1. TRAUMATIC DELIVERY
Guslihan Dasa Tjipta Division of Perinatology Department of Child Health Medical School University of Sumatera Utara

2. Predisposing Factors Maternal factors: Primigravida
Cephalopelvic disproportion,
small maternal stature
maternal pelvic anomalies
Prolonged or rapid labor
Dystocia
Oligohydramnios

3. Predisposing factors Fetal factors: Abnormal presentation
Breech, face
VLBW or extreme prematurity
Fetal macrosomia
Large fetal head
Fetal anomalies

4. Predisposing Factors Obstetrical Interventions:
Use of mid-cavity forceps or vacuum extraction
Versions and extractions

5. Types of Injury Soft tissue injuries Head and Skull Face
Musculoskeletal injuries
Intra-abdominal injuries
Peripheral nerve injuries

6. Soft Tissue Injuries Erythema & Abrasions - Forceps, Dystocia
Petechiae head/neck/chest/back - Cord around neck /breech - thrombocytopenia
Ecchymoses breech/prematurity

8. Soft Tissue Injuries Lacerations scalp, buttocks, thighs
(Fetal scalp electrodes, surgeons knife!)
Infection a risk, but most heal uneventfully
Management:
careful cleaning, application of antibiotic ointment, and observation
Bring edges together using Steri-Strips
Lacerations occasionally require suturing

9. Soft Tissue Injuries Subcutaneous fat Necrosis (SFN)
Not usually detected at birth
Irregular, hard, non-pitting, subcutaneous plaques with overlying dusky red-purple discoloration on the extremities, face, trunk, or buttocks
May be caused by pressure during delivery
Hypothermia/ischemia/asphyxia
days
6-8 wk/atrophy
Sometimes calcifies

11. Soft Tissue Injuries SFN: Treatment
Treat symptomatic hypercalcemia aggressively
increased fluid intake
low calcium/ vit. D diet
furosemide -calcium-wasting diuretic
Steroids-inhibit metabolism of vit. D
Biphosphonates-reduce bone resorption

12. Injuries to the Head Caput Succedaneum most frequently observed lesion
pressure on the scalp against cervix
subcutaneous, extraperiosteal accumulation of blood/serum
presenting part involved
overlying bruising/Petechiae
crosses suture lines
resolves within days

13. Injuries to the Head Cephalhematoma 0.4%-2.5% of all live births
sub-periosteal hemorrhage from rupture of blood vessels between the skull and the periosteum
buffeting of fetal head against the pelvis
no extension across suture lines
most commonly parietal, may occasionally be observed over the occipital bone

14. Injuries to the Head Cephalhematoma increases in size with time
15% bilateral
18% associated skull fracture
Forceps
Vacuum

15. Injuries to the Head Subgaleal Hemorrhage
Diagnosis is generally clinical:
fluctuant boggy mass developing over the scalp (especially over the occiput)
develops gradually hours after delivery
hematoma spreads across the whole calvarium
Usually insidious and may not be recognized for hours
swelling may obscure the fontanelle and cross suture lines (distinguishing it from cephalhematoma)

16. Injuries to the Head Subgaleal Hemorrhage
Rx if signs of substantial volume loss:
compression wrap
restore blood volume
surgical drainage
25% mortality

18. Caput Succedaneum
Cephalhematoma
Subgaleal hemorrhage with skull fracture

19. extradural hemorrhage
Skin
Caput
Cephalhematoma
Epicranial aponeuroses
Subgaleal hemorrhage
extradural hemorrhage
Periosteum
Skull
Dura
Lesion
External swelling
↑ after birth
Crosses suture lines
↑↑↑acute blood loss
Caput succedaneum
Soft, pitting No
Yes
Cephalhematoma
Firm, tense
Subgaleal hematoma
Firm, fluctuant
Extracranial hemorrhages:
Caput succedaneum:
Subdermal edema, secondary to compression of uterus/cervix against the presenting parts
Occurs % of deliveries with vacuum extraction
Resolves gradually, no intervention is recommended
Cephalhematoma
A circumscribed region of hemorrhages overlying the skull and confined by cranial sutures
Caused by mechanical force
No intervention is recommended
Subgaleal hematoma
Hemorrhage beneath the aponeurosis covering the scalp and connecting the fromtal and occipital components of the occipito-frontalis muscle
A strong association with vacuum delivery
Observe closely for acute massive blood loss and signs of DIC

20. Injuries to the Head Skull Fractures
Uncommon because of compressible skull & open
sutures
Forceps/Prolonged labor
Linear/Depressed
Usually asymptomatic
Associated intracranial hemorrhage may produce symptoms

22. Injuries to the Head Skull Fractures
Rx – conservative elevation of depressed fracture - Thumb pressure Hand pump
- Vacuum extractor Surgical elevation Healing within a few months

23. Injuries to the Head Intracranial hemorrhage
- Subdural/Subarachnoid/IVH
Usually asymptomatic
Forceps/Vacuum
Prolonged labor
Usually associated with fracture

24. Injuries to the Head Subarachnoid hemorrhage
-more frequent than realized
-usually asymptomatic
-may cause seizures (day 2-3)
-bloody CSF
- CT/MRI

26. Injuries to the Head Subdural Hematoma
- may be silent for several days
-head circumference
poor feeding /vomiting /lethargy
altered consciousness/seizures
DX- CT/MRI
RX- Subdural taps/surgical drainage

