Birth trauma

Birth trauma are categorized as injuries to the infant that result from mechanical forces (ie, compression, traction) during the birth process ¹. The National Vital Statistics Report defines birth trauma as “an impairment of the neonate’s body function or structure due to an adverse event that occurred at birth” ². These injuries include a wide range of minor to major injuries that may occur due to various mechanical forces during labor and delivery. Birth injuries are different from birth defects or malformations and are often easily distinguishable from congenital defects by a focused clinical assessment. Significant birth trauma accounts for fewer than 2% of neonatal deaths and stillbirths in the United States ¹. Birth trauma rates have steadily declined over the last few decades due to refinements in obstetrical techniques and the increased use of cesarean delivery in cases of dystocia or difficult vaginal deliveries. The birth trauma rate fell from 2.6 per 1000 live births in 2004 to 1.9 per 1000 live births in 2012. The rates of instrumental deliveries have also gradually declined over the past three decades with a reduction in the number of both forceps and vacuum-assisted deliveries ³. In general, larger infants are more susceptible to birth trauma. Higher rates are reported for infants who weigh more than 4500g.

Most birth traumas are self-limiting and have a favorable outcome. Nearly one half are potentially avoidable with recognition and anticipation of obstetric risk factors. Infant outcome is the product of multiple factors. Separating the effects of a hypoxic-ischemic insult from those of traumatic birth injury is difficult.

Risk factors for birth trauma include the following ⁴:

• Large-for-date infants, especially infants who weigh more than 4500 g
• Instrumental deliveries, especially forceps (midcavity) or vacuum ⁵
• Vaginal breech delivery
• Abnormal or excessive traction during delivery

Occasionally, injury may result from resuscitation. Recognition of birth trauma necessitates a careful physical and neurologic evaluation of the infant to establish whether additional injuries are present. Symmetry of structure and function should be assessed, the cranial nerves should be examined, and specifics such as individual joint range of motion and scalp/skull integrity should be evaluated.

The clinical management and prognosis of infants with birth injuries vary widely depending on the type and severity of the injury. The common sites for birth trauma can include the head, neck, and shoulders. Other less common locations include the face, abdomen, and lower limbs. A summary of the common traumatic clinical conditions occurring related to birth is listed below.

Birth trauma causes

The birth process is a blend of compression, contractions, torques, and traction. When fetal size, presentation, or neurologic immaturity complicates this event, such intrapartum forces may lead to tissue damage, edema, hemorrhage, or fracture in the neonate. The use of obstetric instrumentation may further amplify the effects of such forces or may induce injury alone. Under certain conditions, cesarean delivery can be an acceptable alternative but does not guarantee an injury-free birth.

The risk factors associated with birth trauma can group into those related to the fetus, pregnancy, mother or iatrogenic factors (use of instrumentation during delivery) ⁶. Fetal and pregnancy-related factors include macrosomia (estimated fetal weight greater than 4000g), macrocephaly, very low birth weight, extreme prematurity, fetal congenital anomalies, oligohydramnios and malpresentations including breech presentation as well as other abnormal presentations (such as the face, brow, or transverse). Maternal factors may include maternal obesity, maternal diabetes, cephalopelvic disproportion, small maternal stature, primiparity, dystocia, difficult extraction, use of vacuum or forceps, prolonged or rapid labor ⁷.

Factors predisposing to birth trauma include the following:

• Primigravida (a woman who is pregnant for the first time)
• Cephalopelvic disproportion, small maternal stature, maternal pelvic anomalies
• Prolonged or rapid labor
• Deep, transverse arrest of descent of presenting part of the fetus
• Oligohydramnios
• Abnormal presentation (breech)
• Use of midcavity forceps or vacuum extraction
• Versions and extractions
• Very ̶ low-birth-weight infant or extreme prematurity
• Fetal macrosomia
• Large fetal head
• Fetal anomalies

Birth trauma types

Birth trauma account for fewer than 2% of neonatal deaths. From 1970-1985, rates of infant mortality due to birth trauma fell from 64.2 to 7.5 deaths per 100,000 live births, a remarkable decline of 88%. This decrease reflects, in part, the technologic advancements that allow today’s obstetrician to recognize birth trauma risk factors using ultrasonography and fetal monitoring prior to attempting vaginal delivery. The use of potentially injurious instrumentation, such as midforceps rotation and vacuum delivery, has also declined. The accepted alternative is a cesarean delivery ⁸.

