3][5]

• 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]

• 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
  • Peripheral facial nerve palsy; : difficulty feeding; , incomplete eye closure; , absent nasolabial fold
• Treatment: eye care with artificial tears and ointment
• Prognosis: spontaneous recovery in 90% of cases within several weeks

References:^[2][10]

• 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
• Prognosis: approx. 25% of affected infants experience persistent functional impairment ^[11]

• 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

• 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:^{[12][13][14][15]}