28. Injuries to the Head Fractures of Facial bones
-nasal fracture/dislocation
-deviated nasal septum
-maxillary fracture
-mandibular fracture

29. EYE INJURIES Eye Lids edema/ecchymoses/laceration
Subconjuntival hemorrhage
Orbital fracture/hemorrhage
Extra Ocular Muscle injury
Corneal Abrasion
Intra Ocular hemorrhage

30. Injuries to the Ear
Ecchymoses
Abrasion
Avulsion
Hematoma

31. Neck and Shoulder injuries
Fractured Clavicle
-most frequently fractured bone
-difficult delivery
-shoulder dystocia
-breech
-Crepitus or deformity at the site
-movement/moro on affected side
-associated brachial plexus palsy

32. Neck and Shoulder injuries
Fractured Clavicle
DX- X-ray
RX- conservative immobilization reduce pain pain subsides in 7-10 days
good prognosis

33. Neck and Shoulder injuries
Fracture of the Humerus
second most common fracture
difficult delivery/traction
shoulder dystocia
breech
deformity

34. Neck and Shoulder injuries
Fractured Humerus: Management
Splinting/immobilization in adduction
Closed reduction and casting when displaced
Watch for evidence of radial nerve injury
Callus formation occurs, and complete recovery expected in 2-4 weeks
In 8-10 days, the callus formation is sufficient to discontinue immobilization

35. Intra-abdominal Organ Injury
Uncommon
sometimes overlooked as a cause of death in the newborn
Hemorrhage is the most serious acute complication
liver is the most commonly damaged internal organ

36. Nerve Palsies Facial Nerve Etiology Compression Of peripheral nerve
-forceps
-prolonged labor
-in-utero compression
CNS Injury
-temporal bone fracture
-tissue destruction

37. Nerve Palsies Facial Nerve Clinical Manifestation
Paralysis apparent day 1-2
Unilateral/bilateral
Affected side smooth/drooping
Amplified by crying

38. Nerve Palsies Facial Nerve: central nerve injury
asymmetric facies with crying
mouth is drawn towards the normal side
wrinkles are deeper on the normal side
movement of the forehead and eyelid is unaffected
the paralyzed side is smooth with a swollen appearance
absent nasolabial fold on affected side
corner of the mouth droops on affected side
no evidence of trauma is present on the face

39. Nerve Palsies Facial Nerve: peripheral nerve injury
asymmetric facies with crying
Unable to close eye on affected side
may be evidence of forceps mark

41. Nerve Palsies Facial Nerve Palsy: prognosis 85% recover in 1 week
90% recovery in 1 year
Surgery if no resolution in 1 yr
Palsy due to trauma usually resolves or improves
palsy that persists is often due to absence of the nerve

42. Nerve Palsies Brachial Plexus injury Types of Injury Stretch Rupture
Avulsion

43. Nerve Palsies Brachial Plexus injury Types of Injury
Stretch % recovery in 1 year
Rupture-needs surgical repair
Avulsion-needs surgical repair

44. Nerve Palsies Brachial Plexus injury
Weakness or total paralysis of muscles innervated by the brachial plexus C-5 to C-8 and T1
Erb's Palsy C5-C7- proximal muscle weakness
Klumpke’s Palsy C8 and T1- weakness in the intrinsic muscles of the hand

46. Nerve Palsies Brachial Plexus injury Neurological Features
Erb's Palsy (C5-C6)
The involved extremity lies:
in adduction
in pronation and internally rotated
Moro, biceps and radial reflexes are absent
Grasp reflex is usually present
2-5% ipsilateral phrenic nerve paresis
The "waiter's tip" posture

48. Nerve Palsies Brachial Plexus Injury Neurological Features
Klumpke’s Palsy (C7-8, T1)
weakness of the intrinsic muscles of the hand
grasp reflex is absent

49. Nerve Palsies Brachial Plexus Injury Neurological Features
Total Plexus Palsy
Erb's Palsy + absent grasp reflex
Sensory loss worse than Erb's

50. Nerve Palsies Brachial Plexus Prognosis
Depends on severity and extent of lesion
88% resolved by 4 months
92% by 12 months
93% by 48 months

51. Nerve Palsies Brachial Plexus Prognosis
Depends on severity and extent of lesion
88% resolved by 4 months
92% by 12 months
93% by 48 months

52. Nerve Palsies Brachial Plexus Management Prevention of contractures
immobilize limb gently across the abdomen for first week and then
start passive range of motion exercises at all joints
supportive wrist splints

53. Nerve Palsies Brachial Plexus Management Electrotherapy-controversial
Surgical exploration-if no significant functional recovery by 3 months
Exploration after 6 months is of little benefit

54. Nerve Palsies Laryngeal nerve injury
The infant presents with a hoarse cry or respiratory stridor
most often unilateral nerve paralysis
Swallowing may be affected if the superior branch is involved
Bilateral 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 stem
Patients with bilateral paralysis often present with severe respiratory distress or asphyxia

55. Nerve Palsies Laryngeal nerve injury & Prognosis:
Paralysis often resolves in 4-6 wk, although full recovery may take 6-12 months
Treatment
symptomatic
Small frequent feeds, once infant is stable
Minimize the risk of aspiration
Infants with bilateral involvement may require gavage feeding and tracheotomy

56. THANK YOU