Birth trauma with a favorable long-term prognosis

• Soft tissue injuries with a favorable long-term prognosis include the following:
  • Abrasions and lacerations. Abrasions and lacerations sometimes may occur as scalpel cuts during cesarean delivery or during instrumental delivery (ie, vacuum, forceps). Infection remains a risk, but most of these lesions uneventfully heal. Management consists of careful cleaning, application of antibiotic ointment, and observation. Bring edges together using Steri-Strips. Lacerations occasionally require suturing.
  • Erythema petechia
  • Ecchymosis
  • Subcutaneous fat necrosis. Subcutaneous fat necrosis is thought to be a result of ischemic injury to the adipose tissue and characterized by palpation of soft, indurated nodules in the subcutaneous plane. No treatment is necessary. These lesions resolve gradually over the course of a few weeks. Hypercalcemia is one of the complications; therefore it is recommended to monitor serum calcium ⁹. Subcutaneous fat necrosis sometimes calcifies.
• Head trauma with a favorable long-term prognosis include the following:
  • Caput succedaneum. Caput succedaneum is a serosanguineous, subcutaneous, extraperiosteal fluid collection with poorly defined margins; it is caused by the pressure of the presenting part against the dilating cervix. Caput succedaneum extends across the midline and over suture lines and is associated with head molding. Caput succedaneum does not usually cause complications and usually resolves over the first few days. Management consists of observation only. Rare complications include bruising of the skin over the swelling with necrosis resulting in scarring and alopecia, and rarely systemic infection.
  • Cephalhematoma. Cephalhematoma is a subperiosteal collection of blood secondary to rupture of blood vessels between the skull and the periosteum; suture lines delineate its extent. Cephalohematoma is more common in deliveries involving vacuum or forceps and occurs in up to 2.5% of all deliveries ¹⁰. Most commonly parietal, cephalhematoma may occasionally be observed over the occipital bone. The extent of hemorrhage may be severe enough to cause anemia and hypotension, although this is uncommon. The resolving hematoma predisposes to hyperbilirubinemia. Rarely, cephalhematoma may be a focus of infection that leads to meningitis or osteomyelitis. Linear skull fractures may underlie a cephalhematoma (5-20% of cephalhematomas). Resolution occurs over weeks, occasionally with residual calcification. No laboratory studies are usually necessary. Skull radiography or computed tomography (CT) scanning is performed if neurologic symptoms are present. Usually, management solely consists of observation. The usual course is a spontaneous resolution in 2 weeks to 3 months without any intervention, but complications such as calcification of the hematoma, deformities of the skull, infection of the hematoma and osteomyelitis of the skull can occur. Transfusion for anemia, hypovolemia, or both is necessary if blood accumulation is significant. Aspiration is not required for resolution and is likely to increase the risk of infection. Hyperbilirubinemia occurs following the breakdown of the red blood cells (RBCs) within the hematoma. This type of hyperbilirubinemia occurs later than classic physiologic hyperbilirubinemia. The presence of a bleeding disorder should be considered. Skull radiography or CT scanning is also performed if a concomitant depressed skull fracture is a possibility.
