clinical teaching birth injuries
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BIRTH INJURIES
Introduction:
As a result of the birth process ,some injuries occur that may be minor, where as others may be
more serious. Parental reaction to any injury sustained by their newborn infant at birth may be
out of proportion to the harm that has occurred.
Birth injuries:
It is defined as those sustained during Labour and delivery. Birth injuries may be severe enough
to cause neonatal
death , still birth or number of morbidities.
Risk factors:
Maternal
Primiparity
Short stature
Maternal pelvic anomalies
Prolonged or extremely rapid labour
Oligohydramnios
Deep transverse arrest of descent of presenting part of the fetus
Foetal
fetal head
Foetal anomalies
Interventional/ inorganic
Versions& extractions
Types of birth trauma and management
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HEAD & NECK INJURIES
1. Associated with foetal monitoring
Fetal scalp blood sampling for the estimation of PH- heomorrhage and infection
Foetal scalp electrode for FHR monitoring
2. Cephal hematoma
Definitipon: Subsperiosteal collection of blood secondary to rupture of blood vessels between
the skull and periosteum; its extent is well delineated by the suture line over few days
Complication:
Resolution: Very slow resorption
Management:
hyperbilirubinemia and infection
Rule out bleeding disorders
4. Caput Succedaneum
Definition: Serosanguinous , subcutaneous, extraperitoneal fluid collection with poorly defined
margins, it may extend across the midline & over the surface line and is usually associated with
head moulding.
Complications:
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alopecia
5. Vacuum
Resolution:
Slow resolution
5. Vacuum caput:
Definition : Serosanguiness fluid collection well defined by the position of the vacuum extractor
on the scalp
Complications
bilirubinemia are very rare, local infection with scalp abrations andlacerations
Resolution:With in few hours after birth
Management:
Treatment for blood loss, hyperbilirubinemia and infection
Rule out bleeding disorders
6. Intracranial haemorrhages:
i. Subependymal haemorrhage- IVH
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Clinical features: Due to blood loss- shock, pallor , respiratorty distress , DIC, jaundice, bulging
ant. frontanel, excessive somnolence,, hypotonia, weakness , seizures, temperature instability,
brain stem signs( apnoea, lost extra ocular movements, facial weakness)
Investigation:
Others- ABC, Haematocrit- low , thrombocytopenia, prolonged PT, PTT& hyper
bilirubinemia
Complications:
Post hemorrhagic hydrocephalus
Management:
- to maintain temperature, oxygen, & humidity
cally active agents,
haemorrhagic hydrocephalus
ii. Posterior fossa haemorrhage
Clinical features:
Bulging frontanel, increasing head circumference, lethargy, irritability
Investigations:
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Management:
open surgical evacuation of the clots
in the patient with neurologic symptoms
iii. Ant. fossa haemorrhage
Clinical features:
Neurological manifestations- focal neurological signs, irritability , lethargy, focal seizures,
hemiparesis, gaze preferences, sixth nerve dysfunction, 3rd nerve compression- dilated and
poorly reactive pupil
Investigation:
Complication: Hydrocephalus rarely
Management:
-anticonvulsants, blood loss correction
Nursing consideration:
Vigilant observation of the baby for possible associated complications such as infection or
rarely blood loss and hypovolemia
7. Skull fractures
Bones involved- Frontal, parital, occipital
complications:
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Management:
ray and CT scan for diagnosis
- observation
- neurological evaluation
- rays at 8-12 weeks to look for growing fractures
8. Facial mandibular fractures
Features:
Dislocation of the cartilaginous nasal septumComplications:- craniofacial malformations, ocular, respiratory
& mastication problems
Management:
CT scan
Nursing considerations:
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9. Ocular injuries
Types:
a. retinal and subconjunctival haemorrhages- vaginal delivery
b. ocular and periorbital injuries- forceps delivery
c.
d. HYphaema, Vittreous haemorrhage
e. local lacerations
f. palpebral oedema
g. orbital fractures with abnormal extra ocular muscle function
h. lacrimal gland / duct damage
Management:
10. Ear injuries
Types:Haematoma of the external pinna- Cauliflower ear
- refractory perichondritis
- Haemotympanum & ossicular disarticulation
Management:
11. Sternocledomastoid (SCM )muscle injury
Pathology:
Injury to the SCM muscle/ fascia disruption during delivery
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haematoma formation
Torticollis
Management:
Nursing Management:
Tilting the head away from the affected side so that the ear can be brought into contact with
the opposite shoulder
Rotating the chin towards the tight SCM muscle. When head is in the stretched position , it
should be held there for about 10 seconds
The exercise should be done 4-6 times in a day with about 20 repetitions of each exercise at
each time.
The infant is positioned in the crib sothat the head is supported by sandbags in the corrected
positions. This is done to prevent the flattening of the occiput or the development of facial
asymmetry
looks towards the side of the tight muscle.
