Birth Injuries-Excluding Scalp and Intracranial Injuries

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Birth Injuries-Excluding Scalp and Intracranial
Injuries

• Adapted from a presentation by Vandana Nayal

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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

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Prognosis

• 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

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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

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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.

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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

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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

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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

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Treatment

• 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

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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

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Treatment

• O2 for cyanosis or hypoxemia, IV fluids, gavage
  feedings, antibiotics are indicated if pneumonia
  occurs
• If bilateral, assisted ventilation shortly after
  delivery
• 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

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Injuries to spine and spinal cord

• Result from breech deliveries, brow and face
  presentations
• 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
  20

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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
  palsy

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Treatment

• 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

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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

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Treatment

• 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

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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

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Adrenal hemorrhage

• Increased size and vascularity at birth
• Macrosomic, IDM, cong syphilis, neuroblastoma,
  hemorrhagic disease
• Fever, tachypnea, cyanosis, mass in flank and
  purpura
• 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