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Birth Injuries-Excluding Scalp and Intracranial Injuries


Birth Injuries-Excluding Scalp and Intracranial Injuries Adapted from a presentation by Vandana Nayal Skull fractures Bones of the skull are less mineralized at birth ... – PowerPoint PPT presentation

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Title: Birth Injuries-Excluding Scalp and Intracranial Injuries

Birth Injuries-Excluding Scalp and Intracranial
  • Adapted from a presentation by Vandana Nayal

Skull fractures
  • Bones of the skull are less mineralized at birth
    and thus more compressible.
  • Follow repeated forceful contact of the fetal
    skull against the maternal pelvis
  • Linear fractures of the skull are accompanied by
    soft tissue changes and cephalhematoma
  • Depressed fractures are visible palpable
    indentations in the smooth contour of the skull(
    ping-pong) ball

  • Simple fractures heal without sequelae
  • Leptomeningeal cyst may develop, if detected
    early, cyst can be excised successfully and brain
    atrophy prevented
  • Repeat radiographs within 2-3 months to detect
    early widening of the fracture line

Facial nerve palsy
  • Prolonged 2nd stage and midforceps delivery
  • Central paralysis- limited to lower 1/2 or 2/3 of
    the contralateral side
  • Peripheral-entire side of the face
  • Persistently open eye on the affected side

Vocal cord paralysis
  • Uncommon injury, unilateral- symptom free or
    hoarseness with mild inspiratory stridor or
    bilateral-stridor, left more common than right
  • Unilateral- gentle handling and frequent small
    feedings, usually resolves within 6 wks
  • Bilateral is caused by hypoxia or hemorrhage into
    the brain stem
  • Bilateral-immediate intubation, tracheostomy
    required in most patients.

Fracture of the clavicle
  • Complete and some greenstick fractures may be
    apparent shortly after birth. Obvious callus at
    7-10 days of age
  • Movement of the arm may be affected
  • Pain subsides in 7-10 days

Brachial palsy
  • Erb-Duchenne- C5 C6 upper arm paralysis,Moro,
    biceps and radial reflexes are absent, grasp
    reflex is intact, ipsilateral phrenic nerve
    injury with respiratory distress
  • Klumpke-lower arm paralysis-C8T1-rare-intrinsic
    muscles of the hand and the long flexors of the
    wrist and fingers affected, grasp reflex is
    absent and tendon reflexes are present,
    ipsilateral Horner, delayed pigmentation of the
    iris- sensory deficit-ulnar
  • Paralysis of the entire arm- all reflexes
    absent,flaccid, sensory deficit up to shoulder

Eval and Therapy
  • Thorough physical-palpate sternomastoid,
    fractures of clavicle, humerus or ribs
  • Abdominal asymmetry- indicate paralysis of
    hemidiaphragm, ocular asymmetry- Horner syndrome
  • CT, MRI or myelography for avulsions
  • Electromyography is unreliable in predicting
    extent of damage
  • Exercises involving shoulder rotation,elbow
    flexion and extension, wrist flexion, thumb
    abduction,adduction and opposition

  • Infant evaluated every month and if no
    improvement in deltoid, biceps and triceps
    function occurs by 3rd month, good outcome
    without surgery is not likely
  • Primary brachial plexus exploration during the
    fourth month
  • Exploration,evaluation and repair of the injury
    has resulted in 90 of patients having useful
    function above the elbow
  • Function below the elbow has resulted in 50 to
    70 recovery

Phrenic nerve paralysis
  • Difficult breech delivery
  • Recurrent episodes of cyanosis, irregular and
    labored respirations
  • Breathing is almost completely thoracic, no
    bulging of the abdomen, excursions on the
    involved side are ineffectual
  • Areas of atelectasis appear bilaterally
  • US shows abnormal motion of the diaphragm
  • Fluoroscopy only for the equivocal case

  • O2 for cyanosis or hypoxemia, IV fluids, gavage
    feedings, antibiotics are indicated if pneumonia
  • If bilateral, assisted ventilation shortly after
  • Infants who did not recover diaphragmatic
    function within 30 days did not demonstrate
    recovery-disruption of the phrenic nerve
  • Candidates for plication of the diaphragm early
    in the 2nd month of life

Injuries to spine and spinal cord
  • Result from breech deliveries, brow and face
  • High cervical-Stillborn, respiratory depression,
    shock, hypothermia
  • Upper or mid-cervical region-flaccidity and
    immobility of the lower limbs, cardiac function
    is strong, urinary retention may be the first
    symptom, paralysis of the abdominal wall,
    intercostal muscles may be affected , sensation
    is absent over the lower half of the body, absent
    DTR, constipation, brachial plexus involved in

Spinal cord injuries
  • 3rd group-C7-T1- survive for long periods,
    transient paraplegia, skin is dry and scaly,
    muscle atrophy, contractures and bony
    deformities, bladder distention and constant
    dribbling followed by paraplegia in flexion,
    spontaneous micturition, mass reflex and profuse
    sweating over the involved part of the body
  • 4th group- partial spinal cord injury and CVA.
    subtle neurologic signs of spasticity- cerebral

  • Infants affected at birth require basic
    resuscitative measures
  • In case of vertebral fracture-immediate
    neurosurgical consultation for reduction and
    relief of cord compression, followed by
    appropriate immobilization
  • Position of paralyzed parts should be changed
    every 2 hrs, indwelling urinary catheter should
    be inserted
  • Urology consult

Injuries to intra-abdominal organs
  • Rupture of the liver- large infants, IDM,breech
  • May appear normal from 1-3 days of life, any
    infant with shock, abdominal distension, pallor,
    anemia, and irritability with no evidence of
    blood loss
  • Crit and hgb stable initially, then sudden
    circulatory collapse, with rupture of the
    hematoma through the capsule
  • Abdomen is rigid, bluish discoloration of the
    overlying skin. CT scan may help in diagnosing
    subcapsular hematoma

  • Prompt transfusion of prbcs and correction of
    coagulation disorder
  • Laparotomy with evacuation of the hematoma and
    repair of any lacerations
  • Any fragmented, devitalized liver tissue should
    be removed
  • Blood transfusion and the tamponade of
    intra-abdominal pressure might be adequate
    therapy in some infants

Rupture of the spleen
  • Large infants in breech position,
    erythroblastosis, congenital syphilis
  • Underlying clotting defect
  • Clinical signs of hemoperitoneum and blood loss
  • Left upper quadrant mass and medial displacement
    of the gastric bubble
  • Packed rbcs and exploratory laparotomy
  • Attempt to repair and preserve the spleen

Adrenal hemorrhage
  • Increased size and vascularity at birth
  • Macrosomic, IDM, cong syphilis, neuroblastoma,
    hemorrhagic disease
  • Fever, tachypnea, cyanosis, mass in flank and
  • Adrenal insufficiency, poor feeding, vomiting,
    uremia, convulsions and shock
  • US- initially solid appearance then cystic
  • Blood , IVF and corticosteroids
  • Laparotomy, evacuation of clots if extends to
    peritoneal cavity
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