 INTRODUCTION:

Birth injury refers to damage or injury to the child before, during, or just after the birthing process. "Birth
trauma" refers specifically to mechanical damage sustained during delivery (such as nerve damage and
broken bones). The term "birth injury" may be used in two different ways:

1. the ICD-10 uses "birth injury" and "birth trauma" interchangeably to refer to mechanical injuries
sustained during delivery;
2. the legal community uses "birth injury" to refer to any damage or injury sustained during
pregnancy, during delivery, or just after delivery, including injuries caused by trauma.

Birth injuries must be distinguished from birth defects. "Birth defect" refers to damage that occurs while
the fetus is in the womb, which may be caused by genetic mutations, infections, or exposure to toxins.
There are more than 4,000 types of birth defects

 DEFINITION:

o An impairment of infant’s body function or structure due to adverse influences that occur at birth.
(National Vital Statistics Report).
o It is the avoidable or unavoidable trauma during birth process sustained by the neonate, which is
an important cause of perinatal mortality and morbidity. It reflects the standard of obstetrical
service of the health care delivery system.

 INCIDENCE:
The incidence of birth injuries varies from one institution to another. It can be prevented by adequate
antenatal check-up and skilled management of labor. The injury may occur antenatally, intrapartum and
during resuscitation. Over the years, obstetrical vigilance and early resort to caesarean section has
considerably reduced the incidence of serious mechanical birth injuries though the reduction in perinatal
hypoxic brain damage has not been impressive.
The common site of birth injury is head, because 96 % babies are delivered by cephalic presentations.
Other parts of the body may also be injured i.e. nerves, bones, muscles and superficial tissues.
 RISK FACTORS:

A. Maternal:
1. Primiparity
2. Small maternal Stature
3. Maternal pelvic anomalies
4. Prolonged or unusually Rapid labour
5. Oligohydramnios

B. Fetal:
6. Malpresentation of the fetus
7. Use of mid forceps or vacuum extraction
8. Versions and extractions
9. Very low birth weight or extreme prematurity
10. Fetal macrosomia or large fetal head
11. Fetal anomalies
12. Dystocia
 C. Iatrogenic:
13. Exposure to environmental toxins like mercury or lead.
14. Genetic mutations
15. Vertically transmitted infections

 TYPES:

1. Head & Neck Injuries

2. Intracranial Injury
3. Nerve Injuries
4. Facial Injuries
5. Injuries to the Bones
6. Injuries to the skin and subcutaneous tissue
7. Visceral Injury

 HEAD & NECK INJURIES:

CAPUT SUCCEDANEUM:
o Definition:

Caput succedaneum is a neonatal condition involving a serosanguinous, subcutaneous, extra-periosteal

fluid collection with poorly defined margins caused by the pressure of the presenting part of the scalp
against the dilating cervix due to the tourniquet effect of the cervix occurring during delivery. It involves
bleeding below the scalp and above the periosteum
o Causes:
The edematous swelling on the scalp of newborn occurs due to infiltration of serosanguinous fluid by the
pressure of girdle i.e. cervix, bony pelvis or vulval ring. The swelling develops due to reduced venous
blood supply and lymphatic drainage from unsupported part of the scalp that is lying over the cervical os.
The area becomes congested, edematous and is present as caput at birth.
o Clinical Manifestation:

It may cross the suture line and tends to grow less. It pits on pressure, is non-fluctuant and is diffuse in
nature.
o Management:
No management requires of the condition because it usually disappear within 36 hours. It should be
differentiated from cephalhematoma. Maternal anxiety should be reduced by reassurance.
 CEPHALHEMATOMA:

o Definition:

A cephalhematoma is a collection of blood between the skull and the periosteum of a neonate secondary to
rupture of superficial blood vessels crossing the periosteum, following a normal or complicated delivery.
Because the swelling is subperiosteal, its boundaries are limited by the individual bones, in contrast to a
caput succedaneum.
o Causes:
The usual causes of a cephalohematoma are a prolonged second stage of labor or instrumental delivery,
particularly forceps delivery. Ventose application does not increase the incidence of cephalhematoma.
Vitamin C deficiency has been reported to possibly be associated with development of cephalhematoma.
Predisposing factors for this are uncertain.
o Clinical Manifestation:

