Neonatal trauma

• Neonatal birth traumas or injuries


  Avoidable and unavoidable injuries to the newborn that occur during the birth process
• Neonatal birth traumas or injuries

  • Less common now because of more use of C/S
  • Can occur during prenatal, natal, or postnatal period

  
• Risk factors for birth injuries

  • Prim-parity
  • Maternal pelvic anomalies
  • Prolonged or unusually rapid labor
  • Oligo-hydramnios
  • Mal-presentation of fetus
  • Use of mid-forceps or vacuum extraction
  • Versions and extractions
  • VLBWT or extreme prematurity
  • Fetal macrosomia or large fetal head
  • Fetal anomalies

  
• Evaluation of Birth injuries

  1. History

  2. Thorough examination, including neurologic examination

  3. Special attention to symmetry of structure and function, cranial nerves, range of motion of joints, integrity of scalp and skin
• Types of birth injuries

  • Soft tissues injuries
  • Nerve injuries
  • Fractures
  • Visceral trauma
  • Intracranial Hemorrhage
  • Neonatal Cold injury

  
• Caput succedaneum


  Subcutaneous, extra-periosteal fluid collection over the presenting part in vertex presentation
• Cephal hematoma


  Sub-periosteal Hg due to rupture of vein of Galen between the skull and periostium

  
• Cephal hematoma is confined to suture lines, usually over parietal bones, the centre feel soft, it becomes visible on second or third day of life, it resolves over several weeks(8 weeks), when they are extensive can cause jaundice and anemia

  
• Cephal hematoma is occasionally associated with linear fracture of skull (5-20%), it requires no treatment, but treats infection, anemia and jaundice

  
• Aspiration of blood collection in cephal hematoma is contraindicated as it will induce infection
• Differences between caput and cephalhematoma

  • Not blood
  • Not blood

  
• Chignon


  Bruising edema from ventose extraction delivery
• Soft tissue injuries


  • Bruising of face after face presentation
  • Bruising of genitalia after breech delivery due to repeated PV exam
  • Abrasion of the skin from scalp electrodes applied during labor, or accidental scalpel incision at C/S
• Subgaleal Hg


  Sub-aponeurotic Hg (under skull aponeurosis), spread rapidly over head downward to the eye
• Subgaleal Hg is very uncommon, may be associated with serious blood loss, and may be associated with ICH, 90% associated with vacuum extraction
• Subgaleal Hg requires no treatment unless there is shock or ICH that require blood transfusion
• Subconjuctival or Retinal Hg

  Frequent and common, requires no treatment
• Brachial plexus nerve injuries


  Result from traction to the cervical nerve roots, may occur after breech delivery or with shoulder dystocia
• Erbs' palsy


  Upper nerve roots injury (C5-C6), waiters' tip posture, moro, biceps reflexes are absent, but grasp reflex is preserved
• Klumpks' palsy


  Lower nerve roots injury (C7, 8T1), weakness of long flexors of wrists and fingers and intrinsic muscles of the hand, grasp reflex is absent
• Treatment of brachial plexus nerve injuries

  1. Immobilize for one week, then passive range of motion exercise of all joints of limb

  2. Physiotherapy from second week of life
• Most brachial plexus palsies resolve over few weeks, occasionally following severe injury, paralysis is permanent, surgical reconstruction of the nerve is attempted
• Facial nerve injury


  Most common peripheral nerve injury in neonates, may result from compression of the facial nerve by forceps blades or against mothers' pelvis
• Symptoms of facial nerve injury


  • Asymmetrical crying face
  • Inability to close the eye firmly
  • Absent nasolabial fold
  • Deviation of the mouth to healthy side
• Treatment of facial nerve injury

  1. Care of the eyes with eye drops & ointment

  2. Care of feeding

  3. Physiotherapy if persist more than 3 months → neuroplasty
• Phrenic nerve injury


  Involves 3rd, 4th, 5th cervical nerves, results in ipsilateral diaphragm paralysis
• 75% of phrenic nerve injuries have brachial plexus injury, present with respiratory distress and cyanosis, diagnosed by U/S, fluoroscopy

  
• Skull fractures


  Rare, usually linear, usually in parietal bones, requires no treatment, just observation
• Depressed skull fractures


  Unusual, may be seen with complicated forceps delivery, if no neurologic deficit no treatment, if neurologic deficit do CT scan and surgical elevation
• Fracture clavicle


  Usually from shoulder dystocia, prognosis is excellent
• Fracture of humerus and femur

  Usually mid-shaft, occurring at breech delivery, present with loss of spontaneous arm or leg movement, pain and swelling in passive movement if displaced, diagnosed by x ray, treated by splinting, close reduction and casting
• Visceral trauma


  Trauma to liver, spleen, and adrenals, uncommon, seen in macrosomic infants, very premature infants, with or without breech or vaginal deliveries

  
• Subcapsular hematoma of liver


  Most common visceral trauma, may follow macrosomia, hepatomegaly, breech presentation
• Treatment of visceral trauma

  Restore blood volume, correct coagulation disorder, surgical consultation for possible laprotomy
• Neonatal adrenals are large, friable, highly vascular, unilateral in 90%, mainly on the right side
• Types of intracranial hemorrhage

  • Subdural Hemorrhage
  • Subarachnoid Hemorrhage
  • Peri-ventricular Hemorrhage
  • Intra-ventricular Hemorrhage
  • Intra-parenchymal Hemorrhage or cerebral Hemorrhage
• Subdural Hemorrhage (SDH)

  Usually seen in association with birth trauma, cephalo-pelvic disproportion, LGA babies, forceps deliveries, skull fracture, and postnatal head trauma, may be asymptomatic initially as Rbcs undergoes hemolysis, the water is drawn into the Hg resulting in expanding symptomatic lesion

  
• Symptoms of SDH include anemia, vomiting, seizure, macrocephaly in infants 1-2 months old, occasionally massive SDH in neonate by rupture of the vein of Galen or by inherited coagulation disorder as hemophilia
• Treatment of symptomatic SDH


  Surgical evacuation
• Neonatal Cold injury


  LBWT neonates and full term neonates with CNS disorders are risk groups, usually in inadequately heated homes and damp cold spells