Fetal Birth Injuries and Intracranial Hemorrhage

Definition
The term birth injury is used to denote:
avoidable and unavoidable
mechanical, hypoxic and ischemic injury
affecting the infant
during
labor and delivery.

Definition
• Birth injuries may result from :
1.Inappropriate or deficient medical
skill or attention.
2.They may occur, despite skilled
and competent obstetric care.

Incidence
Has been estimated at 2-7/1,000 live births.
Predisposing factors:
1. Macrosomia,
2. Prematurity,
3. Cephalopelvic disproportion,
4. Dystocia,
5. Prolonged labor, and
6. Breech presentation.

Incidence
• 5-8/100,000 infants die of birth
trauma, and
• 25/100,000 die of anoxic injuries;
Such injuries represent 2-3% of
infant deaths.

Erythema, abrasions,
ecchymoses,
• Of facial or scalp soft tissues may
be seen after forceps or vacuum-
assisted deliveries.
• Their location depends on the
area of application of the forceps.

Subconjunctival ,retinal hemorrhages
and petechiae of the skin of the head and
neck
• All are common.
• All are probably secondary to a sudden
increase in intrathoracic pressure during
passage of the chest through the birth
canal.
• Parents should be assured that they are
temporary and the result of normal
hazards of delivery.

Molding
• Molding of the head and overriding of the
parietal bones are frequently associated
with caput succedaneum and become
more evident after the caput has receded
but disappear during the first weeks of life.
• Rarely, a hemorrhagic caput may result in
shock and require blood transfusion.

Caput succedaneum
• Diffuse, sometimes ecchymotic, edematous
swelling of the soft tissues of the scalp
involving the portion presenting during vertex
delivery.
• It may extend across the midline and across
suture lines.
• The edema disappears within the first few
days of life.

Caput succedaneum
• Analogous swelling, discoloration, and
distortion of the face are seen in face
presentations.
• No specific treatment is needed, but if
there are extensive ecchymoses,
phototherapy for hyperbilirubinemia may
be indicated.

Cephalhaematoma
• It is a subperiosteal
haematoma most commonly
lies over one parietal bone.
• It may result from difficult
vacuum or forceps extraction .

Cephalhaematoma
Management:
- It usually resolves
spontaneously.
- Vitamin K 1 mg IM is given.

Cephalohematoma
• Is a subperiosteal hemorrhage, so it is always
limited to the surface of one cranial bone.
• There is no discoloration of the overlying scalp, and
swelling is usually not visible until several hours
after birth, because subperiosteal bleeding is a slow
process.
• An underlying skull fracture, usually linear and not
depressed, is occasionally associated with
cephalohematoma.

Cephalohematoma
Cranial meningocele
is differentiated from cephalohematoma by:
1. Pulsation,
2. Increased pressure on crying, and the
3. Radiologic evidence of bony defect.
• Most cephalohematomas are resorbed within
2 wk-3 mo, depending on their size.
• They may begin to calcify by the end of the
2nd wk.

Cephalohematoma
• A sensation of central depression
suggesting( but not indicative )of an
underlying fracture or bony defect is
• Cephalohematomas
require no treatment, although
phototherapy may be necessary to
ameliorate hyperbilirubinemia.

Cephalohematoma
• Incision and drainage are contraindicated
because of the risk of introducing infection in a
benign condition.
• A massive cephalohematoma may rarely
result in blood loss severe enough to require
transfusion.
• It may also be associated with a skull fracture,
coagulopathy, and intracranial hemorrhage.

Diagnosis and Differential Diagnosis

Fractures of the skull
May occur as a result of pressure from :
1. Forceps or from
2. The maternal symphysis pubis.
3. Sacral promontory, or
4. Ischial spines.

Fracture Skull:
Usually occurs due to difficult forceps delivery.
It may be:
(1) Vault fracture:
• Usually affecting the frontal or parietal bone.
• It may be linear or depressed fracture.
• It needs no treatment unless there is intracranial
haemorrhage.
(2) Fracture base:
• Usually associated with intracranial haemorrhage.

1. Linear fractures, the most common,
cause no symptoms and require no
treatment.
2. Depressed fractures are usually
indentations similar to a dent in a Ping-
Pong ball; they usually are a
complication of forceps delivery or fetal
compression.