Swelling appears 2-3 days after birth. A cystic or fluctuant swelling limited by suture lines appears. The
edges of the swelling may give a false impression of depressed skull fracture due to organized rim of
cephalhematoma. Though the swelling may appear at any site but unilateral parietal cephalhematomas are
most common. Hematoma may even extend to form periorbital and auricular edema and ecchymosis.
However, if the hematoma is severe, the neonate may develop jaundice, anemia or hypotension. In some
cases it may be an indication of a linear skull fracture or be at risk of an infection leading to osteomyelitis
or meningitis.
The swelling of a cephalohematoma takes weeks to resolve as the blood clot is slowly absorbed from the
periphery towards the center. In time the swelling hardens (calcification) leaving a relatively softer center
so that it appears as a 'depressed fracture'.
o Management:
Most hematomas disappear spontaneously after a variable period of few days or weeks depending upon the
size. Vitamin K 1-2 mg is administered intramuscularly to correct any coexistent coagulation abnormality.
The incision and drainage is indicated only when the cephalhematoma gets infected or is contributing to
critical hyperbilirubinemia.
While aspiration to remove accumulated blood and prevent calcification has generally been recommended
against due to risk of infection, modern surgical standards and antibiotics may make this concern
unfounded, and needle aspiration can be considered a safe intervention for significantly-sized
cephalohematomas that do not resolve spontaneously after one month.

SUBGALEAL HAEMORRHAGE:
o Definition:
Subgaleal hemorrhage or hematoma is bleeding in the potential space between the skull periosteum and the
scalp galea aponeurosis.
o Causes:
The majority of neonatal cases (90%) result from applying a vacuum to the head at delivery (ventose-
assisted delivery). The vacuum assist ruptures the emissary veins (i.e., connections between Dural sinus
and scalp veins) leading to accumulation of blood under the aponeurosis of the scalp muscle and superficial
to the periosteum.
Additionally, subgaleal hematoma has a high frequency of occurrence of associated head trauma (40%),
such as intracranial hemorrhage or skull fracture. The occurrence of these features does not correlate
significantly with the severity of subgaleal hemorrhage.
o Clinical Manifestations:
A subgaleal hemorrhage presents as a firm-to-fluctuant mass that crosses suture lines with a fluctuant
boggy mass developing over the scalp (especially over the occiput) with superficial skin bruising. The
swelling develops gradually 12–72 hours after delivery, although it may be noted immediately after
delivery in severe cases.
Subgaleal hematoma growth is insidious, as it spreads across the whole calvaria and may not be recognized
for hours to days. If enough blood accumulates, a visible fluid wave may be seen. Patients may develop
periorbital ecchymosis.
Patients with subgaleal hematoma may present with hemorrhagic shock given the volume of blood that can
be lost into the potential space between the skull periosteum and the scalp galea aponeurosis, which has
been found to be as high as 20-40% of the neonatal blood volume in some studies. The swelling may
obscure the fontanel and cross cranial suture lines, (distinguishing it from cephalohematoma).
o Management:
The neonate is monitored for serial hemoglobin, hematocrit, coagulation profile to investigate for the
presence of a coagulopathy and bilirubin levels.

Supportive treatment is given. Management consists of vigilant observation over days to detect progression
and, if required, of management of complications (e.g., hemorrhagic shock, unconjugated
hyperbilirubinemia and jaundice from hemolyzed red blood cells). The subgaleal space is capable of
holding up to 40% of a newborn baby's blood and can therefore result in acute shock and death. Fluid bolus
may be required if blood loss is significant and patient becomes tachycardic. Transfusions may be required
if blood loss is significant. In severe cases, surgery may be required to cauterize the bleeding vessels. These
lesions typically resolve over a 2 to 3 weeks period.

