SEMINAR

BIRTH INJURIES

Submitted by, Submitted to,

Mrs Gayathri R Mrs Greeshma
Sarath
1st Year MSc Nursing Senior Lecturer
Upasana College Of Upasana College Of
Nursing Kollam Nursing Kollam

Submitted on:20.03.2019

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INTRODUCTION
Birth injuries are defined as those sustained during labour and delivery. Birth injuries
may be severe enough to cause neonatal deaths, still birth or number of morbidities.
Therefore birth injury remains an important cause of perinatal morbidity and mortality
in all countries when antenatal and intranatal care is inadequate and child birth is
supervised by untrained attendance.
CLASSIFICATION OF BIRTH INJURIES
The birth injuries are classified under the following conditions:

INTRA
INJURIES TO
CRANIAL
HEAD
INJURY

INJURY TO
INTERNAL INJURY TO
ORGAN NERVE
BIRTH
INJURIES

TRAUMA TO SKIN
AND MUSCLE
SUPERFICIAL TRAUMA
TISSUE

FRACTURES AND
DISLOCTION

HIGH RISK FACTORS

 Prolonged or obstructed labour
 Fetal macrosomia
 Cephalopelvic disproportion
 Abnormal presentation(breech)
 Instrumental delivery(forceps or ventouse)
 Difficult labour
 Shoulder dystocia
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  Inadequate maternal pelvis
 Oligohydramnios
 Fetal anomalies
 Precipitate labour
 Manipulative delivery(IPV)
TYPE OF INJURY ORGANS AFFECTED
 Soft tissue  Skin laceration, abrasions, fat necrosis
 Muscle  Sternocleidomastoid
 Nerve  Facial nerve, brachial plexus, spinal cord
 Eye  Hemorrhage : Sub conjunctiva, vitreous, retina
 Viscera  Rupture of liver, adrenal gland, spleen, testicular
 Scalp injury
 Dislocation  Laceration, abscess, hemorrhage
 Skull  Hip, shoulder, cervical vertebrae
 Intracranial  Cephal hematoma, subgaleal hematoma
 Bones  Haemorrhage: Intra ventricular, subdural arachnoid
 Fracture :Clavicle, humerus, femur, skull, nasal
bones

CAUSES OF BIRTH INJURIES

Injuries to a baby are more likely during a difficulty delivery. The difficulty of delivery
is affected by such factors as:
 The baby’s size: When a baby weighs more than eight pounds (4 kg), birth
injury becomes more likely. Similarly, premature babies (those born before 37
weeks) are susceptible to injury.
 Cephalopelvic disproportion: The size and shape of the mother’s pelvis is not
adequate for the child to be born by vaginal delivery.
 Difficult labour or child birth: Dystocia or prolonged labour.
 The baby’s position: A ‘breech birth”, where the fetus buttocks or legs are
presented first, is more likely to result in birth injury.

In mother experienced complications during a prior birth, doctors should be on

alert for possible complications during any subsequent birth.

Medical malpractice
Medical error can cause birth injuries, or can increase their severity or performance.
Medical errors which may support a malpractice action include:
 Failing to anticipate birth complications with a large baby, or in cases involving
maternal health complications.
 Failure to respond appropriately to bleeding.
 Failure to observe or respond to umbilical cord entrapment.
 Failure to respond to fetal distress (including irregularities in fetal heartbeat).
 Delay in ordering cesarean section when medically necessary.
 Misuse of forceps or a vacuum extractor during delivery.
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  Inappropriate administration of Pitocin, a synthesized hormone used to induce
or augment (speed up) labour.

Prolonged or obstructed labour

Fetal macrosomia

Cephalopelvic disproportion

Abnormal presentation

Instrumental delivery

Difficult labour

Shoulder dystocia

Precipitate labour

Manipulative delivery

*Causes of birth injuries

INTRACRANIAL HEMORRHAGE (ICH)

It is very scary when an infant suffers a birth injury, especially when it is serious.
Bleeding in the brain, also known as Intracranial Hemorrhage has been known to
affect newborns, although it is much more prevalent among premature infants.
Intracranial hemorrhage (ICH) may be-(a) External to the brain (epidural, subdural or
subarachnoid space) (b) in the parenchyma of brain (cerebrum or cerebellum) (c)
into the ventricles from sub ependymal germinal matrix or choroid plexus.
Traumatic
 Extradural hemorrhage: Usually associated with fracture skull bone.
 Subdural hemorrhage: This condition occurs when there is bleeding between
the outer and inner layers of the brain covering. Subdural hemorrhage is not
as common as it used to be, as there have been medical advancements
made in the childbirth process.

Anoxic

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  Subarachnoid hemorrhage: This term is used to describe bleeding that occurs
below the innermost area of the two membranes that cover the brain. It is the
most common type of bleeding in the skull.
 Intraventricular hemorrhage: This term describes bleeding in the normal fluid-
filled spaces, also known as ventricles, in the brain. It affects the brain tissue.