  • Subgaleal hematoma. Subgaleal hemorrhage is bleeding in the potential space between the skull periosteum and the scalp galea aponeurosis. The injury occurs when there is traction pulling the scalp away from the stationary bony calvarium, resulting in the shearing or severing of the bridging vessels. A difficult vaginal delivery resulting in the use of forceps or vacuum is the most common predisposing event in the formation of subgaleal hemorrhage. Subgaleal hemorrhage has been estimated to occur in 4 of 10,000 spontaneous vaginal deliveries and 59 of 10,000 vacuum-assisted deliveries ¹¹. Subgaleal hematoma has a high frequency of occurrence of associated head trauma (40%), such as intracranial hemorrhage or skull fracture ¹². The occurrence of these features does not significantly correlate with the severity of subgaleal hemorrhage ¹³. Since the subgaleal space is a significant potential space extending over the entire area of the scalp from the anterior attachment of the galea aponeurosis near the frontal bones to the posterior attachment at the nape of the neck, there is a potential for massive bleeding into this space that could result in acute hypovolemic shock, multi-organ failure, and death. The diagnosis is generally a clinical one, with a fluctuant, boggy mass developing over the scalp (especially over the occiput). The swelling develops gradually 12-72 hours after delivery, although it may be noted immediately after delivery in severe cases. The hematoma spreads across the whole calvaria; its growth is insidious, and subgaleal hematoma may not be recognized for hours. Patients with subgaleal hematoma may present with hemorrhagic shock. The swelling may obscure the fontanelle and cross suture lines (distinguishing it from cephalhematoma). Watch for significant hyperbilirubinemia. In the absence of shock or intracranial injury, the long-term prognosis is generally good. Laboratory studies consist of a hematocrit evaluation. Treatment includes supportive care with early recognition and restoration of blood volume using blood or fresh frozen plasma to correct the acute onset hypovolemia. The hemorrhage itself is not drained and allowed to resorb over time. A workup for bleeding disorders may be considered in selected cases if the degree of bleeding is out of proportion to the trauma at birth.
  • Skull fractures: Skull fractures from birth trauma are most often a result of instrumented vaginal delivery. These fractures could be linear or depressed and are usually asymptomatic unless associated with an intracranial injury. Plain film radiographs of the skull usually clarify the diagnosis, but computed tomography (CT) or magnetic resonance imaging (MRI) of the brain is the recommendation if there is suspicion of intracranial injury or presence of neurologic symptoms.
• Facial injuries with a favorable long-term prognosis include the following:
  • Subconjunctival hemorrhage. Subconjunctival hemorrhages are superficial hematomas seen under the bulbar conjunctiva, commonly seen in infants born after going through labor. It is suggested to be due to ruptured subconjunctival capillaries from venous congestion, occurring from increased back pressure in the head and neck veins. This injury can result from either a nuchal cord or from increased abdominal or thoracic compression during uterine contractions ¹⁴. Subconjunctival hemorrhages is a benign condition in the newborn and resolves without intervention. A more significant ocular injury may occur with the use of instrumentation during delivery (forceps), resulting in corneal abrasions, vitreous hemorrhages, etc. that require immediate attention and referral to an ophthalmologist to prevent long term visual defects ¹⁵.
  • Retinal hemorrhage
• Intra-abdominal injuries with a favorable long-term prognosis include the following:
  • Liver hematoma
  • Splenic hematoma
  • Adrenal hemorrhage
  • Renal hemorrhage