 INTRACRANIAL INJURY
Bleeding can occur, External to the brain into the epidural, subdural or subarachnoid space. Bleeding can
also occur in to the parenchyma of the cerebrum or cerebellum and into the ventricles from the
subependymal germinal matrix or choroid plexus.
Subdural hemorrhage includes laceration of the tentorium, with rupture of the straight sinus, vein of Galen
transverse sinus, or infratentorial veins causing a posterior fossa clot and brainstem compression. It also
includes laceration of the falx, with rupture of the inferior sagittal sinus resulting in a clot in the
longitudinal cerebral fissure. Laceration of the superficial cerebral vein causes bleeding over the cerebral
convexity. Occipital osteodiastasis with rupture of the occipital sinus results in a posterior fossa clot.
Precipitate delivery, difficult forceps, vacuum extraction in a large baby, breech extraction, other abnormal
presentations may be associated with intracranial hemorrhage.
The baby is generally asphyxiated at birth with no spontaneous respiration may be established even after
resuscitation. The neonate has apneic spells and recurrent seizures. The abnormal neurological behavior
(cerebral depression or irritability) often manifests within first 24 hours.
The injury can be identified by cranial computed tomography showing a high-density lentiform lesion in
the temporoparietal region and skull radiographs.

STERNOMASTOID ‘TUMOR’
During second week of life, a firm mass of 1to 2 cm in diameter may be noticed in the mid-portion of
sternomastoid muscle.It is either a small hematoma from injury to the muscles at birth or due to
fibromatous malformation of the muscle. It is associated mostly with tortocolis of the affected side.
The mother is advised to over extend the affected muscle by turning the infant’s head in the opposite
direction and flexing thenecktowards unaffected side. The majority of the tumors resolve spontaneously by
six months to one year of age. It torticolis persists beyond an year then surgical correctionis to be under
taken.

SPINAL CORD TRANSECTION

This is relatively rare form of birth injury which follows difficult breech extraction when fracture of
cervical spine or avulsion of cervical cord may occur. Sometimes a click or crack may be heard during
delivery. It is characterised by flaccid paraplegia, with retention of urine and overflow incontinence.
Respiratory failure due to diaphragmatic paralysis may dominate the clinical picture. Sensations may be
dulled or absent below the site of lesion. Prognosis is grave.

ERB’S PALSY
When upper cervical roots (C5, C6) are affected, the arm hangs limply, adducted and internally rotated with
elbow extended and pronated. Arm recoil is lost. If there is diaphragmatic paralysis, it manifests respiratory
distress. Spontaneous movement is lost and there is asymmetric Moro reflex. It may be associated with
fracture of clavicle and involvement of lower cervical roots. The most commonly involved nerves are the
suprascapular nerve, musculocutaneous nerve, and the axillary nerve. Erb's palsy include loss of sensation
in the arm and paralysis and atrophy of the deltoid, biceps, and brachialis muscles.
The lack of development to the circulatory system can leave the arm with almost no ability to regulate its
temperature, which often proves problematic during winter months when it would need to be closely
monitored to ensure that the temperature of the arm was not dropping too far below that of the rest of the
body. However, the damage to the circulatory system also leaves the arm with another problem. It reduces
the healing ability of the skin, so that skin damage takes far longer than usual to heal, and infections in the
arm can be quite common if cuts are not sterilized as soon as possible.
These injuries arise most commonly, but not exclusively, from shoulder dystocia during a difficult birth.
Depending on the nature of the damage, the paralysis can either resolve on its own over a period of months,
necessitate rehabilitative therapy, or require surgery. Neonatal/pediatric neurosurgery is often required for
avulsion fracture repair. Lesions may heal over time and function return. Physiotherapeutic care is often
required to regain muscle usage. Although range of motion is recovered in many children under one year in
age, individuals who have not yet healed after this point will rarely gain full function in their arm and may
develop arthritis.
Latissimus dorsi tendon transfers involve cutting the latissimus dorsi in half horizontally in order to pull
part of the muscle around and attach it to the outside of the biceps. This procedure provides external
rotation with varying degrees of success. A side effect may be increased sensitivity of the part of the biceps
where the muscle will now lie, since the latissimus dorsi has roughly twice the number of nerve endings per
square inch of other muscles.