Causes
1. Preterm baby because of protection by their soft skull bones and wide
sutures.
2. Trauma: Compression and stretching in moulding.
 Excessive compression of fetal head due to contracted pelvis, occipito
posterior position, and large baby.
 Rapid compression on fetal head, breech delivery, precipitate labour.
 Upward compression as in breech delivery, face presentation.
3. Instrumental delivery.
Clinical features
 Baby cannot establish respiration himself.
 In severe cases, at birth, the infant is shocked, the eyes roll upward.
 Trunk and limbs may be rigid, the first clenched, limpness is also common.
 Difficult grunting expiration after most due to excess mucosa.
 Sometimes shallow, rapid and irregular with attack of apnea and cyanosis.
 Worried and anxious expression, eyes are widen open for long period,
starring with a knowing lock, sunken eyes, rigid neck, and spongy fontanelle.
Prevention
Comprehensive intranatal and antenatal care is the key to success in the reduction
of intracranial injuries.
 Prevent or detect intrauterine fetal asphyxia in earliest by intensive fetal
monitoring.
 Liberal episiotomy and use of forceps to deliver the premature baby minimize
the intracranial disturbances.
 Avoid traumatic vaginal delivery in preference to caesarian section.
 Difficult forceps should be avoided.
 In vaccum delivery, traction is made only after proper cephalic application.
 Extend the use of caesarian section in breech more liberally. Utmost
gentleness is to be executed in vaginal breech delivery. Never be at haste
especially during delivery of head. Forceps delivery of the after coming head
is preferable.
 Avoid prolonged and difficult labour.
Treatment and Management
1. The baby should be nursed in quiet, warm and well ventilated surrounding.
2. Maintain cleanliness of the passage, suction immediately after birth to remove
the secretion that occludes the pharynx.
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 3. Incubator nursery is preferable to supply oxygen and to maintain the
temperature and humidity.
4. If respiration is established wrap properly and keep the infant on one side
turns.
5. Restrict handling the baby. Bathing, weighing and measuring should be
withheld because it may provoke convulsions.
6. Feeding by nasogastric tube is advisable, fluid balance is too maintained, if
necessary by parenteral route.
7. Administer vitamin K 1mg intramuscularly to prevent further bleeding due to
hyoprothrombinaemia.
8. Prophylactic antibiotics is to be administered as needed.
9. Anticonvulsant may need to prevent convulsion i.e.
 Phenobarbitone 5-10mg/kg/day in divided doses at 6 hourly interval
intramuscularly.
 Phenytoin 10-15mg/kg intravenously as loading dose at the rate of
0.5mg/kg/min for maintenance dose of 5mg/kg/day with cardiac
monitoring.
 Diazepam 0.1mg/kg IM thrice daily.
10. Subdural haematoma can be aspirated through lateral angles of the anterior
fontanelle if excessive haematoma is formed. Surgical removal of clot may
needed.
11. The following equipment should be at hand.
 Suction machine
 Oxygen
 Laryngoscope
 Endotracheal tube
12. Keep close observation on:
 Vital signs Q4H as needed.
 Skin color.
 Respiration; type & regularity.
 Apex beat; type & regularity.
 Convulsion: spasm of muscles, part, duration.

INJURIES TO HEAD
The commonest site of birth injury is head, because 96% babies are delivered by
cephalic presentation. Meninges, brain and great cerebral veins are the delicate
organ of the body. Skull bone is protecting these vital organs. During the labour
process, the fetus pass through narrow birth canal. There may be change in shape
of skull due to excessive or rapid compression of fetal head during labour.
Sometimes prolonged, precipitate, difficult labour need instrumentation such as
forceps, vaccum etc. There may be pressure on the fetal head and cause intracranial
injury and hemorrhage. Few babies who are still birth or who are die during first
week of life are found to have intracranial injury. The babies who survive may have
impaired physical and mental status.

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 Cephalhematoma

Caput succedaneum

Scalp injuries

Skull fracture

CAPUT SUCCEDAENUM
A caput succedaneum is an edema of the scalp at the neonates presenting part of
the head. It often appears over the vertex of the newborns head as a result of
pressure against the mother’s cervix during labour. The edema in caput
succedaneum crosses the suture lines. It may involve wide areas of the head or it
may just be a size of a large egg.
Causes
 Mechanical trauma of the initial portion of scalp pushing through a narrowed
cervix.
 Prolonged or difficult delivery.
 Vacuum extraction.
The pressure (at birth) interferes with blood flow from the area causing a localized
edema. The edematous area crosses the suture lines and is soft. Caput
Succedaneum also occurs when a vacuum extractor is used. In this case, the caput
corresponds to the area where the extractor is used to hasten the second stage of
labour.
Signs & Symptoms
 Scalp swelling that extends across the midline and over suture lines.
 Soft and puffy swelling of part of a scalp in a newborns head.
 May be associated with increased molding of the head.
 The swelling may or may not have some degree of discoloration or bruising.
 Tends to disappear within 24-36 hours and tends to reduce to size.
Management
 Needs no treatment. The edema is gradually absorbed and disappears about
the third day of life.
 Advice not to applying pressure over caput.
 Mother is very anxious so we must explain about what it is, its causes in
simple language.
 Baby should be handled gently apply dressing on abrasions.