Depressed
fractures
Ping-Pong
ball

• Affected infants may be
asymptomatic unless there is
associated intracranial injury.
• It is advisable to elevate severe
depressions to prevent cortical
injury from sustained pressure.

• Fracture of the Occipital bone almost
causes fatal hemorrhage due to
disruption of the underlying vascular
sinuses.
• It may result during breech deliveries
from traction on the hyperextended
spine of the infant with the head fixed
in the maternal pelvis.

Intracranial Haemorrhage:
Causes:
1. Sudden compression and
decompression of the head as in
breech and precipitate labour.
2. Marked compression by forceps or in
cephalopelvic disproportion.
3. Fracture skull.

Predisposing factors:
1. Prematurity due to physiological
hypoprothrombinaemia, fragile
blood vessels and liability to
trauma.
2. Asphyxia due to anoxia of the
vascular wall .
3. Blood diseases.

Intracranial Haemorrhage Sites:
1. Subdural : results from damage to the superficial veins
where the vein of Galen and inferior sagittal sinus
combine to form the straight sinus.
2. Subarachnoid: The vein of Galen is damaged due to
tear in the dura at the junction of the falx cerebri and
tentorium cerebelli.
3. Intraventricular :into the brain ventricles.
4. Intracerebral : into the brain tissues .
• In (1) and (2) it is usually due to birth trauma,
• in (3) and (4) the foetus is usually a premature exposed
to hypoxia.

Clinical picture:
1- Altered consciousness.
2- Flaccidity.
3- Breathing is absent, irregular and periodic or gasping.
4- Eyes: no movement, pupils may be fixed and dilated.
5- Opisthotonus, rigidity, twitches and convulsions.
6- Vomiting .
7- High pitched cry.
8- Anterior fontanelle is tense and bulging.
9- Lumbar puncture reveals bloody C.S.F.

Intracranial
Haemorrhage
Investigations:
1. Ultrasound is of value.
2. CT scan is the most reliable.
3. MRI

Prophylaxis:
1. Vitamin K: 10 mg IM to the mother in late
pregnancy or early in labour.
2. Episiotomy: especially in prematures and
breech delivery.
3. Forceps delivery: carried out by an
experienced obstetrician respecting the
instructions for its use.

Intracranial Haemorrhage Treatment
1. Minimal handling, warmth and oxygen to the baby.
2. No oral feeding for 72 hours.
3. IV fluids.
4. Vitamin K 1mg IM.
5. Lumbar puncture: is diagnostic and therapeutic to relieve the
intracranial tension if the anterior fontanelle is bulging.
6. Sedatives for convulsions.
7. 60 cc. of 10% sodium chloride per rectum to relieve brain oedema.
8. 1 cc of 50% magnesium sulphate IM to relieve brain oedema and
convulsions.
9. Antibiotics : to guard against infections particularly pulmonary.

ETIOLOGY AND EPIDEMIOLOGY
Intracranial hemorrhage may
result from:
1. Birth trauma or
2. Asphyxia and, rarely, from a
3. Primary hemorrhagic disturbance or
4. Congenital vascular anomaly.

ETIOLOGY AND EPIDEMIOLOGY
• Intracranial hemorrhages often
involve the ventricles
( intraventricular hemorrhage [IVH])
of premature infants delivered
spontaneously without apparent
trauma.

CLINICAL MANIFESTATIONS
The incidence of IVH increases with decreasing
birthweight:
1. 60-70% of 500- to 750-g infants and
2. 10-20% of 1,000- to 1,500-g infants.
IVH is rarely present at birth; however,
1. 80-90% of cases occur between birth and the 3rd day .
2. 50% occur on the 1st day.
3. 20% to 40% of cases progress during the 1st wk of life.
4. Delayed hemorrhage may occur in 10-15% of patients
after the 1st wk of life.

The most common symptoms are:
1. Diminished or absent Moro reflex.
2. Poor muscle tone.
3. Lethargy.
4. Apnea.
5. Somnolence.

1. Periods of apnea,
2. Pallor, or cyanosis;
3. Failure to suck well;
4. Abnormal eye signs;
5. A high-pitched cry;
6. Muscular twitches, convulsions, decreased muscle
tone, or paralyses;
7. Metabolic acidosis; shock, and a
8. Decreased hematocrit or its failure to increase
after transfusion may be the first indications.
9. The fontanel may be tense and bulging.

