Birth injury Amy J. Gagnon, M.D. Maternal-Fetal Medicine Colorado Perinatal Care Council November 18, 2011

Birth injury: overview Cephalohematoma Subgaleal hemorrhage Retinal hemorrhage Facial nerve palsy Fracture Hypoxic injury Minor lacerations/bruising – cumulatively are of a minor nature and respond well to therapy Rare things: abscess 2/2 FSE, skull fracture

Operative vaginal delivery 1997 U.S. rate operative vaginal delivery: 9.4% 2007 U.S. rate operative vaginal delivery: 4.3% Indications Prolonged second stage: Nulliparous women: lack of continuing progress for 3 hours with regional anesthesia, or 2 hours without regional anesthesia Multiparous women: lack of continuing progress for 2 hours with regional anesthesia, or 1 hour without regional anesthesia Suspicion of immediate or potential fetal compromise. Shortening of the second stage for maternal benefit. Outlet forceps Scalp is visible at the introitus without separating labia. Fetal skull has reached pelvic floor. Sagittal suture is in anteroposterior diameter or right or left occiput anterior or posterior position. Fetal head is at or on perineum. Rotation does not exceed 45º. Low forceps   Leading point of fetal skull is at station >= +2     cm and not on the pelvic floor.  Rotation is 45º or less (left or right occiput     anterior to occiput anterior, or left or right     occiput posterior to occiput posterior).  Rotation is greater than 45º. Midforceps  Station is above +2 cm but head is engaged. High forceps  Not included in classification. *our rate could be confounded by higher than nat’l rate of PTD (17% rate PTD at UCH same time period vs. 11.5% nationally) *c/s rate UCH 28% vs. 21% nationally in 1997 ACOG Practice Bulletin. Number 18, June 2000. Martin et al. National Center for Health Statistics; 2010.

Operative vaginal delivery Cochrane review (Issue 2, 1999) Use of vacuum associated with much less maternal trauma Vacuum associated with an increase in neonatal retinal hemorrhages and cephalohematoma Retinal hemorrhages: twofold higher risk with vacuum versus forceps; data on the long-term consequences of these hemorrhages fails to demonstrate any significant effect Some studies reveal neonates delivered by VAVD more likely to be readmitted with jaundice Vacuum: designed to limit amount of traction (can achieve 50 lbs. pressure) Forceps: unlimited amt of pressure Carmody F, et al. Acta Obstet Gynecol Scand 1986;65:763-766

Vacuum versus Forceps Vacuum Forceps Easier to apply?? More difficult to apply? Slower delivery Faster delivery Increase risk scalp trauma/intracranial trauma Increased maternal soft tissue trauma Requires better analgesia Higher chance failure Not recommend <34-36wks Any gestational age Gei & Pacheco. Obstet Gynecol Clin N Am. 2011; 38:323-49. Williams. Clin Perinatol. 1995;22:933-52. Schaal et al. J Gynecol Obstet Biol Reprod. 2008;37:S231-43 Lurie et al. Arch Gynecol Obtet. 2006;274(1):34-6.

Vacuum versus Forceps Particular indication for procedure Anesthesia Availability of instruments Training/experience of physician Patient preference

Vacuum-assisted vaginal delivery Prospective observational study of 134 VAVD. 28 infants (21%) with scalp trauma. 17 superficial lacerations; none required sutures. 6 with large caput succedaneum. 12 cephalohematomas. 1 infant with subgaleal, subdural, and subarachnoid hemorrhage. (This infant did not become anemic or hypotensive.) Logistic regression analysis showed duration of vacuum application to be the best predictor of scalp injury (duration 0.5 to 26 minutes, with a median length of 3 minutes) UCLA prospectively looked at all neonates del’d by vacuum in 1995 with above results The one infant with intracranial hemorrhage underwent head CT after repeated episodes of apnea/bradycardia; later dx’d with congenital hypothyroidism; the ICH was an “incidental finding” Can ask question: could they have missed intracranial hemorrhages? Multiple studies show ICH rare in term infants without any neuro symptoms Duration of application (time). >10min (6 of 9 with scalp injury) <10min (22 of 121 with scalp injury, p < 0.01). Teng & Sayre. Obstet Gynecol. 1997 Feb;89(2):281-5

Cephalohematoma Bridging vein ruptures between the outer skull table and the periosteum of the parietal bone The periosteum is circumferentially anchored to the edges of the parietal bone. Usually a self-limited lesion. Rates: Vacuum: 112/1,000 Forceps: 63/1,000 SVD: 17/1,000

Cephalohematoma Secondary analysis of 322 infants randomized to be delivered by vacuum. Logistic regression identified three factors associated with clinically diagnosed cephalohematoma. Time required for delivery. Increasing asynclitism. Station at application Neonates indication for VAVD randomized to either intermittent or continuous technique (no difference found) Station at application (not significant after stepwise multiple logistic regression analysis) Bofill et al., J Repro Med 1997;42:565-9.