Birth trauma resulting in abdominal visceral injuries is uncommon and primarily consists of hemorrhage into the liver, spleen or adrenal gland. The clinical presentation depends on the volume of blood loss and can include pallor, bluish discoloration of the abdomen, distension of the abdomen, and shock. Treatment is supportive with volume resuscitation and surgical intervention if needed.

• Peripheral nerve injuries with a favorable long-term prognosis include the following:
  • Facial palsy
  • Unilateral vocal cord paralysis
  • Radial nerve palsy
  • Lumbosacral plexus injury

• Musculoskeletal injuries with a favorable long-term prognosis include the following:
  • Clavicular fractures
  • Fractures of long bones
  • Sternocleidomastoid injury

Most of the fractures resulting from birth trauma are associated with difficult extractions or abnormal presentations. Clavicular fractures are the most common bone fracture during delivery and can occur in up to 15 per 1000 live births. The clinical presentation is significant for crepitus at the site of fracture, tenderness and decreased movement of the affected arm with an asymmetric Moro reflex. Clavicular fractures have a good prognosis with spontaneous healing occurring in the majority of infants. The humerus is the most common long bone to fracture during birth, and this can be associated with a brachial plexus injury. The clinical presentation could be similar to a clavicular fracture with an asymmetric Moro reflex, inability to move the affected arm. Also, a significant deformity might be noted on the affected arm with swelling and tenderness at the site of the fracture. Rare conditions may involve a distal humeral epiphyseal separation due to birth trauma requiring expert orthopedic intervention ¹⁶. In general, immobilization for 3 to 4 weeks is necessary and often heals well without deformities. Other fractures such as femur fracture, rib fractures can occur during birth but are rare ¹⁷. On the other hand, femur fractures are extremely rare in newborns and may be seen in difficult vaginal breech extraction deliveries. Diagnosis is made by clinical exam with tenderness, swelling, and deformity of the thigh and confirmed further on plain radiographs. Orthopedic consultation is the recommendation for long bone fractures for appropriate immobilization.

Intracranial hemorrhages

Traumatic intracranial hemorrhages include epidural, subdural, subarachnoid, intraventricular and less frequently intracerebral and intracerebellar hemorrhages.

• Epidural hemorrhage is very rare in neonates and usually accompanies linear skull fractures in the parietal-temporal region following an operative delivery. Signs include bulging fontanelle, bradycardia, hypertension, irritability, altered consciousness, hypotonia, seizures. Diagnosis is via CT or MRI of the head which shows a convex appearance of blood collection in the epidural space. Prompt neurosurgical intervention is necessary due to the potential to deteriorate rapidly.
• Subdural hemorrhage is the most common type of intracranial hemorrhage in neonates. Operative vaginal delivery is a major risk factor, and hemorrhage over the cerebral convexities is the most common site. Presenting signs/symptoms include bulging fontanelle, altered consciousness, irritability, respiratory depression, apnea, bradycardia, altered tone, and seizures. Subdural hemorrhages can occasionally be found incidentally in asymptomatic neonates. Management depends on the location and extent of the bleeding. Surgical evacuation is reserved for large hemorrhages causing raised intracranial pressure and associated clinical signs.
• Subarachnoid hemorrhage is the second most common type of neonatal intracranial hemorrhage and is usually the result of the rupture of bridging veins in the subarachnoid space. Operative vaginal delivery is a risk factor, and the infants are typically asymptomatic unless the hemorrhage is extensive. Ruptured vascular malformations are a rare cause of subarachnoid hemorrhages, even in the neonatal population. Treatment is usually conservative.
• Intraventricular hemorrhage even though most commonly seen in premature infants, can also occur in term infants depending on the nature and extent of the birth injury ¹⁸. Intracerebral and intracerebellar hemorrhages are less common and occur as a result of occipital diastasis.

Brachial plexus injury

Peripheral nerve damage in the form of brachial plexus injury occurs most commonly in large babies, frequently with shoulder dystocia or breech delivery. Incidence for brachial plexus injury is 0.5-2.5 per 1000 live births. Most cases are Erb palsy; entire brachial plexus involvement occurs in 10% of cases.

Traumatic lesions associated with brachial plexus injury include the following:

• Fractured clavicle (10%)
• Fractured humerus (10%)
• Subluxation of cervical spine (5%)
• Cervical cord injury (5-10%)
• Facial palsy (10-20%)

Erb palsy (C5-C6) is most common and is associated with lack of shoulder motion. The involved extremity lies adducted, prone, and internally rotated. Moro, biceps, and radial reflexes are absent on the affected side. The grasp reflex is usually present. Five percent of patients have an accompanying (ipsilateral) phrenic nerve paresis.

Klumpke paralysis (C7-8, T1) is rare and results in weakness of the intrinsic muscles of the hand; the grasp reflex is absent. If cervical sympathetic fibers of the first thoracic spinal nerve are involved, Horner syndrome is present.

A study by Iffy et al ¹⁹ indicated that an approximately four-fold rise in the incidence of shoulder dystocia has occurred in the United States since the mid-20th century, with a review of 11 other countries revealing no comparable increase in most other nations. The investigators considered the rise in dystocia to be primarily related to a trend in the United States, starting in the 1980s, toward active management of the birthing process, in place of a more conservative approach ¹⁹.