aches for them
B. CRANIAL NERVE , SPINAL CORD & PERIPHARAL NERVE INJURIES
Commonly associated with breech deliveryCause- Hyper extension , traction,& over stretching with simultaneous rotation
Types- Localized neurapraxia to complete nerve and cord transaction
1. Cranial nerve injuries
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i. Facial nerve injury
Cause:Compression by the forceps blades
Clinical features:
- Assymmetrical crying facies, mouth drawn to normal side, wrinkles are
more on the normal side, forehead and eyelid unaffected, nasolabial fold is absent on the
affected side , corner of the mouth droops on the affected side
Peripheral nerve injury:- Asymmetrical crying facies
Peripharal nerve branch injury- asymmetrical crying facies, paralysis limited to forehead, eye
or mouth
Mangement:
Protection of open eye- patches and synthetic tears 4th hourly
Nursing management:
by NG tube in order to prevent aspiration
ii. Recurrent laryngeal nerve injury
Clinical Feature;
Unilateral abductor paralysis(hoarse cry, respiratory stridor)
- Severe respiratory distress, asphyxia
Management:
Unilateral paralysis-small frequent feed to minimize risk of aspiration
l paralasis- intubation may be required
2. Spinal cord injuries
Cause:
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Clinical feature:
Low APGAR score
Motor function absent distal to the level of injury with loss of deep tenden reflexes
Management:
Neurological examinations and cervical spinal Xrays
T scan, myelogram, MRI if required
3. Cranial nerve root injuries
i. phrenic nerve palsy(C3, 4, & 5)
Unilateral and associated with brachial plexus injuries
Clinical features:
Respiratory distress ipsilaterally diminished breath sounds
Management:
USG/Fluroscopic studies- Paradoxical movements of the diaphragm
Refractory cases- diagphramatic placation, phrenic nerve pacing
Nursing management:
oxygen is given as necessary
improves
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may complicate the infants
condition
ii. Injuries to Brachial plexus
Clinical features:
Duchenne Erb paralysis(C5-6):
Affected arm in adducted and internally rotated with elbow extended (Waiters tip position)
The limb falls limply to the side of the body when passively adducted
Klumpkes paralysis (C7& T1)
intrinsic muscles of the hand are affected & grasp is absent( claw Hand)
the entire arm is flaccid , all reflexes are absent
Complications
Management:
Xray studies to rule out bony injury, chest examination to rule out diagphragmatic
involvement
-10 days( After resolution of the nerve edema)
Recovery:
-2 wks normal function
permanent deficit
Nursing Management:
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nonparalysed muscles cannot exert pull on the affected muscles
degrees and rotate internally at the shoulder with the elbow flexed so that the palm of the
hand is turned towards the head
neutral position and the hand is placed over a small pad
immobilization may be necessary for some infants.
-10 days , complete ROM exercises may be given gently several times each day inorder
to maintain muscle tone and prevent contraction deformity
Before or splint or brace is obtained , the nurse can pin the infants long shirt sleeve to the
mattress covering
coldness or discolouration and the skin for signs of irritation
be taught how to apply it properly and how to
provide the skin care
- affected hand first and on removingthe unaffected hand first
More physical contact and affection than normal child
C. BONE INJURIES
Common in breech delivery & shoulder dystocia in macrosomic infants
Cause: limb traction and rotation
1. Clavicular fracture
Most common injury
Clinical features:
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Palpable bony irregularity & sternocledomastoid muscle spasm
Management:
- ray studies of the chest, shoulders and cervical spine
2. Long bone injuries
Bones : Hemurus, femur
Clinical features:Swelling, crepitus and pain
Complication :injury to nerve in vicinity
Management :Splinting ; closed reduction & casting if required
3. Epiphyseal displacement
Cause :Rotation with strong traction
Clinical features:swelling, crepitus, pain
Management :X- ray not very useful as epiphyses are not ossified at birth Limb immobilization
for 10-14 days allows callus formation
D. INTRAABDOMINAL INJURIES
Types : Rupture/ Subscapular haemorrhage into liver spleen or adrenal gland
Clinical features:Abdominal distension, pallor, poor feeding, tachycardia, tachypnoea, shock etc
Management :Clinical examination and serial determinations of the haematocrit levels
-Abdominal USG
- Paracentesis in case of intraperitoneal bleeding
E. SOFT TISSUE INJURIES:
1) Patechiae and echymosis
eous resolution in 1 week.
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- Anemia; hyperbilirubinemia
2) Abrations And laceration
3) Subcutaneous fat necrosis
Clinical features :Appear in first two weeks of life Irregularly shaped , hard , non pitting,
subcutaneous plaque with overlying dusky, red purple discolouration
Sites :Cheeks, arms, back , buttocks, thighs
PREVENTION OF BIRTH INJURIES IN NEWBORN
A comprehensive antenatal and postnatal care is key to the success in the reduction of birth
trauma.
Antenatal Period:
the at risk babies
Intranatal period:
Normal delivery:
Preterm delivery:
Forceps delivery:
- LSCS
Ventouse delivery:
Vaginal breech delivery:
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Conclusion:
Since many of the birth injuries do not require treatment , the nurse can help to clear up the
misconceptions and alleviate anxieties by simple explanations.Assisting the parents to cope
with the more serious injuries requires more through explanations and constant support by
members of the health team.
Bibliography:
1. Wong D.L etal . Essentials Of Paediatric Nursing. 6th edition. Missouri: Mosby;2001
2. Marlow D.R. Redding B. Textbook of Paediatric nursing. 1st edition.Singapore: Harwourt Brace
& company; 1998
3. Judith S.A. Straight As in Pediatric Nursing. 2nd edition.Lippincott Williams and
Wilkins:Philadelphia; 2008
4. Parthasarathy IAP textbook of Paediatrics. 2nd edition. jaypee: NewDelhi; 2002
5. Hatfield N.T. Broadribbs introductory Paediatric nursing. 7th edition. Wolters Kluwer: New
Delhi; 2009
6. D.C Dutta. Textbook Of Obstetrics including Perinatology & Contraception. 6th edition. Central
Publication; Culcutta: 2004
7. Meharban Singh . Care of Newborn . 6th
edition. Published by Narinder K. Sagar; NewDelhi:2004