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  An abraded chignon usually heals rapidly if the area is kept clean, dry & is
irritated.
 Advice mother about not applying pressure over caput.
 Advice the mother that caput need no treatment and disappear within 36
hours of birth.
Complication
Jaundice results as the bruise breaks down into bilirubin.

CEPHALHEMATOMA
Cephalhematoma is a collection of blood between the periosteum of a skull bone
and the bone itself. It occurs in one or both sides of head. It occasionally forms over
the occipital bone. The swelling with Cephalhematoma is not present at birth rather it
develops within the first 24 to 48 hours after birth.
Causes
 Rupture of a periosteal capillary due to pressure of birth.
 Instrumental delivery
 Precipitate delivery
 Prolonged pressure on the head
 Cephalopelvic disproportion
Signs & Symptoms
 Swelling of the infants head 24-48 hours after birth
 Discoloration of the swollen site due to presence of coagulated blood
 Has clear edges that end at the suture lines
Management
 Observation and support of the affected part
 Transfusion and phototherapy may be necessary if blood accumulation is
significant
Complication
Jaundice
Difference between a caput succedaneum and Cephalhematoma
INDICATORS CAPUT SUCCEDANEUM CEPHALHEMATOMA

Location Presenting part of head Periosteum of skull bone

Extent of involvement Both hemisphere; crosses the Individual bone; does not
suture lines cross the suture line
Period of absorption 3 to 4 days Few weeks to month
Treatment None Support

SCALP INJURIES
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Minor injuries of the scalp such as abrasions in forceps delivery (tip of blades),
incised wound inflicted during caesarean section or episiotomy may be met with on
occasion, the increased wound may cause brisk hemorrhage and require stitches.
The wound should be dressed with an antiseptic solution. E.g. Betadine
SKULL FRACTURE
Fracture of the vault of the skull 9 frontal or anterior part of the parietal bone may be
of fissure or depressed type.
Causes
 Effect of difficult forceps delivery in disproportion or due to wrong application
of the forceps.
 Projected sacral promontory of the flat pelvis may produce depressed fracture
even though the delivery is spontaneous.
Clinical features
 The fracture may be associated with Cephalhematoma, extradural or subdural
hemorrhage or a hematoma.
 Fissure fracture if uncomplicated is usually symptom less.
 Depressed fracture may occasionally cause pressure defect.
 Neurological manifestation may occur later on due to compression effect.
Treatment and Management
Treatment is conservative in symptom less cases. In presence of symptom, the
depressed bone has to be elevated or subdural hematoma may have to be aspirated
or excised surgically.
INJURY TO THE NERVES
There are different conditions which causes injury to nerves are as follows:

Facial
palsy

Klumpk
Inuries
Brachial
e's
palsy
to palsy
nerves
Erbs
palsy

FACIAL PALSY

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It is also known as Bell’s palsy. The facial nerve may injured by direct pressure of the
forceps blades or by hemorrhage or edema around the nerve. It may occur in normal
delivery with much pressure on the ramus of the mandible where the nerve crosses
superficially. Facial nerve remain unprotected after its exit through the stylomastoid
foramen. It is involved by direct pressure of the forceps blades or by hemorrhage
and edema around nerve.
Causes
 Forceps delivery.
It may occur in spontaneous delivery when grasping the head or due pressure
is applied on the mastoid process or over the ramus of lower jaw where the
facial nerve lies superficially.
Clinical features
 There is unilateral facial weakness with the eyelid of the affected side
remaining open and mouth drawn over to the normal side.
 The paralyzed side is smooth.
 On crying the mouth is drawn to the uninjured side of the face.
 If the baby cannot form an effective seal on the nipple or treat, there may be
some initial feeding difficulties.
Management
 There is no special treatment, improve the conduction on 1 to 2 weeks.
 Protect the eyes, which remain open even during sleep, with antiseptic
ointment.
 Feeding difficulties are usually overcome by the baby’s own adaptation,
although alternative feeding position can be adopted.
 Maintain oral hygiene.
 If instrumental delivery and the baby have any injury, clean and dress with
antiseptic lotion.
 The condition usually disappears within weeks unless complicated by
intracranial hemorrhage.
BRACHIAL PALSY
The damage occur in the brachial nerve roots in the trunk of the brachial plexus due
to stretching or effusion or hemorrhage inside the nerve sheath or tearing of the
fibers. Sometimes tearing of the fiber is rare. This causes the hyperextension of the
neck during attempted delivery of shoulder dystocia or even in spontaneous vaginal
delivery or during difficult breech extraction. Unilateral involvement is common. The
two common clinical types are:
1. Erb’s palsy
This is the commonest type when the 5 th and 6th cervical nerve roots are
involved. The resulting paralysis causes the arm to lie on the side with
extension of the elbow, pronation of the forearm and the flexion of the wrist.
The Moro reflex and biceps jerks are absent on the affected side. The arm is
inwardly rotated and the half closed hand turned outwards.