DIAGNOSIS
Intracranial hemorrhage is diagnosed on
the basis of the:
1. History,
2. Clinical manifestations,
3. Transfontanel cranial ultrasonography
or
4. Computed tomography (CT), and

DIAGNOSIS
Lumbar puncture
is indicated in the presence of signs of:
1. Increased intracranial pressure or
2. Deteriorating clinical condition
to identify gross subarachnoid hemorrhage
or to rule out the possibility of bacterial
meningitis

PROGNOSIS
Neonates with:
( massive hemorrhage
associated with tears of the
tentorium or falx cerebri)
rapidly deteriorate and may die
after birth.

PREVENTION
The incidence of traumatic
intracranial hemorrhage may be
reduced by:
judicious management of
cephalopelvic disproportion and
operative delivery.

PREVENTION
Fetal or neonatal hemorrhage due to:
1. Maternal idiopathic thrombocytopenic
purpura (ITP) or
2. Alloimmune thrombocytopenia
may be prevented by maternal treatment
with:
1. Steroids,
2. Intravenous immunoglobulin, or
3. Fetal platelet transfusion.

PREVENTION
• The incidence of IVH may be reduced
by antenatal steroids and by postnatal
administration of low-dose
indomethacin.
• Vitamin K should be given before
delivery to all women receiving
phenobarbital or phenytoin during the
pregnancy.

TREATMENT
• Seizures are treated with
anticonvulsant drugs.
• Anemia-shock, requires transfusion
with packed red blood cells or fresh
frozen plasma.
• Acidosis is treated with slow
administration of sodium bicarbonate.

TREATMENT
Symptomatic subdural hemorrhage
in large term infants should be
treated by removing the subdural
fluid collection by means of a
spinal needle placed through the
lateral margin of the anterior
fontanel.

Spine and Spinal Cord
Strong traction exerted:
1. When the spine is hyperextended or
2. When the direction of pull is lateral, or
3. Forceful longitudinal traction on the trunk
while the head is still firmly engaged in
the pelvis:
(may produce fracture and
separation of the vertebrae).

• Such injuries, rarely diagnosed clinically,
are most likely to occur with shoulder
dystocia.
• The injury occurs most commonly at the
level of the 4th cervical vertebra with
cephalic presentations and
• The lower cervical-upper thoracic
vertebrae with breech presentations.

• Transection of the cord may occur with
or without vertebral fractures.
• Hemorrhage and edema may produce
neurologic signs that are not
distinguished from those of transection
(except that they may not be
permanent).

1. Areflexia,
2. Loss of sensation, and
3. Complete paralysis of
voluntary motion
Occur below the level of injury

• If the injury is severe, the infant,
(who may be in poor condition
owing to respiratory depression,
shock, or hypothermia),
May deteriorate rapidly to death
within several hours before
neurologic signs are obvious.

• The course may be protracted,
with symptoms and signs
appearing at birth or later in the
1st wk; may not be recognized for
several days.
• Constipation may also be present.

• The diagnosis is confirmed by :
Ultrasonography or MRI.
• Treatment of the survivors is:
supportive, including home
ventilation; patients often remain
permanently injured.

Brachial Plexus Palsy:

It is due to over traction on
the neck as in:
1. Shoulder dystocia.
2. After-coming head in breech
delivery.

(1)Erb's palsy:
1. It is the common, due to injury to C5
and C6 roots.
2. The upper limb drops beside the
trunk, internally rotated with flexed
wrist
(policeman’s or waiter’s tip hand).

(2) Klumpke’s palsy:
- It is less common,
- Due to injury to C7 and C8 and
1st thoracic roots.
- It leads to paralysis of the muscles
of the hand and weakness of the
wrist and fingers' flexors.

Treatment
• Support to prevent stretching of
the paralyzed muscles.
• Physiotherapy: massage,
exercise and faradic stimulation.

BRACHIAL PALSY
• Injury to the brachial plexus may
cause paralysis of the upper arm with
or without paralysis of the forearm or
hand or, more commonly, paralysis of
the entire arm.
• Approximately 45% are associated
with shoulder dystocia.

BRACHIAL PALSY
• These injuries occur in :
1.Macrosomic infants and when lateral traction
is exerted on the head and neck during
delivery of the shoulder in a vertex
presentation,
2. When the arms are extended over the head in
a breech presentation, or
3.When excessive traction is placed on the
shoulders.

