guslihan dasa tjiptaguslihan dasa tjipta division of...

Guslihan Dasa TjiptaGuslihan Dasa TjiptaDivision of Perinatology

Department of Child Health Medical SchoolUniversity of Sumatera Utara

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Predisposing FactorsPredisposing FactorsMaternal factors:

Primigra idaPrimigravida Cephalopelvic disproportion,

small maternal stature maternal pelvic anomalies

Prolonged or rapid labor DystociaDystocia Oligohydramnios

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Predisposing factorsPredisposing factorsF t l f tFetal factors:

Abnormal presentation Breech, face

VLBW or extreme prematurity p yFetal macrosomia Large fetal headLarge fetal head Fetal anomalies

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Predisposing FactorsPredisposing Factors

Ob t t i l I t tiObstetrical Interventions:Use of mid-cavity forceps or vacuum extraction Versions and extractions

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Types of InjuryTypes of Injury

Soft tissue injuriesHead and Skull Face Musculoskeletal injuriesMusculoskeletal injuries Intra-abdominal injuries Peripheral nerve injuries

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Soft Tissue InjuriesSoft Tissue Injuries

E th & Ab iErythema & Abrasions- Forceps, Dystocia

Petechiae-head/neck/chest/back- Cord around neck /breech- thrombocytopeniay p

Ecchymosesbreech/prematurity

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-breech/prematurity

Soft Tissue InjuriesSoft Tissue InjuriesLacerations

l b tt k thi hscalp, buttocks, thighs(Fetal scalp electrodes, surgeons knife!)Infection a risk, but most heal uneventfullyManagement:

careful cleaning, application of antibiotic ointment and observationointment, and observation Bring edges together using Steri-Strips Lacerations occasionally require suturing

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Soft Tissue InjuriesSoft Tissue InjuriesSubcutaneous fat Necrosis (SFN)

N t ll d t t d t bi thNot usually detected at birthIrregular, hard, non-pitting, subcutaneous plaques with overlying dusky red-purple p q y g y p pdiscoloration on the extremities, face, trunk, or buttocks May be caused by pressure during deliveryMay be caused by pressure during deliveryHypothermia/ischemia/asphyxiaappear @ 6-10 dayspp @ yresolve @ 6-8 wk/atrophySometimes calcifies

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Soft Tissue InjuriesSoft Tissue Injuries

SFN: TreatmentSFN: TreatmentTreat symptomatic hypercalcemia

i laggressivelyincreased fluid intakelow calcium/ vit. D dietfurosemide -calcium-wasting diureticSteroids-inhibit metabolism of vit. DBiphosphonates-reduce bone resorption

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Injuries to the HeadjCaput Succedaneum

most frequently observed lesionmost frequently observed lesionpressure on the scalp against cervixsubcutaneous extraperiosteal accumulation ofsubcutaneous, extraperiosteal accumulation of blood/serumpresenting part involvedpresenting part involvedoverlying bruising/Petechiaecrosses suture linescrosses suture linesresolves within days

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Injuries to the HeadInjuries to the HeadCephalhematomap

0.4%-2.5% of all live birthssub-periosteal hemorrhage from rupture of blood p g pvessels between the skull and the periosteumbuffeting of fetal head against the pelvisg g pno extension across suture linesmost commonly parietal, may occasionally be y p , y yobserved over the occipital bone

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Injuries to the HeadInjuries to the Head

CephalhematomaCephalhematomaincreases in size with time 15% bilateral18% associated skull fractureForcepsVacuumVacuum

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Injuries to the Headj

Subgaleal HemorrhageSubgaleal HemorrhageDiagnosis is generally clinical:

fluctuant boggy mass developing over the scalp ggy p g p(especially over the occiput) develops gradually 12-72 hours after deliveryhematoma spreads across the whole calvarium Usually insidious and may not be recognized for hhoursswelling may obscure the fontanelle and cross suture lines (distinguishing it from

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suture lines (distinguishing it from cephalhematoma)


Subgaleal HemorrhageSubgaleal HemorrhageRx if signs of substantial volume loss:

compression wrap restore blood volumerestore blood volumesurgical drainage25% mortality25% mortality

