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

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

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

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

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

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

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

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 appear @ 6-10 days resolve @ 6-8 wk/atrophy Sometimes calcifies

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

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

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

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

Injuries to the Head Subgaleal Hemorrhage Diagnosis is generally clinical: fluctuant boggy mass developing over the scalp (especially over the occiput) develops gradually 12-72 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)

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

Caput Succedaneum Cephalhematoma Subgaleal hemorrhage with skull fracture

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 240-40% 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

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

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

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

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

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

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

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

Injuries to the Ear Ecchymoses Abrasion Avulsion Hematoma

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

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

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

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

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

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

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

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

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

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

Nerve Palsies Brachial Plexus injury Types of Injury Stretch Rupture Avulsion

Nerve Palsies Brachial Plexus injury Types of Injury Stretch- 90-100% recovery in 1 year Rupture-needs surgical repair Avulsion-needs surgical repair

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

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

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

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

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

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

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

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

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

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

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