Dr Mashanga 16/07/2014 Birth Injuries - PowerPoint Presentation

Slide1

Dr Mashanga16/07/2014

Birth Injuries

Slide2

outline

Definition

Incidence

Risk Factors

Types of Birth Injuries

Approach to a neonate with birth trauma

Investigations

Slide3

Definition

Birth injuries are injuries that occur during the birth process

Incidence

~2-7 per 1000 live births.

Slide4

What are the risk factors??

Macrosomia

Dystocia

Prolonged labour

Abnormal presentation (especially breech)

Cephalopelvic disproportion

Prematurity

Instrumental delivery

Slide5

Types of Birth injuries

Slide6

HEAD

Caput Succedaneum

This is an area of oedema over the presenting part of the scalp during a vertex delivery.

It crosses the midline of the skull and suture lines.

The area of oedema is usually associated with bruising and petechiae

The bleeding is external to the periosteum.

Cephalohaematoma

This is caused by bleeding that occurs below the periosteum overlying one cranial bone (usually the parietal bone).

There is no crossing of the suture lines.

The overlying scalp is not discoloured

The swelling sometimes takes days to become apparent.

The incidence of associated skull fracture is 5-10% and is most often a linear fracture.

Slide7

HEAD

3.

Subgaleal

hemorrhage

This is a collection of blood in the soft tissue space under the aponeurosis but above the periosteum of the skull.

Diffuse swelling of the soft tissue, often spreading toward the neck and behind the ears, can be seen.

Periorbital

swelling is also evident.

Associated

symptoms include

anemia

,

hypotonia

, seizures, and pallor

Slide8

HEAD

4. Intracranial Haemorrhage

a. Subarachnoid:

usually asymptomatic.

b. Epidural:

very rare and also very difficult to diagnose. Clinical symptoms are usually delayed.

c. Subdural:

These infants present shortly after birth with stupor, seizures, a full fontanelle, unresponsive pupils, and coma.

Slide9

HEAD

5. Skull Fracture

.

uncommon in neonates

most are linear and are associated with a Cephalohaematoma.

Depressed fractures are often visible.

Fractures at the base of the skull may result in shock.

Slide10

FACE

Fractures

Fractures of the nose, mandible, maxilla, and septal cartilage can occur.

These can often present as respiratory distress or feeding problems.

Dislocations Of The Facial Bones

.

Nasal septal dislocation (the most common facial injury) can occur and present as stridor and cyanosis

Facial nerve palsy

This often occurs secondary to forceps compressing the nerve.

Slide11

EYE

Eyelids

Oedema and bruising can occur.

Swollen eyelids should be forced open to examine the eyeball.

Laceration of the eyelid can also occur.

Orbit fracture

can occur rarely.

Horner's syndrome

(

miosis

, partial ptosis,

enophthalmos

, and

anhidrosis

of the

ipsilateral

side of the face). Delayed pigmentation of the

ipsilateral

iris can be seen.

Subconjunctival

hemorrhage

. This is a common finding.

Cornea

Haziness can occur secondary to

edema

. With persistent haziness, suspect rupture of

Descemet's

membrane.

Slide12

EYE

6. Intraocular haemorrhage

Retinal haemorrhage:

Most commonly, a flame-shaped or streak haemorrhage is found near the optic disk. A sheet haemorrhage is associated with a subdural bleed.

Hyphemas

: Gross blood is seen in the anterior chamber.

Vitreous haemorrhage

: Indicated by floaters, absent red reflex, and blood pigment seen on slit-lamp exam by the ophthalmologist.

Slide13

EAR

Abrasions and bruising.

Hematomas

Avulsion of the auricle. This can occur because of misplacement of the forceps

Laceration of the auricle.

Slide14

Neck And Shoulder Injuries

Clavicular

fracture

.

commonest bone fracture during delivery.

If the fracture is complete, symptoms involve decreased or absent movement of the arm, gross deformity of the clavicle, tenderness on palpation, localized crepitus, and an absent or asymmetric Moro's reflex.

Greenstick fracture usually presents with no symptoms, and the diagnosis is made because of callus formation at 7-10 days.

Slide15

Neck And Shoulder Injuries

2. Brachial Plexus injuries:

There are three different presentations

Duchenne-Erb

.

This involves the

upper arm

and is the commonest type.

The

fifth

and

sixth cervical roots

are affected

The arm is adducted and internally rotated.

Moro's reflex is absent (sometimes it can be asymmetric or weakened), but the

grasp reflex is intact

.