Vacuum time and cephalohematoma Bofill et al., J Repro Med 1997;42:565-9.

Subgaleal hemorrhage Blood collects in the loose areolar tissue in space between the galea aponeurotica and periosteum. The subgaleal space has potential area of several hundred milliliters (can contain the entire blood volume of the neonate.) Bounded laterally by the zygomatic arches, anteriorly by the orbital ridges, and posteriorly by the nape of the neck. Severe hemorrhage can lead to profound hypovolemia, hypoxia, DIC, end-organ damage and death

Subgaleal hemorrhage Incidence: 4/10,000 SVD 26-45/1,000 VAVD ** Occurs almost exclusively with the vacuum device. Led to FDA issuing a “public health advisory” regarding the use of vacuum-assisted delivery devices in May 1998 Cited fivefold increase in rate of deaths and serious morbidity during previous 4 years when compared to previous 11 years

FDA Public health advisory regarding vacuum-assisted delivery devices Persons should be versed in their use and aware of indications, contraindications, precautions as supported in accepted literature & current device labeling Apply steady traction in line of birth canal. No rocking or applying torque. Notify pediatricians Educate neonatal care staff re: complications of VAVD Report reactions associated with use to FDA Device labeling: don’t use before 36 weeks ACOG: can use down to 34 wks if indicated

Forceps-assisted delivery Nationally, decrease in experienced teachers/training Facial nerve palsy: 5-year period at Brigham and Women's Hospital 81 cases of acquired facial-nerve palsy (44,292 deliveries)  incidence of 1.8 per 1000 74 of the 81 (91 percent) associated with forceps delivery FAVD, birth weight >3500gm, and primiparity all significant risk factors for acquired facial palsy Recovery complete for 59 patients (89%) and incomplete for the remaining 7 (mean follow-up 34 months) FAVD more risky for mom and talking about birth injury here Retrospective study of neonates with facial weakness or paralysis over a 5 year period f/u by interview with family member Etiology either 2/2 physiologic pressure (sacral promontory/fetal shoulder) or due to forceps WHERE PRESSURE? Falco NA and Eriksson E. Plast Reconstr Surg. 1990 Jan;85(1):1-4

Sequential use of vacuum & forceps Sequential use increases liklihood of adverse outcomes more than the sum of the relative risks of each individual instrument X ↔

Operative vaginal delivery: Long term sequalae? 1993 Kaiser (Oakland): 1,192 FAVD vs. 1,499 SVD – no difference in IQ at 5 years 10-year matched follow-up evaluation of 295 children delivered by VAVD vs. 302 controls (SVD) revealed no differences between the two groups in terms of scholastic performance, speech, ability of self-care, or neurologic abnormality ** Does not appear to be any long-term effect of operative vaginal delivery on cognitive development Wesley BD, et al. Am J Obstet Gynecol 1993;169:1091-1095 Ngan HY, et al. Aust N Z J Obstet Gynaecol 1990;30:111-114

“Failure” “In cases of operative vaginal delivery, a true failure is not when a vaginal delivery is not accomplished but when a preventable injury is inflicted” Lowe B. Br J Obstet Gynaecol 1987;94:60-6.

Shoulder dystocia Incidence 0.3 – 2% of deliveries Lack of uniform definition ACOG: additional obstetric maneuvers following failure of gentle downward traction on the fetal head to effect delivery of the shoulders prolonged head-to-body delivery time (eg, more than 60 seconds) Risk factors macrosomia and fetal anthropometric variations maternal diabetes and obesity operative vaginal delivery precipitous delivery and prolonged second stage of labor history of shoulder dystocia or macrosomic fetus postterm pregnancy advanced maternal age ACOG practice bulletin 2002

Brachial plexus injury C4: phrenic nerve palsy C5-C6 +/-C7: Erb’s or Erb-Duchenne palsy (80% of brachial plexus injuries) C8-T1: Klumpke’s palsy C5-T1: Complete brachial plexus injury, or Erb-Klumpke palsy

Erb-Duchenne palsy (C5-C6 +/- C7) Classic posture result of paralysis/weakness in shoulder muscles, elbow flexors, & forearm supinators. Affected arm hangs & is internally rotated, extended, and pronated Oftentimes, C7 also involved causing loss of innervation to the forearm, wrist, and finger extensors. The loss of extension causes the wrist to flex and the fingers to curl up in the ‘‘waiter’s tip’’ position.