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 The cause of Erb’s palsy are twisted on neck in delivery of after coming head,
excessive lateral flexion of the neck when delivering the shoulder in vertex
presentation and forceps delivery.

Treatment
 Use of a splint so as to hold the arm abducted to a right angle and
externally rotated, the forearm is flexed at right angle and supinated
and the hand is dorsiflexed.
 Massage and passive movement are useful.
 Full recovery takes weeks or even months.
 Severe injury may produce permanent disability.

2. Klumpke’s palsy
It occurs due to damage of 7th or 8th cervical or 1st thoracic nerve roots. The
features are paralysis of the muscles of the forearm with wrist drop and flaccid
digits. The arm is flexed at the elbow, the wrist extended with flaccid hands
and flexed fingers. Mitosis, ptosis and anhidrosis may present due to damage
of cervical sympathetic chain of the first thoracic root.

Management
 Splinting of arm and placing of cotton ball in the baby’s hand to avoid
contractures.
 Massage and passive movement are useful.
Prognosis is usually good, but the permanent deformity may persist in severe
laceration of nerve and hemorrhage. The lesions of upper brachial plexus have a
better prognosis than those of lower or total plexus. If the paralysis persist more than
3 months, neuroplasty is indicated.
MUSCLE TRAUMA
Injuries to muscle can occur when it is torn or when its blood supply is disrupted.
Torticollis (twisted neck)
The most commonly damaged muscle is the sternomastoid muscle during the birth
of the anterior shoulder when the fetus assumes a vertex presentation of during
rotation of the shoulder when the fetus is being born by breech. This damage causes
torticollis, which means twisted neck.
Torticollis presents as a small lump over the sternomastoid muscle on the affected
side of the neck. The lump consist of blood and fibrous tissue and appears to the
painless for the baby.
Stretching of the muscle can be achieved by lying the baby to sleep on the
unaffected side and by using muscle stretching exercise under the guidance of a
physiotherapist. The swelling will resolve over several weeks.
Sternomastoid Hematoma (tumor)
It appears about 7-10 days after birth and is usually situated at the junction of upper
and middle third of the muscle. It is caused by rupture of the muscle fibers and blood
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vessel, followed by a hematoma and cicatrices contraction. It is associated with
difficult breech delivery or attempted delivery following shoulder dystocia or
excessive lateral flexion of the neck even during normal delivery. Gentle movements
with stretching of the neck muscles carried out after feeds are helpful.
Necrosis of the subcutaneous tissues
I may occur while the superficial skin remain intact. After a few days, a small hard
subcutaneous nodule appears. It is the resultant of the fat necrosis due pressure,
and takes many weeks to disappear. No treatment is required and it has no clinical
importance.

FRACTURES
a. Skull Fractures ( see under injuries to head )
b. Spine Fractures
Fracture of the odentiod process or fracture dislocation of the 5 th – 6th cervical
vertebrae may occur due to acute bending of the spine while delivering the
after coming head, the result is instantaneous death of the baby due to
compression on the medulla.
c. Long Bone Fractures
 Bones commonly involved in fractures are humerus, clavicle and femur.
 These occur in breech delivery.
Fractures are usually of greenstick type but may be complete.
 Rapid union occurs with callus information.
 Deformity is a rarity even where the bone ends are not in good aligment.
Treatment
 In clavicle fracture: A pad of cotton or wool is placed in the axilla and the
upper arm is lightly bandaged to the side of the chest.
 In fracture Femur: The whole length of the affected limbs may be
bandaged to the front of the abdomen or may be flexed by a posterior cast
or treated by vertical extension by fastering the baby’s ankles to the
crossbar placed above the cot. Healing usually occurs in about 3 weeks.
 Fracture of the humerus is treated by bandagining the arm to the side of
the chest.
DISLOCATION
The common site of dislocations of joints are shoulder, hip, jaw and 5-6 th cervical
vertebrae. Conformation is done by radiology and the help of an orthopedic surgeon
should be sought.

DEVELOPMENTAL DISLOCATION OF HIP

The hip is a "ball-and-socket" joint. In a normal hip, the ball at the upper end of
the thighbone (femur) fits firmly into the socket, which is part of the large pelvis
bone. In babies and children with developmental dysplasia (dislocation) of the hip
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(DDH), the hip joint has not formed normally. The ball is loose in the socket and
may be easy to dislocate.

Although DDH is most often present at birth, it may also develop during a child's
first year of life. Recent research shows that babies whose legs are swaddled
tightly with the hips and knees straight are at a notably higher risk for developing
DDH after birth. As swaddling becomes increasingly popular, it is important for
parents to learn how to swaddle their infants safely, and to understand that when
done improperly, swaddling may lead to problems like DDH.