ANATOMY OF THE BRACHIAL PLEXUS

1

2

3
4
5
Roots 6
9
8
Trunks
7
Cords

Nerves
1 Upper 4 Lateral 7 Ulnar
2 Middle 5 Posterior 8 Median
3 Lower 6 Medial 9 Radial

In Erb-Duchenne paralysis
• The injury is limited to the 5th and 6th
cervical nerves.
• The characteristic position consists of:
( Adduction and internal rotation of
the arm with pronation of the
forearm).
• Moro reflex is absent on the affected side

In Erb-Duchenne paralysis
• There may be some sensory impairment
on the outer aspect of the arm.
• The power in the forearm and the hand
grasp are preserved unless the lower part
of the plexus is also injured;
(the presence of the hand grasp is a
favorable prognostic sign).

Klumpke's paralysis
• Is a rarer form of brachial palsy;
• Injury to the 7th and 8th cervical nerves
and the 1st thoracic nerve produces a
paralyzed hand,
(Horner syndrome)
• If the sympathetic fibers of the 1st thoracic
root are also injured : paralyzed hand
and ipsilateral ptosis and miosis.

Klumpke's paralysis
• The mild cases may not be detected
immediately after birth.
• Differentiation must be made from :
1. Cerebral injury;
2. Fracture, dislocation, or epiphyseal
separation of the humerus;
3. Fracture of the clavicle.
MRI demonstrates nerve root rupture or avulsion

common uncommon
edema and hemorrhage Laceration

The prognosis
• Depends on whether the nerve was
merely injured or was lacerated.
• If the paralysis was due to edema and
hemorrhage about the nerve fibers,
function should return within a few
months;
• If due to laceration, permanent damage
may result.

The prognosis
• Involvement of the deltoid is usually
the most serious problem and may
result in a shoulder drop secondary to
muscle atrophy.
• In general, paralysis of the upper arm
has a better prognosis than paralysis
of the lower arm.

Treatment
• Partial immobilization and appropriate
positioning to prevent development of
contractures.
• In upper arm paralysis: the arm should
be abducted, with external rotation at the
shoulder and with full supination of the
forearm and slight extension at the wrist
with the palm turned toward the face.

Treatment
• In lower arm or hand paralysis:
the wrist should be splinted in a
neutral position and padding
placed in the fist.
• Gentle massage and range of motion
exercises may be started by 7-10 days
of age.

Treatment
If the paralysis persists without
improvement for 3-6 months:
neuroplasty, neurolysis, end-to-
end anastomosis, or nerve
grafting
offers hope for partial recovery.

PHRENIC NERVE PARALYSIS
• Phrenic nerve injury (3rd, 4th, 5th
cervical nerves) with diaphragmatic
paralysis must be considered when
cyanosis and irregular and labored
respirations develop.
• Such injuries, usually unilateral, are
associated with ipsilateral upper brachial
palsy.

• The diagnosis
is established by ultrasonography or
fluoroscopic examination, which reveals
elevation of the diaphragm on the
paralyzed side
• There is no specific treatment:
infants should be placed on the involved
side and given oxygen if necessary.


• Recovery usually occurs
spontaneously by 1-3
months; rarely, surgical
plication of the diaphragm
may be indicated.

Facial Palsy (Bell’s palsy):
- It is usually due to pressure by the
forceps blade on the facial nerve at:
1. Its exit from the stylomastoid foramen or
2. In its course over the mandibular ramus.
- It appears within 1-2 days after delivery
due to resultant oedema and
haemorrhage around the nerve.

Facial Palsy (Bell’s palsy):
Manifestations:
1. There is paresis of the facial muscles on the
affected side with:
2. Partially opened eye and:
3. Flattening of the nasolabial fold.
4. The mouth angle is deviated towards the healthy
side.
Spontaneous recovery usually occurs
within 14 days.

FACIAL NERVE PALSY
• When the infant cries, there is movement
only on the non paralyzed side of the face,
and the mouth is drawn to that side.
• On the affected side the forehead is
smooth, the eye cannot be closed, the
nasolabial fold is absent, and the corner of
the mouth drops.

FACIAL NERVE PALSY
• The prognosis depends on
whether the nerve was injured by
pressure or whether the nerve
fibers were torn.
• Care of the exposed eye is
essential.