Erb-Duchenne palsy (C5-C6 +/- C7) Obstetrical literature: <10% permanent Persistent injury more common with BW > 4500 g and infants of diabetic mothers Pediatric/orthopedic literature: permanent injury in up to 15% to 25% of cases

Klumpke’s palsy: C8-T1 Weakness of triceps, forearm pronators, & wrist flexors leading to a ‘‘clawlike’’ paralyzed hand with good elbow and shoulder function. Upper-arm function differentiates Klumpke’s palsy from Erb’s palsy. Only 40% of Klumpke’s palsies resolve by 1 year of life Associated Horner’s syndrome with sensory deficits on the affected side, contraction of the pupil, and ptosis of the eyelid is caused by cervical sympathetic nerve injury.

Brachial plexus injury: ? Birth injury 34%–47% brachial plexus injuries not associated with SD 4% occur after cesarean birth Other causes of injury: normal forces of labor and delivery (symphysis against the brachial plexus) abnormal intrauterine pressures arising from uterine anomalies (anterior lower uterine segment leiomyoma, septum, or a bicornuate uterus) Performance of electromyeolography within 24–48 hours of delivery can help determine the timing of brachial plexus injury Electromyelographic evidence of muscular denervation normally requires 10 to 14 days to develop Its finding in the early neonatal period strongly suggests an insult predating delivery Koenigsberger MR. Ann Neurol 1980;8:228. Mancias P, et al. Muscle Nerve 1994;17:1237–8. Peterson GW, et al. Muscle Nerve 1995;18:1031.

Brachial plexus injury No matter the cause, care should involve a multidisciplinary approach including pediatrics, pediatric neurology, physical therapy, and possible referral to a brachial pleuxus injury center.

Fracture Majority involve clavicle Often occurs in the absence of shoulder dystocia Incidence at the time of SD ranges from 3-9.5% Increasing risk with greater birth weight Humerus most common long bone fracture Almost invariably heal with simple supportive therapy & do not lead to permanent disability Fractured clavicles are found in up to 2.9% of term infants, more frequently on the right side.  They are often silent but may be noticed later when a palpable callous forms at a few weeks of age. There is often minimal pain apparent, but if the infant is uncomfortable strapping may be all that is required for a few days. The radiograph to the right shows a linear lucency at the lateral one third of the clavicle. Midshaft (diaphyseal) humeral fractures are often diagnosed at birth when a "crack" or "snap" is heard or felt on delivery of the baby.  Clinical signs are variable - the baby may be asymptomatic, may be in pain, or may present with a pseudoparalysis. Treatment is by immobilisation of the arm by the side with the elbow held at 90°.  These fractures usually heal very well over the following weeks. The images to the left demonstrate a humeral fracture which was suspected at delivery after a difficult extraction.  The top image shows the fracture immediately after birth; the second image shows the fracture three weeks later, with good callous formation.  The third image shows the fracture 2 months after the initial injury with minimal angulation.

Hypoxic injury Essential criteria (must meet all four) Evidence of a metabolic acidosis in fetal umbilical cord arterial blood obtained at delivery (pH <7 and base deficit =12 mmol/L) Early onset of severe or moderate neonatal encephalopathy in infants born at 34 or more weeks of gestation Cerebral palsy of the spastic quadriplegic or dyskinetic type Exclusion of other identifiable etiologies such as trauma, coagulation disorders, infectious conditions, or genetic disorders ACOG & American Academy of Pediatrics

Hypoxic injury Criteria that collectively suggest an intrapartum timing (within close proximity to labor and delivery, eg, 0-48 hours) but are nonspecific to asphyxial insults A sentinel (signal) hypoxic event occurring immediately before or during labor A sudden and sustained fetal bradycardia or the absence of fetal heart rate variability in the presence of persistent late, or variable decelerations, usually after a hypoxic sentinel event when the pattern was previously normal Apgar scores of 0-3 beyond 5 minutes Onset of multisystem involvement within 72 hours of birth Early imaging study showing evidence of acute nonfocal cerebral abnormality Persistent late decelerations with absent beat-to-beat variability

Teamwork! >60% obstetric medical negligence claims relate to events alleged to occur during L&D >80% damages awarded Soon after delivery, discussion with the patient and family (complete, immediate, accurate information) Events of the delivery must be documented by all careteam members involved Communicate! ***If a any sort of injury is present, the clinician should NOT speculate regarding the cause

Additional References Martin JA, Hamilton BE, Sutton PD, et al. Final data for 2007. National vital statistics reports, vol 58. Hyattsville (MD): National Center for Health Statistics; 2010. ACOG. Professional liability and risk management: an essential guide for obstetrician-gynecologists. 2005. Gabbe, 5th edition. Gottlieb, AG & Galan HL. Shoulder dystocia: An update. Obstet Gynecol Clin N Am. 34 (2007) 501–531

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