In all cases of DDH, the socket (acetabulum) is shallow, meaning that the ball of
the thighbone (femur) cannot firmly fit into the socket. Sometimes, the ligaments
that help to hold the joint in place are stretched. The degree of hip looseness, or
instability, varies among children with DDH.
 Dislocated. In the most severe cases of DDH, the head of the femur is
completely out of the socket.
 Dislocatable. In these cases, the head of the femur lies within the
acetabulum, but can easily be pushed out of the socket during a
physical examination.
 Subluxatable. In mild cases of DDH, the head of the femur is simply
loose in the socket. During a physical examination, the bone can be
moved within the socket, but it will not dislocate.
Cause
DDH tends to run in families. It can be present in either hip and in any individual. It
usually affects the left hip and is predominant in:
 Girls
 Firstborn children
 Babies born in the breech position (especially with feet up by the
shoulders). The American Academy of Pediatrics now recommends
ultrasound DDH screening of all female breech babies.
 Family history of DDH (parents or siblings)
 Oligohydramnios (low levels of amniotic fluid)
Symptoms
Some babies born with a dislocated hip will show no outward signs.

Contact your pediatrician if your baby has:

 Legs of different lengths

 Uneven skin folds on the thigh
 Less mobility or flexibility on one side
 Limping, toe walking, or a waddling gait
Treatment
When DDH is detected at birth, it can usually be corrected with the use of a
harness or brace. If the hip is not dislocated at birth, the condition may not be
noticed until the child begins walking. At this time, treatment is more complicated,
with less predictable results.
Nonsurgical Treatment
Treatment methods depend on a child's age.

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Newborns. The baby is placed in a soft positioning device, called a Pavlik
harness, for 1 to 2 months to keep the thighbone in the socket. This special
brace is designed to hold the hip in the proper position while allowing free
movement of the legs and easy diaper care. The Pavlik harness helps tighten the
ligaments around the hip joint and promotes normal hip socket formation.

Parents play an essential role in ensuring the harness is effective. Your doctor and
healthcare team will teach you how to safely perform daily care tasks, such as
diapering, bathing, feeding, and dressing.

1 month to 6 months. Similar to newborn treatment, a baby's thighbone is

repositioned in the socket using a harness or similar device. This method is usually
successful, even with hips that are initially dislocated.

How long the baby will require the harness varies. It is usually worn full-time for at
least 6 weeks, and then part-time for an additional 6 weeks.

If the hip will not stay in position using a harness, your doctor may try an abduction
brace made of firmer material that will keep your baby's legs in position.

In some cases, a closed reduction procedure is required. Your doctor will gently
move your baby's thighbone into proper position, and then apply a body cast (spica
cast) to hold the bones in place. This procedure is done while the baby is under
anesthesia.

Caring for a baby in a spica cast requires specific instruction. Your doctor and
healthcare team will teach you how to perform daily activities, maintain the cast, and
identify any problems.

6 months to 2 years. Older babies are also treated with closed reduction and spica
casting. In most cases, skin traction may be used for a few weeks prior to
repositioning the thighbone. Skin traction prepares the soft tissues around the hip for
the change in bone positioning. It may be done at home or in the hospital.
Surgical Treatment
6 months to 2 years. If a closed reduction procedure is not successful in putting the
thighbone is proper position, open surgery is necessary. In this procedure, an
incision is made at the baby's hip that allows the surgeon to clearly see the bones
and soft tissues.

In some cases, the thighbone will be shortened in order to properly fit the bone into
the socket. X-rays are taken during the operation to confirm that the bones are in
position. Afterwards, the child is placed in a spica cast to maintain the proper hip
position.

Older than 2 years. In some children, the looseness worsens as the child grows and
becomes more active. Open surgery is typically necessary to realign the hip. A spica
cast is usually applied to maintain the hip in the socket.
Recovery
In many children with DDH, a body cast and/or brace is required to keep the hip
bone in the joint during healing. The cast may be needed for 2 to 3 months. Your
doctor may change the cast during this time period.
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X-rays and other regular follow-up monitoring are needed after DDH treatment until
the child's growth is complete.

Complications
Children treated with spica casting may have a delay in walking. However, when the
cast is removed, walking development proceeds normally.

The Pavlik harness and other positioning devices may cause skin irritation around
the straps, and a difference in leg length may remain. Growth disturbances of the
upper thighbone are rare, but may occur due to a disturbance in the blood supply to
the growth area in the thighbone.

Even after proper treatment, a shallow hip socket may still persist, and surgery may
be necessary in early childhood to restore the normal anatomy of the hip joint.

Outcomes
If diagnosed early and treated successfully, children are able to develop a normal hip
joint and should have no limitation in function. Left untreated, DDH can lead to pain
and osteoarthritis by early adulthood. It may produce a difference in leg length or
decreased agility.