FACIAL NERVE PALSY
• Improvement occurs within
few weeks.
• Neuroplasty may be
indicated when the
paralysis is persistent.

Other peripheral
nerves
are seldom injured in utero
or at birth except when they
are involved in fractures or
hemorrhages.

V) VISCERAL INJURIES

(Liver, spleen and kidney)
may be injured in breech
delivery which should be
avoided by holding the fetus
from its hips.

Viscera (The liver )
• The liver is the only internal organ other
than the brain that is injured with any
frequency during birth.
• The damage usually results from pressure
on the liver during delivery of the head in
breech presentations.
• Incorrect cardiac massage is a less
frequent cause.

• Hepatic rupture may result in the
formation of a subcapsular hematoma.
• The hematoma may be large enough
to cause anemia.
• Shock and death may occur if the
hematoma breaks through the capsule
into the peritoneal cavity.

• A mass may be palpable in the right upper
quadrant; the abdomen may appear blue.
• Early suspicion by means of
ultrasonographic diagnosis and prompt
supportive therapy can decrease the
mortality of this disorder.
• Surgical repair of a laceration may be
required.

Rupture of the spleen
• May occur alone or in
association with rupture of the
liver.
• The causes, complications,
treatment, and prevention are
similar.

Adrenal hemorrhage
• Occurs with some frequency, especially after
breech delivery in LGA infants or infants of
diabetic mothers.
• 90% are unilateral; 75% are right sided.
• The symptoms are profound shock and
cyanosis
• If suspected, abdominal ultrasonography may
be helpful, and treatment for acute adrenal
failure may be indicated

BONE INJURIES
These usually occur during difficult
breech delivery.
(A) Vertebral Column Injuries:
• These are fatal if associated with spinal cord
transection above C4 ,due to diaphragmatic
paralysis.
(B) Femur, Humerus and Clavicle:
• Managed by splint to the long bone and a sling for
clavicular fracture.

CLAVICLE
This bone is fractured during labor and
delivery
more frequently than any other bone;
It is particularly vulnerable when there is:
1. Difficulty in delivery of the shoulder in
vertex presentations and of
2. The extended arms in breech deliveries.

CLAVICLE
• The infant characteristically does not
move the arm freely on the affected
side;
• Crepitus and bony irregularity may be
palpated, and
• Discoloration is occasionally visible
over the fracture site.

CLAVICLE
•Treatment, consists of immobilization
of the arm and shoulder on the affected
side.
•A remarkable degree of callus develops
at the site within a week and may be
the first evidence of the fracture.
•The prognosis is excellent.

EXTREMITIES
• In fractures of the long bones,
spontaneous movement of the
extremity is usually absent.
• The Moro reflex is also absent from
the involved extremity.
• There may be associated nerve
involvement.

EXTREMITIES (Humerus)
• Satisfactory results of treatment for a
fractured humerus are obtained with
2-4 wk of immobilization
(during which the arm is
strapped to the chest).
• A triangular splint and a bandage are
applied, or a cast is applied.

EXTREMITIES
• In fracture femur : good results are
obtained with traction-suspension of both
lower extremities, even if the fracture is
unilateral;
• The legs, immobilized in a cast, are
attached to an overhead frame.
• Splints are effective for treatment of
fractures of the forearm or leg.

EXTREMITIES
• Healing is usually accompanied
by excess callus formation.
• The prognosis is excellent for
fractures of the extremities.
• Fractures in preterm infants may
be related to osteopenia

Dislocations and
epiphyseal separations
• Rarely result from birth trauma.
• The upper femoral epiphysis may be
separated by forcible manipulation of
the infant's leg, as, for example, in
breech extraction or after version.

Dislocations and epiphyseal
separations
• The affected leg shows swelling, slight
shortening, limitation of active motion,
painful passive motion, and external
rotation.
• The diagnosis is established radiologically
• The prognosis is good for the milder
injuries.

MUSCLE INJURIES
Strenomastoid injury
Due to :
• Exaggerated lateral flexion of the neck
leading to torticollis and swelling in the
muscle.
• It is usually improved within 2 weeks
but permanent torticollis may continue.

Fetal Birth Injuries and Intracranial Hemorrhage

Fetal Birth Injuries and Intracranial Hemorrhage

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