KLUMPKE’S PALSY
Klumpke's paralysis is a variety of partial palsy of the lower roots of the brachial plexus. The brachial
plexus is a network of spinal nerves that originates in the back of the neck, extends through the axilla
(armpit), and gives rise to nerves to the upper limb. The paralytic condition is named after Augusta
Déjerine-Klumpke.
Symptoms include intrinsic minus hand deformity, paralysis of intrinsic hand muscles, and C8/T1
Dermatome distribution numbness. Involvement of T1 may result in Horner's syndrome, with ptosis, and
miosis. Weakness or lack of ability to use specific muscles of the shoulder or arm. It can be contrasted to
Erb-Duchenne's palsy, which affects C5 and C6. It manifests as wrist drop, flaccid paralysis of hand with
absent grasp response. The presence of miosis, ptosis and anhidrosis though uncommon would suggest
associated damage to the cervical sympathetic chain of the first thoracic root.
The injury can result from difficulties in childbirth. The most common etiological mechanism is caused by
a traumatic vaginal delivery. The risk is greater when the mother is small or when the infant is of large
weight. Risk of injury to the lower brachial plexus results from traction on an abducted arm, as with an
infant being pulled from the birth canal by an extended arm above the head. Klumpke's paralysis is a form
of paralysis involving the muscles of the forearm and hand, resulting from a brachial plexus injury in which
the eighth cervical (C8) and first thoracic (T1) nerves are injured either before or after they have joined to
form the lower trunk.
The subsequent paralysis affects, principally, the intrinsic muscles of the hand (notably the interossei,
thenar and hypothenar muscles) and the flexors of the wrist and fingers (notably flexor carpi ulnaris and
ulnar half of the flexor digitorum profundus). The classic presentation of Klumpke’s palsy is the “claw
hand” where the forearm is supinated, the wrist extended and the fingers flexed. If Horner syndrome is
present, there is miosis (constriction of the pupils) in the affected eye.
As management, a cotton ball should be placed in the baby’s hand to avoid contractures. Massage and
passive movements of muscles would aid complete recovery within few weeks or months. In severe cases,
which is associated with laceration of nerve, the affected limb may remain permanently short and stunted.
If paralysis persists for more than 3 months, neuroplasty is indicated.
 PHRENIC NERVE PALSY
The Phrenic Nerve injury, though rare, is often associated with upper brachial palsy. Diaphragmatic
paralysis results in irregular labored thoracic breathing without any visible abdominal movements. The
diaphragm is elevated on the affected side breath sounds are diminished. The characteristic see-saw
movements of two sides of diaphragm during respiration is found in fluoroscopic examination. The
paradoxical movements of diaphragm is seen in USG.

There is no specific therapy. Baby should be placed on the affected side. Administration of oxygen, CPAP
and gavage feeding, depending on the severity of respiratory difficulty are often indicated. The recovery is
often complete but it may be complicated due to respiratory infection. If recovery is incomplete, the weak,
flabby and elevated leaf of diaphragm may manifest as eventration during infancy. In symptomatic cases
diaphragmatic plication may be needed.

 FACIAL INJURY:
FACIAL PALSY
Facial nerve paralysis involves the paralysis of any structures innervated by the facial nerve. It may occur
with or without forceps application. It is manifested by facial asymmetry, inability to close the eye, absence
of rooting reflex on the affected side. The recovery is excellent and complete due to greater regenerative
power and short length of the nerve. Bilateral facial palsy or its association with 6th nerve paralysis
suggests a central lesion such as agenesis of seventh nerve nucleus.
 PARTIAL FACIAL PALSY
Partial facial palsy or Congenital Absence of depressor Anguli Oris muscle is a relatively frequent
condition. Facial asymmetry on crying is limited to the corner of the mouth and mandible gets pulled
downwards on the normal side. There is high incidence of cardio-vascular, genito-urinary and skeletal
anomalies associated with congenital absence or hypoplasia of depressor anguli oris muscle.

 INJURIES TO THE BONES:

FRACTURE

o Skull:

Ability of the skull to mold during birth process protects it from injury during normal uncomplicated labor.
Linear skull fracture maybe associated in one-fourth of infants with cephalhematoma and are of no
therapeutic significance.
The depressed fractures may occur due to compression as a result of forceps or against the maternal
symphysis pubis and sacral promontory. These also disappear spontaneously through surgical elevation
may be required if they are associated with neurological manifestations.

o Clavicle:
Fracture of clavicle is most common and often follows breech extraction or shoulder impaction. It may
even occur after uncomplicated vaginal delivery. Incidence rate varies from 0.2 to 3.5 %. The baby cries
due to pain when handled, other than which there are little physical findings.
However, a greenstick fracture is picked up by callus formation at 7 to 10 days of birth. It restricts the
movement of the affected limb and Moro reflex becomes asymmetric. Associated Erb’s palsy and fracture
humerus is to be excluded. The prognosis is excellent. Callus may form within 1 week. Infant’s arm is
immobilized by restraints. Safe analgesic drugs are used as needed.