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Caput Succedaneum

Cephalhematoma

Subgaleal hemorrhage with skull fractureSubgaleal hemorrhage with skull fracture

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SkinEpicranial aponeuroses

Caput CephalhematomaSubgaleal hemorrhageaponeuroses

Periosteumextradural hemorrhage

Skull

DDura

Lesion External swelling ↑ after birth

Crosses suture lines

↑↑↑acute blood losslines loss

Caput succedaneum Soft, pitting No Yes NoCephalhematoma Firm tense Yes No No

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Cephalhematoma Firm, tense Yes No No

Subgaleal hematoma Firm, fluctuant Yes Yes Yes


Skull FracturesSkull FracturesUncommon because of compressible skull & opensuturesForceps/Prolonged laborLinear/DepressedUsually asymptomaticAssociated intracranial hemorrhage may produce

symptoms

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Injuries to the HeadInjuries to the HeadSkull FracturesRx – conservative

- elevation of depressed fractureelevation of depressed fracture- Thumb pressure- Hand pumpHand pump- Vacuum extractor

Surgical elevationSurgical elevationHealing within a few months

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Injuries to the HeadInjuries to the HeadIntracranial hemorrhage

- Subdural/Subarachnoid/IVH- Subdural/Subarachnoid/IVH- Usually asymptomatic

F /V- Forceps/Vacuum- Prolonged labor

U ll i t d ith f t- Usually associated with fracture

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Subarachnoid hemorrhagef t th li d-more frequent than realized

-usually asymptomatic-may cause seizures (day 2-3)-bloody CSF- CT/MRI

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Injuries to the Head

Subdural Hematoma- may be silent for several daysmay be silent for several days-↑head circumference- poor feeding /vomiting /lethargypoo eed g / o t g / et a gy- altered consciousness/seizures - DX- CT/MRI- RX- Subdural taps/surgical drainage

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Fractures of Facial bonesFractures of Facial bones-nasal fracture/dislocation-deviated nasal septum-maxillary fracture-mandibular fracture

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EYE INJURIESEYE INJURIES

Eye Lidsedema/ecchymoses/lacerationSubconjuntival hemorrhageOrbital fracture/hemorrhageE t O l M l i jExtra Ocular Muscle injuryCorneal AbrasionIntra Ocular hemorrhageIntra Ocular hemorrhage

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Injuries to the Ear

EcchymosesAbrasionAvulsionHematoma

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Neck and Shoulder injuriesjFractured Clavicle

-most frequently fractured bone-difficult delivery-shoulder dystocia-breech -Crepitus or deformity at the site-↓movement/moro on affected side-↓movement/moro on affected side-associated brachial plexus palsy

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Neck and Shoulder injuriesNeck and Shoulder injuriesFractured ClavicleDX- X-rayDX- X-rayRX- conservative

immobilizationreduce painreduce painpain subsides in 7-10 days

good prognosis

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N k d Sh ld i j iNeck and Shoulder injuries

Fracture of the Humerussecond most common fracturedifficult delivery/tractiondifficult delivery/tractionshoulder dystociabreech

deformity

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Neck and Shoulder injuries

Fractured Humerus: ManagementFractured Humerus: Management Splinting/immobilization in adductionClosed reduction and casting when displacedClosed reduction and casting when displacedWatch for evidence of radial nerve injuryC ll f ti d l tCallus formation occurs, and complete recovery expected in 2-4 weeksIn 8 10 days the callus formation is sufficientIn 8-10 days, the callus formation is sufficient to discontinue immobilization

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Intra abdominal Organ InjuryIntra-abdominal Organ Injury

UncommonUncommonsometimes overlooked as a cause of death in the newbornthe newbornHemorrhage is the most serious acute complicationcomplicationliver is the most commonly damaged internal organg

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Nerve PalsiesFacial NerveEtiology

Compression Of peripheral nerve-forceps-prolonged labor-in-utero compressionCNS Injury-temporal bone fracture-tissue destruction

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Nerve PalsiesNerve Palsies

Facial NerveFacial NerveClinical Manifestation

Paralysis apparent day 1-2Unilateral/bilateralAffected side smooth/droopingAmplified by crying

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Nerve PalsiesNerve PalsiesFacial Nerve: central nerve injury

t i f i ith iasymmetric facies with cryingmouth is drawn towards the normal sidewrinkles are deeper on the normal sidewrinkles are deeper on the normal sidemovement of the forehead and eyelid is unaffectedthe paralyzed side is smooth with a swollen appearanceabsent nasolabial fold on affected sideabsent nasolabial fold on affected sidecorner of the mouth droops on affected sideno evidence of trauma is present on the face