Even with appropriate treatment, hip deformity and osteoarthritis may develop later
in life. This is especially true when treatment begins after the age of 2 years.

OTHER INJURIES

Trauma to skin and superficial tissues

Damage to the skin is often iatrogenic resulting from forceps blades, vacuum
extractor cups, scalp electrodes and scalpels. The scalp may be edematous and
bruished, if allowed to remain on the perineum for a long period. Buttocks in breech
presentation, an eyelids, lip or nose in face presentation, similarly become
edematous and congested.
The healing is perfect without leaving behind any trace of the injury. Abrasion and
laceration should be kept clean and dry. If there is any indication of infection, medical
advice should be sought and antibiotics may be required.
Injury to the internal Organs
Liver, kidney, adrenal or lungs are commonly injured mainly during breech delivery.
The most common result of the injury is hemorrhage, severe hemorrhage is fatal. In
minor hemorrhage, the baby presents features of blood loss in addition to the
disturbed function of the organ involved.
Treatment is directed
 To correct hypovolemia and anemia.
 Specific management – surgical or otherwise, to tackle the injured viscera.

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Persistent Pulmonary Hypertension of the Newborn (PPHN)
Persistent pulmonary hypertension of the newborn (PPHN) occurs when fetal
circulation does not transition to life outside the womb. Throughout pregnancy, the
placenta provides oxygen to the fetus. After birth, however, the newborn must learn
to breathe on his or her own. If this transition is unsuccessful, then the newborn may
be suffering from PPHN.
PPHN is often the result of a difficult birth, yet in many instances it arises due to
medical negligence. For example, prescription-based medications such as Zoloft,
Celexa, and Paxil have been linked to an increase in blood pressure and during
pregnancy this can place stress on the infant. Other causes include failure to treat
maternal infections, failure to detect and prevent infant asphyxia, and performing an
unnecessary C-section.

MATERNAL CAUSES OF BIRTH INJURY

PLACENTAL BIRTH INJURIES
The placenta, an organ attached to the mother’s womb while an infant is in utero,
has one of the most important functions during pregnancy. It not only supplies
nutrients to the baby, but it transfers both oxygen and blood. If there are placental
birth injuries during pregnancy, the consequences can be life-threatening, especially
if not diagnosed and treated as early as possible.
EPIDURAL BIRTH INJURIES
An epidural is a popular pain-management method used by millions of women each
year while going through the labor and delivery. In fact, an epidural is the most
common type of pain relief used during labor and delivery; more than half of all
pregnant women in the United States are given an epidural. Yet, despite its
popularity and common use, there are a variety of risks associated with epidurals
which can lead to epidural birth injuries as well as long-term maternal injuries.
An epidural, also known as epidural anesthesia, is a regional anesthesia
administered intravenously to block pain in the lower part of the body. A long needle
is typically inserted into your back, around the spinal cord area, usually after the
cervix has dilated to at least 4 centimeters. A thin catheter is threaded through the
needle, which ensures that the medication hits the epidural area and the catheter
stays in place. Once the catheter is in place, medication will fluidly disperse either
intermittently or continuously.

Types of Medications Used in Epidurals

Medications used is epidurals are known as local anesthetics, meaning medicines
used to reduce pain sensation in the targeted areas without you being fully unaware
or unfeeling of other local senses. The most common types of medications used in
epidurals include:

 Bupivacaine

 Lidocaine, or

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  Chloroprocaine

In the majority of instances, these medications are used in combinations with

narcotics or opoids to ensure maximum pain relief and to help reduce the dosage
amount of the local anesthetics.
Infant risks associated with epidurals include:

 Difficulties with breastfeeding

 Lack of oxygen, leading to more serious health problems, such as cognitive

disorders and cerebral palsy

 Brain injuries

 Infant stroke

 Coma

 Low Apgar scores

 Poor muscle tone

Medical Mistakes and Epidural Injuries

Administering an epidural must always be done by a professional anesthesiologist or
nurse-anesthetist with proper education, experience, and training. Since the area
involved is so close to the spinal cord, even a small mistake can lead to devastating
consequences. Typical reasons for epidural injuries due to medical mistakes include:

 Administering too much medication

 Administering medication the mother is allergic to

 Injecting the needle into the wrong area

 Failure to monitor maternal and fetal distress

 Administering the epidural before proper cervix dilation

 Administering an epidural to a mother who uses blood thinners or has a low

platelet counts

CESAREAN SECTION INJURIES

Cesarean sections (C-section) have increased in popularity over the past decade.
Although the numbers have remained steady during the past few years, in 2010
alone, a little over 32% of all deliveries in the United States were C-sections. There
are a myriad of reasons why C-sections are performed, but one thing each C-section
has is common in the risk of C-Section injuries, to both mother and infant.