o Humerus:
The forcible manipulations and pulling at baby’s arm during delivery may result in fracture of humerus.
The diagnosis is suspected by pain, limited movement in affected arm and asymmetric Moro reflex. The
strapping of arm by the side of chest for 2 weeks is recommended for immobilization. The prognosis is
excellent unless epiphysis is damaged in which case the limb may be permanently shortened.

o Femur:
Fracture of femur is rare and is caused by forcible manipulation of legs during breech extraction.
Spontaneous healing with excess callus formation occurs without any splintage. However, better results are
obtained by overhead traction-suspension of both lower limbs. Spica cast is applied for 4 weeks. In infants
with more than one fracture, Osteogenesis imperfecta is to be ruled out.
  VISCERAL INJURY:
VICERAL TRAUMA
Capsular laceration of liver, spleen, adrenal haemorrage may follow difficult breech extraction. The
damage may also occur due to over-zealous attempt at extermal cardiac massage. The haemorrage may
remain concealed as subcapsular hematoma or the capsule may rupture leadind to peritoneal haemorrage.
The baby may manifest pallor, tachycardia and exhibits shock.
Abdominal USG is useful diagnostic procedure. Early recognition, administration of vitamin K, Blood
transfusion, Monitoring of CVP may salvage some babies. Surgical laparotomy is used to seal the bleeding
sites in liver and spleen.
Hepatic Subcapsular Haemorrhage in neonate

 PREVENTION OF BIRTH INJURIES:

 o Regular Prenatal Care:

A safe delivery for both the baby and the mother begins with proper prenatal care. The doctor should meet
with the patient regularly and perform required investigations. A few of the most commonly performed
tests during prenatal care include ultrasound scans, AFP screening, and amniocentesis.

There are countless reasons why these tests are necessary, including to detect any genetic disorders prior to
birth. But they also play a pivotal role in birth injury prevention. Numerous birth injuries can be prevented
just by an ultrasound and ordering a c-section. By taking note of such risk factors as a breech position or
complications with the umbilical cord, doctors can reduce the risk of birth injuries.

o Monitoring for Fetal Distress:

The next component of birth injury prevention is monitoring for fetal distress. This is important throughout
the pregnancy, but especially so in the months preceding and during childbirth. When a doctor determines
that the fetus is in distress, this frequently indicates insufficient access to oxygen. The signs of fetal distress
should be taken care of:

1. Unusual volume of amniotic fluid

2. Lack of movement in the fetus
3. Atypical heart rate
4. Maternal cramping or bleeding

All of these signs indicate that the fetus is in distress and may experience irreversible damage. Your doctor
should take appropriate action immediately.

o Ordering a C-Section When Necessary:

A competent and responsible health personnel will recognize the signs that a vaginal delivery puts the baby
at risk. In this case, the proper course of action almost always takes the form of a c-section. Beyond a
doubt, c-sections are one of the most effective components of birth injury prevention.

When vaginal delivery becomes difficult, a doctor may have to rely on tools to assist in the delivery
process. Additionally, the baby may not receive the oxygen they need to thrive. Both of these cause the risk
of birth injury to skyrocket. A c-section can circumvent these complications, resulting in a far quicker and
safer delivery.

 BIBLIOGRAPHY:

1. Dutta Parul, ‘Pediatric Nursing’, Published by Jaypee Brothers Medical Publishers; 4th Edition
2018, page no: 104-108.
2. Singh Meharban, ‘Care of the Newborn’, Published by CBS Publishers & distributors, 8th
Edition, 2017, page no:301-313.
3. Marlow Dorothy R, ‘Textbook of Pediatric Nursing’, Published by Elsevier, South Asian
Edition 2013, page no: 323-334.
4. Paul VK, Bagga A, ‘Ghai Essential Pediatrics’, Published by CBS Publishers & Distributors
Pvt Ltd, 9th Edition, 2013, page no: 125 – 136.
5. https://en.wikipedia.org/wiki
6. https://pubmed.ncbi.nlm.nih.gov/17762409/
7. https://www.slideshare.net/arunaapkarunakaran/birth-injuries-27373006?qid=bcf4e985-5908-
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