Management

Management consists of prevention of contractures. Immobilize the limb gently across the abdomen for the first week and then start passive range-of-motion exercises at all joints of the limb. Use supportive wrist splints.

The best results from surgical repair appear to be obtained in the first year of life ²⁰. Several investigators have recommended surgical exploration and grafting if no function is present in the upper roots at age 3 months, although the recommendation for early explorations is far from universal ²¹.

Complications of brachial plexus exploration include infection, poor outcome, and burns from the operating microscope. Patients with root avulsion do not do well.

Palliative procedures involving tendon transfers have been of some use. Results from a study by Ruchelsman et al ²² of 21 children who suffered brachial plexus birth injury indicated that patients who have no active wrist extension following the trauma can be successfully treated with a tendon transfer but that surgical outcomes tend to be worse in patients with global palsy.

Latissimus dorsi and teres major transfers to the rotator cuff have been advocated for improved shoulder function in Erb palsy. One permanent and 3 transitory axillary nerve palsies have been reported from the procedure.

Prognosis

No uniformly accepted guidelines for determining prognosis are available. Narakas ²³ developed a classification system (types 1-5) based on the severity and extent of the lesion, providing clues to the prognosis in the first 2 months of life.

According to the collaborative perinatal study (59 infants), 88% of cases resolved in the first 4 months, 92% resolved by 12 months, and 93% resolved by 48 months ²⁴. In another study ²⁵, which examined 28 patients with upper plexus involvement and 38 with total plexus palsy, 92% spontaneously recovered.

Residual long-term deficits may include progressive bony deformities, muscle atrophy, joint contractures, possible impaired growth of the limb, weakness of the shoulder girdle, and/or Erb engram flexion of the elbow accompanied by adduction of shoulder.

Cranial nerve injury

Cranial nerve and spinal cord injuries result from hyperextension, traction, and overstretching with simultaneous rotation; they may range from localized neurapraxia to complete nerve or cord transection.

Unilateral branches of the facial nerve and vagus nerve, in the form of recurrent laryngeal nerve, are most commonly involved in cranial nerve injuries and result in temporary or permanent paralysis.

Compression by the forceps blade has been implicated in some facial nerve injury, but most facial nerve palsy is unrelated to trauma from obstetric instrumentation (eg, forceps). The compression appears to occur as the head passes by the sacrum.

Facial nerve is the most common cranial nerve injured with a traumatic birth. It occurs in up to 10 per 1000 live births and is usually a result of pressure on the facial nerve by forceps or from a prominent maternal sacral promontory during descent. Clinical manifestations include diminished movement or loss of motion on the affected side of the face. Physical findings for central nerve injuries are asymmetrical facies with crying. The mouth is drawn towards the normal side, wrinkles are deeper on the normal side, and movement of the forehead and eyelid is unaffected. The paralyzed side is smooth with a swollen appearance, the nasolabial fold is absent, and the corner of the mouth droops. No evidence of trauma is present on the face. With peripheral nerve branch injury, the paralysis is limited to the forehead, eye, or mouth. Facial nerve palsy requires differentiation from asymmetric crying facies which results from nuclear genesis (Möbius syndrome), congenital absence of the facial muscles, unilateral absence of the orbicularis oris muscle, and intracranial hemorrhage. Although forceps delivery has a strong association, facial palsy can occur in the newborn without apparent trauma ²⁶. The prognosis in traumatic facial nerve injury is good with spontaneous resolution usually noted within the first few weeks of life.

Diaphragmatic paralysis

Diaphragmatic paralysis secondary to traumatic injury to the cervical nerve roots that supply the phrenic nerve can occur as an isolated finding or in association with brachial plexus injury. The clinical syndrome is variable. The course is biphasic; initially the infant experiences respiratory distress with tachypnea and blood gases suggestive of hypoventilation (ie, hypoxemia, hypercapnia, acidosis). Over the next several days, the infant may improve with oxygen and varying degrees of ventilatory support. Elevated hemidiaphragm may not be observed in the early stages. Approximately 80% of lesions involve the right side and about 10% are bilateral.