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F i l NFacial Nerve: peripheral nerve injuryasymmetric facies with cryingUnable to close eye on affected sidemay be evidence of forceps markmay be evidence of forceps mark

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Nerve PalsiesNerve PalsiesFacial Nerve Palsy: prognosisFacial Nerve Palsy: prognosis

85% recover in 1 week90% recovery in 1 year90% recovery in 1 yearSurgery if no resolution in 1 yrPalsy due to trauma usually resolves orPalsy due to trauma usually resolves or improvespalsy that persists is often due to absence of thepalsy that persists is often due to absence of the nerve

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B hi l Pl i jBrachial Plexus injuryTypes of InjuryTypes of Injury

StretchRuptureRuptureAvulsion

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Brachial Plexus injuryT f I jTypes of Injury

Stretch- 90-100% recovery in 1 yearRupture-needs surgical repairAvulsion-needs surgical repairg

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Nerve Palsies

Brachial Plexus injuryBrachial Plexus injuryWeakness or total paralysis of muscles innervated by the brachial plexus C-5 to C-8innervated by the brachial plexus C 5 to C 8 and T1Erb's Palsy C5-C7- proximal muscle weaknessy pKlumpke’s Palsy C8 and T1- weakness in the intrinsic muscles of the hand

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Nerve PalsiesBrachial Plexus injuryNeurological FeaturesNeurological FeaturesErb's Palsy (C5-C6)The involved extremity lies:

in adductionin pronation and internally rotated M bi d di l fl b tMoro, biceps and radial reflexes are absent Grasp reflex is usually present2-5% ipsilateral phrenic nerve paresis2 5% ipsilateral phrenic nerve paresisThe "waiter's tip" posture

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Nerve PalsiesNerve PalsiesBrachial Plexus InjuryNeurological FeaturesKlumpke’s Palsy (C7-8 T1)Klumpke s Palsy (C7-8, T1)

weakness of the intrinsic muscles of the handhandgrasp reflex is absent

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Nerve PalsiesNerve PalsiesBrachial Plexus InjuryNeurological FeaturesTotal Plexus PalsyTotal Plexus Palsy

Erb's Palsy + absent grasp reflex S l th E b'Sensory loss worse than Erb's

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Brachial PlexusBrachial PlexusPrognosisg

Depends on severity and extent of lesionlesion88% resolved by 4 months92% b 12 th92% by 12 months 93% by 48 months

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Brachial PlexusBrachial PlexusPrognosisg

Depends on severity and extent of lesionlesion88% resolved by 4 months92% b 12 th92% by 12 months 93% by 48 months

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Nerve PalsiesNerve PalsiesBrachial PlexusManagement

Prevention of contracturesPrevention of contracturesimmobilize limb gently across the abdomen for first week and thenabdomen for first week and then start passive range of motion exercises at all jointsall joints supportive wrist splints

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Brachial PlexusBrachial PlexusManagement g

Electrotherapy-controversial Surgical exploration if no significantSurgical exploration-if no significant functional recovery by 3 monthsE l ti ft 6 th i f littlExploration after 6 months is of little benefit

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Nerve PalsiesLaryngeal nerve injury

The infant presents with a hoarse cry orThe infant presents with a hoarse cry or respiratory stridor most often unilateral nerve paralysisSwallowing may be affected if the superior branch is involved Bilateral paralysis may be caused by trauma toBilateral paralysis may be caused by trauma to both laryngeal nerves or, more commonly, by a CNS injury such as hypoxia or hemorrhage involving the brain steminvolving the brain stemPatients with bilateral paralysis often present with severe respiratory distress or asphyxia

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Nerve PalsiesLaryngeal nerve injury& Prognosis:& Prognosis:

Paralysis often resolves in 4-6 wk, although full recovery may take 6-12 monthsrecovery may take 6 12 months

TreatmentsymptomaticsymptomaticSmall frequent feeds, once infant is stable Minimize the risk of aspirationMinimize the risk of aspirationInfants with bilateral involvement may require gavage feeding and tracheotomy

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gavage feeding and tracheotomy

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