Birth Injuries

. Injuries sustained during the birth process are responsible for a significant amount of neonatal mor­tality and morbidity. In 2000, birth injuries ranked as the eighth leading cause of infant death in the United States. Predisposing factors for birth injuries include macrosomia, prematurity, cephalopelvic disproportion, and dystocia (i.e., abnormal labor or childbirth).¹²,¹⁸

Cranial Injuries. The contour of the head of the newborn often reflects the effects of the delivery presentation. In vertex (head-first) deliveries, the head is usually flattened at the forehead, with the apex rising and forming a plane at the end of the parietal bones and the posterior skull or occiput dropping abruptly. By 1 to 2 days of age, the head has taken on a more oval shape. Such head molding does not occur in babies born by breech presentation or by ce-sarian section.

Caput succedaneum is a localized area of scalp edema caused by sustained pressure of the presenting part against

TABLE 2-1	Apgar Score Assessment
		Score*
Criterion	0	1	2
Heart rate Absent Respiratory effort Absent Muscle tone Limp Reflex irritability No response Color Pale Total 0	<100 Weak, irregular Some flexion Grimace Cyanotic 5	>100 Crying Well flexed Cry, gag Pink 10

* The Apgar score should be assigned at 1 minute and 5 minutes after birth, using a timer. Each criterion is assessed and assigned a 0, 1, or 2. The total score is the assigned Apgar score. If resuscitation is required beyond the 5 minutes, additional Apgar scores also may be assigned as a method to document the response of the newborn to the resuscitation.

 

the cervix. An accumulation of serum or blood forms above the periosteum from the high pressure caused by the obstruction. The caput succedaneum may extend across suture lines and have overlying petechiae, purpura, or ecchymosis. No treatment is needed, and it usually re­solves over the first week of life.¹²,¹⁸

Cephalohematoma is a subperiosteal collection of blood from ruptured blood vessels. The margins are sharply delineated and do not cross suture lines. It usually is uni­lateral, but it may be bilateral, and it usually occurs over the parietal area. The swelling may not be apparent for 24 to 48 hours because subperiosteal bleeding is slow. The overlying skin is not discolored. An underlying skull frac­ture may be present. Treatment is not needed unless the cephalohematoma is large and results in severe blood loss or significant hyperbilirubinemia. Skull fracture and in-tracranial hemorrhage are associated complications. An uncomplicated cephalohematoma usually resolves within 2 weeks to 3 months.¹¹,¹⁵

Fractures. Skull fractures are uncommon because the in­fant's compressible skull is able to mold to fit the contours of the birth canal. However, fractures can occur and more often follow a forceps delivery or severe contraction of the pelvis associated with prolonged, difficult labor. Skull frac­tures may be linear or depressed. Uncomplicated linear fractures often are asymptomatic and do not require treat­ment. Depressed skull fractures are observable by the pal­pable indentation of the infant's head. They require surgical intervention if there is compression of underlying brain tissue. A simple linear fracture usually heals within several months.^12,18

The clavicle is the bone most frequently fractured dur­ing the birth process. It is more common in LGA infants and occurs when delivery of the shoulders is difficult in vertex (i.e., head) or breech presentations. The infant may or may not demonstrate restricted motion of the upper ex­tremity, but passive motion elicits pain. There may be dis­coloration or deformity and, on palpation, crepitus (i.e., a crackling sound from bones rubbing together), and irregu­larity may be found. Treatment consists of immobilizing the affected arm and shoulder and providing pain relief.¹²,¹⁸

Peripheral Nerve Injuries. The brachial plexuses are situated above the clavicles in the anterolateral bases of the neck. They are composed of the ventral rami of the fifth cervical nerves through the first thoracic nerves. During vertex de­liveries, excessive lateral traction of the head and neck away from the shoulders may cause a stretch injury to the brachial plexus on that side. In a breech presentation, ex­cessive lateral traction on the trunk before delivery of the head may tear the lower roots of the cervical cord. If the breech presentation includes delivery with the arms over­head, an injury to the fifth and sixth cervical roots may re­sult. When injury to the brachial plexus occurs, it causes paralysis of the upper extremity. The paralysis often is incomplete.^12,18,19

Brachial plexus injuries include three types: Erb-Duchenne paralysis (i.e., upper arm), Klumpke's paralysis (i.e., lower arm), and paralysis of the entire arm. Risk fac­tors include an LGA infant and a difficult, traumatic de­livery. Erb-Duchenne paralysis occurs with injury to the fifth and sixth cervical roots. It is the most common type of brachial plexus injury and manifests with variable degrees of paralysis of the shoulder and arm. The position of the affected arm is adducted and internally rotated, with ex­tension at the elbow, pronation of the forearm, and flex­ion of the wrist. When the infant is lifted, the affected extremity is limp. The Moro reflex is impaired or absent, but the grasp reflex is present.

Klumpke's paralysis results from injury to the seventh and eighth cervical and first thoracic nerve roots. It is rare and presents with paralysis of the hand. The infant has wrist drop, the fingers are relaxed, and the grasp reflex is absent. The Moro reflex is impaired, with the upper ex­tremity extending and abducting normally while the wrist and fingers remain flaccid.¹²,¹⁸,¹⁹

Treatment of brachial plexus injuries includes immo­bilization, appropriate positioning, and an exercise pro­gram. Most infants recover in 3 to 6 months. If paralysis persists beyond this time, surgical repair (neuroplasty, end-to-end anastomosis, nerve grafting) may be done.¹⁹