The diagnosis is established by ultrasonography or fluoroscopy of the chest, which reveals the elevated hemidiaphragm with paradoxic movement of the affected side with breathing.

Management and recovery

Most infants begin to recover in the first week, but full resolution may take several months. Palsy that is due to trauma usually resolves or improves, whereas palsy that persists is often due to absence of the nerve.

Management consists of protecting the open eye with patches and synthetic tears (methylcellulose drops) every 4 hours. Consultation with a neurologist and a surgeon should be sought if no improvement is observed in 7-10 days.

Prognosis

The mortality rate for unilateral lesions is approximately 10-15%. Most patients recover in the first 6-12 months. An outcome for bilateral lesions is poorer. The mortality rate approaches 50%, and prolonged ventilatory support may be necessary.

Management consists of careful surveillance of respiratory status, and intervention, when appropriate, is critical.

Psychological birth trauma

Psychological birth trauma, also referred to as traumatic childbirth, is a situation in which the woman has suffered distress as a result of injury to herself and her baby, or pain or sorrow, which is in such a magnitude that it may prone the mother to a traumatic condition, with a prolonged psychological and/or physical effect ²⁷.

It has long been recognized that some women, following a traumatic childbirth, go on to develop some psychological disorders ²⁸. In this connection, Hofberg and Ward ²⁹ believed although pregnancy and childbirth are often desired by women, it is not uncommon to experience some degree of anxiety. Gamble ³⁰ also found a high prevalence of postpartum depression and trauma symptoms occurring after childbirth. The prevalence of psychological birth trauma at a rate between 20 to 30% has been reported by different authors in different countries ³¹. Creedy et al. also reported that one out of every three births can lead mothers to psychological birth trauma. Feeling out of control, depressed, anxious and post-traumatic stress disorders are the consequences of psychological birth trauma ³². In one study, 1.9% of women perceived birth as traumatic and progressed to post-traumatic stress disorder ³³. In addition, about 13% of all women will experience an episode of postnatal depression ³⁴.

Psychological birth trauma can also hurt family relationships ³⁵, reduce the lactation period ³⁶ and, in the long run, the children of these mothers end up with emotional, cognitive and behavioral disorders ³⁷. Postnatal depression may adversely influence infant and child development, as well as having potential negative consequences on women and their families ³⁸. Moreover physical disorders such as those accompanied by excessive fatigue, vital exhaustion, and reduction in functional capacity can be caused by depression following psychological birth trauma ³⁸. Four women in one study suffered from long-term physical consequences from their birth, such as severe pain ³⁹. Furthermore, requesting an elective cesarean birth implies a high level of anxiety about childbirth. However, elective cesarean section does not ‘‘cure’’ the fear of childbirth. Thus, when a pregnant woman requests an elective cesarean section that is not medically endorsed and counseling is recommended ⁴⁰.

Regarding psychological inability to have another child, the most significant finding of one study was that women with a negative experience from their first birth decided not to have another child or considered a longer interval before the second birth ⁴¹. Turning to the mother`s roles, different bonding styles with the child were reported by Nicholls and Ayers which seemed split between “overprotective/anxious bonds and avoidant/rejecting bonds”; in the former, some women reported acting out the mothering role (delayed onset of emotional attachment) ⁴². Also, in one study, initial feelings of rejecting their neonate were reported by the majority of the participants ³⁹. In some cases, women believed that their ability to bond with their children had been affected by the negative childbirth experiences ⁴³. With respect to the relationship with their husband, there is some evidence around sexual avoidance and fear of childbirth. During the first year, following childbirth, some women could not have a sexual relationship with their partners and had a cold and distant sexual behavior with them ²⁸. In addition, some men and women perceived difficulty with intimacy due to birth ⁴¹. In one study all women were under pressure from their relationship with their partners due to the traumatic birth experience ³⁹.

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