Slide16

Klumpke

This involves the lower arm, because the

seventh

and

eighth cervical

and

first thoracic roots

are injured

The hand is paralyzed, the wrist does not move, and the grasp reflex is absent (

ie

, dropped hand).

Cyanosis and

edema

of the hand can also occur.

An

ipsilateral

Horner's syndrome (ptosis,

miosis

, and

enophthalmos

) can be seen because of injury involving the cervical sympathetic

fibers

of the first thoracic root.

Phrenic nerve paralysis with

Klumpke's

palsy is evident.

c. Entire arm paralysis

.

The patient will have a flaccid arm, hanging limply with no reflexes.

Slide17

Neck And Shoulder Injuries

3. Phrenic Nerve Paralysis

Difficult breech delivery can cause diaphragmatic paralysis.

This usually occurs with upper brachial nerve palsy.

It is associated with cyanosis, tachypnea, irregular respirations, and thoracic breathing with no bulging of the abdomen.

4. Sternocleidomastoid Muscle (SCM) Injury (Muscular Or Congenital Torticollis)

.

A well circumscribed, immobile mass in the

midportion

of the SCM that enlarges, regresses, and disappears.

This results in a transient torticollis after birth. The head tilts toward the involved side, the chin is elevated and rotated, and the patient cannot move the head into normal position.

Slide18

Abdominal Organ Injuries

Liver rupture

commonest organ affected

presents with sudden circulatory collapse (a hematoma ruptures through the capsule).

Spleen rupture

Blood loss and

haemoperitoneum

.

Adrenal

hemorrhage

.

Symptoms include fever, tachypnea, mass in the flank, pallor, cyanosis, poor feeding, shock, vomiting, and

diarrhea

.

Kidney damage

.

Same as others; presents as ascites, flank mass, and gross

hematuria

Slide19

Extremity Injuries

Fractured

humerus

This is the second most common fracture during birth trauma.

The arm is immobile, with tenderness and crepitation on palpation.

Moro's reflex is absent on the affected side.

Fractured femur

May occur secondary to breech delivery.

Deformity is usually obvious.

The affected leg does not move, and there is pain with assisted movement.

Dislocation

Usually involves the radial head.

Examination reveals adduction, internal rotation of the affected arm, and poor Moro's reflex.

Palpate lateral and posterior displacement of the radial head.

Slide20

Other Injuries

Skin

Vocal cords

Spinal cord Injuries

Genital

Slide21

Approach to a neonate with Birth Trauma

Skin

Head

Face

Eyes

Ears

Vocal Cords

Neck and Shoulder Injuries

Spinal cord

Abdomen

Extremeties

Genitalia

Slide22

Lab Investigations

Skin: platelet count, HCT, Serum bilirubin

Head: HCT, Serum Bilirubin

Face: ABGs

Eye: no investigations

Ear: no investigations

Vocal cords: no investigations

Neck and shoulder: ABGs, Check O

2

Saturations

Spinal Cord Injuries: ABGs, O

2

Saturations

Slide23

Lab Investigations…..cont..

9. Abdomen

HCT

Urine dipstick, to check for haematuria.

Abdominal

paracentesis

with fluid sent to the laboratory for cell count with differential.

10. Extremities

: No laboratory tests needed

11. Genitalia

: No laboratory tests needed

Slide24

Radiologic and other studies

Skin:

No studies are usually needed.

Head

Skull X Ray

A computed tomography (CT) scan

Face

Radiographs and a cranial CT scan will help diagnose facial fractures.

Eyes

.

Radiographs, to rule out orbit fracture, may be indicated.

Ears

: No radiologic studies are necessary.

Vocal cord injury

: No radiologic studies are necessary.

Slide25

7. Neck and shoulder

A radiograph of the clavicle is necessary for confirmation of the diagnosis.

An x-ray film of the chest for phrenic nerve paralysis will show an elevated diaphragm.

Ultrasonogram

of the diaphragm will show abnormal motion on the affected side.

8. Spinal cord

Cervical and thoracic spine radiographs should be obtained.

Magnetic resonance imaging (MRI) is the most reliable method for diagnosing spinal cord

Slide26

9. Abdomen

Ultrasonogram

will diagnose liver and splenic rupture, adrenal haemorrhage, and kidney damage.

10. Extremities

An x-ray film of the extremities confirms the diagnosis.

11. Genitalia

Ultrasonography may be diagnostic.

Slide27

TREATMENT

Slide28

References

Neonatology: Management, Procedures, On-call Problems, Diseases, And Drugs - 5TH Ed. (2004)

Slide29