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Common Reasons for C-Sections
As mentioned earlier, there are several reasons why a physician may feel a C-
section is the best possible delivery. Some of the most common reasons includes:

 Placental problems, including placental abruption, placental insufficiency, and

placenta previa

 Uterine ruptures, which affects 1 out of every 1,500 births

 An infant in the breech position, making normal delivery difficult

 Umbilical cord prolapse

 Fetal distress

 No progress during labor

 Having previous C-sections

 Preeclampsia

 Diabetes

 Genital herpes (active)

 An infant diagnosed with a birth defect

 Carrying twins or multiples

Risks and Birth Injuries Caused by C-Sections

Unfortunately, many birth injuries and risks occur during C-section deliveries. While
some can’t be prevented, others are a direct result of medical errors and negligence.

Fetal Lacerations
Fetal lacerations are cuts, scrapes, and other similar injuries caused to an infant that
typically occur during a C-section procedure. In most cases, fetal lacerations occur
due to improperly-performed procedures by healthcare providers. Fetal lacerations
range in severity, from mild to serious, and may lead to host of other health
conditions, including Erb’s paly, Klumpke’s palsy, fractures, cervical cord injuries, and
more.

Infant Breathing Problems

Infants are much more likely to experience breathing problems if delivered by C-
section. It’s important that babies are constantly monitored after birth as breathing
problems may lead to respiratory distress syndrome and long-term health problems.

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Delayed C-Section
In some instances, physicians fail to schedule a C-section despite the fact that the
warning signs are there. For example, fetal distress is one of the most common
reasons that C-sections are scheduled and carried out. A delayed C-section can also
be caused by failure to closely monitor the mother for distress, and in some cases,
failure to secure an operation room in time to perform the surgery.
A delayed C-section can lead to a myriad of injuries. In the most severe cases, infant
death may occur. Other consequences may include:

 Lack of oxygen, leading to infant brain damage, cerebral palsy, and/or autism

 Heightened risk of physical injuries

 Physical developmental delays

BIRTH NJURY TREATMENT

Since every birth injury is unique, it’s difficult to determine the exact treatment that
will work for each baby without a proper diagnosis. In addition, some parents may
opt to have their babies go through more traditional treatments while others may
prefer holistic, natural methods of healing. Regardless of which options you choose,
it’s important to speak with your healthcare provider beforehand to weigh out the
pros and cons of each type of treatment.

Surgery
Not all birth injuries will require surgery. However, in some instances, severe injuries
may require surgery in order for the infant to have the best chances of survival. In
other instances, surgery can determine if an infant will be able to have full use of any
injured limbs.
The most common types of birth injuries that generally require surgery include:

 Severe cases of brachial plexus injuries, when other forms of treatment, such
as physical therapy, didn’t work

 Brain hemorrhaging

 A fractured skull

Medications
A wide variety of medications are used to treat birth injuries. As with surgery, not all
birth injuries require medications. In many cases, however, medication is prescribed
for pain, seizures, cognitive disabilities, and more.
The type of medication will depend the type and severity of the birth injury. The most
common types of medication include:

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  Pain management and anti-inflammatory medications, such as aspirin and
corticosteroids

 Anti-spastic medication, such as baclofen, tazidine, and dantrolene

 Seizure medication, such as gabapentin and topiramate

 Anticholinergic medication, including trihexyphenidyl hydrochloride and

benzotropine mesylate

 Botox, to weaken injured muscles in an attempt the “catch up” the injured
muscles to the other muscles

 Stool softeners

Physical Therapy
Physical therapy is one of the most common treatment options for children who have
brachial plexus injuries, cerebral palsy (CP), shoulder dystocia, and any injury that
resulted in weakened muscles, coordination problems, lack of voluntary muscle
control, and more.
Physical therapy is a form of treatment that helps people move better, decrease pain,
and in some cases, restore physical functions. It has been shown to help children
with birth injuries have an easier time with daily tasks and activities, such as walking,
getting out of bed, eating, moving around, and playing.
Trained and licensed physical therapists who specialize in working with babies and
children will generally work diligently with their patients and their parents to help with:

 Strength and balance

 Coordination

 Flexibility

 Reducing physical limitations

 Increasing fitness, gait, and posture

Physical therapy sessions may include strength training, joint mobilization,

specialized exercises, balance ball practice, and more, depending on the child’s
condition and individualized plan. Sessions can take place in a doctor’s office, a
physical therapy center, hospitals, nursing centers, classrooms, and at home with the
trained therapist.

Hyperbaric Oxygen Therapy

In recent years, studies and research have suggested that hyperbaric oxygen
therapy (HBOT) can help reduce the symptoms associated with brain damage in
infants who experienced oxygen deprivation during childbirth. When oxygen

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deprivation occurs, babies are at a heightened risk for brain damage, especially if
there is not immediate medical intervention.
HBOT consists of placing an infant in a hyperbaric chamber that’s filled with 100%
pure oxygen. The air pressure is generally raised up to at least three times normal
air pressure, allowing the the baby to breathe in pure oxygen three times higher than
normal.
Although more research is needed to understand how effective HBOT is for infants,
there is indication that it may play an important role in treating symptoms associated
with CP and autism. However, it’s important to note that the U.S. Department of
Health and Human Services states that HBOT has not been clinically proven to treat
traumatic brain injuries and health conditions.

Neonatal Therapeutic Hypothermia

Neonatal therapeutic hypothermia is a clinical treatment that reduces an infant’s
body temperature in attempt to slow down injuries and diseases. It’s most often used
for newborn babies who are at a heightened risk of developing severe brain damage.
Neonatal therapeutic hypothermia works by placing the infant in a cooling blanket.
The temperature of the blanket is lowered significantly so that the infant’s entire body
temperature is lowered. The therapy usually takes place in a neonatal intensive care
unit.
By reducing the baby’s temperature, research suggests that it will help reduce the
chances of severe brain injury development.
“We have found that therapeutic hypothermia can reduce the chance of severe brain
injury by 25 percent in term-born babies with poor transition or low Apgar scores
after birth”.

Occupational Therapy
Occupational therapy is a form of treatment that focuses on helping children with
cognitive, physical, and sensory disabilities. Occupational therapists who specialize
in working with children with disorders and disabilities focus on a variety of
treatments, including:

 Developing fine motor skills

 Learning basic skills tasks such as brushing teeth and hair

 Developing positive behavior

 Reducing outbursts and impulsiveness

 Improving focus skills and social skills

 Developing and improving hand-eye coordination

 Assisting with learning disabilities

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Occupational therapy can take place in a myriad of settings, including hospitals,
special education classrooms, at-home sessions, rehabilitation facilities, mental
health centers, doctor’s offices, outdoor camps, and more.

PREVENTION OF INJURY IN NEWBORN BABY

The comprehensive antenatal and intranatal care is the key to success in reduction
of birth trauma and consequently in the reduction of perinatal morality and neonatal
morbidity.
Antenatal periods
 Screen out the risk babies.
 Employ liberal use of C/S, malpresentation should be included and
manage accordingly.
Intranatal Period
a. During normal delivery
 Continuous fetal monitoring to detect fetal distress, extract baby before he
become compromised. This can prevent traumatic cerebral anoxia.
 Episiotomy is to be done carefully after placing two fingers in between the
head the stretched perineum to prevent injury to the scalp.
 The neck should not be unduly stretched while delivering the shoulders to
minimize injuries to the brachial plexus or sternomastoid.
b. Special care in preterm delivery
 Prevent anoxia.
 Avoid strong sedation.
 Liberal episiotomy and use of forceps to minimize intracranial
compression.
 Administer vitamin K 1mg intramuscularly to prevent or minimize
haemorrhage from the traumatized area.

c. Forceps delivery
 Difficult forceps are to be withheld in preference to the safer caesarean
section.
 Never apply traction unless the application is a correct one.
d. Ventouse delivery
 It is relatively less traumatic, but it should be avoided in preterm babies.
e. Vaginal breech delivery

 To prevent intracranial injury

 The crucial period in breech delivery is during delivery of the after –
coming head.
 Never be in haste during delivery of the head which find little time to
mould.
 Episiotomy should be done as a routine to minimize head compression.
 Controlled delivery of the head by forceps is preferable.

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  To prevent spinal injury
 Acute bending at the neck is to be prevented while forceps are being
applied to the after coming head or delivery of the bead by Burn’s Marshall
Techniques.

 To prevent injury to the brachial plexus and sternomastoid muscle

 The trunk should not be pulled to one side as to cause too much stretching
to the neck.

 To prevent fracture – dislocation and visceral injuries

 The limbs are delivered in a manner described in breech delivery.
 Rotating the trunk by grasping the thoracic cage not only prevents fracture
of the head by jaw flexion is preferably and shoulder traction, the flexion is
preferably achieved by placing the fingers over the molar prominences.

CONCLUSION
The incidence of birth injuries has dramatically decreased in the last 2 decades. Erb
palsy is the most common brachial plexus injury, and management should include
close follow-up evaluation and physical therapy until 3 to 4 months of age. Shoulder
dystocia is a major risk factor for brachial plexus injury. The birth of a baby is a
complex medical event that carries with it great risk and the possibility of
infant injury. Sometimes trauma to a baby during labor or delivery is unavoidable.
Unfortunately, too often birth injuries are caused by medical mistakes.

BIBLIOGRAPHY
 Nima Bhaskar, Text book of midwifery and obstetrics, EMMESS medical
publishers, 1st edition.
 D.C Dutta, Text book of obstetrics and gynecology, New central agency, 6 th
edition.

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  Wongs;Merilyn,Essentials of Pediatric Nursing,8 th edition,Elsievier Publication.
 Rimple Sharma, Essentials of Pediatric Nursing,2 th edition,Jaypee Brothers
Medical Publishers.
 Manoj Yadav,A Text Book Of ChildhealthNursing,2011 edition,Choice books &
printers (P) ltd.

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