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Traumatic birth injury:wind_blowing_face: (:car: 1.Head trauma (Subgaleal…
Traumatic birth injury:wind_blowing_face:
:tropical_fish:
Introduction
:mostly_sunny:
Risk factors
Failure of adequate birth canal adaptation
Breech position
Precipitous delivery
Large baby relative to size of birth canal
Macrosomia
CPD
Shoulder dystocia
Abnormal presentations (face, brow, transverse)
Use of vacuum or forceps; difficult rotations
Prematurity
Rigid birth canal
Primiparous
Older multipara
Small malformed pelvis
Discrepancy between size or position of fetus in relation to birth canal or an unusually rigid pelvis ➯ Both physical & neurodevelopment handicap
More freq with Instrumented Vx deliveries
:car: 1.
Head trauma
Cephalhematoma
:fried_egg:
Def: localized subperiosteal collections ➯
โย้ได้ข้างใดข้างหนึ่ง แต่ไม่ข้ามmidline
:earth_americas:Incidence
Occurs in 0.2 - 2.5% of live births
:arrow_up: in forceps & vacuum deliveries
Linear skill Fx beneath hematoma เจอ 5% of cases
:sunflower:Causes
By rupture of blood vss that traverse fr Skull to Periosteum
:apple:PE
M/C site = Over the parietal bones
A firm, tense mass that enlarges after birth
:green_apple: Outcomes
Mostly resorb
2 wks - 3 months
(depends on size)➯ leaves some residual circular calcification at the base
Extensive cephalhematoma ➯ can result in Significant hyperbilirubinemia
:deciduous_tree: Mx
ไม่ต้องทำไร มันหายเอง
Subgaleal hematoma
:fried_egg:
Def: occurs beneath scalp in the
subaponeurotic space
— large space ➯ allows extensive blood loss, shock & anemia
:sunflower:Causes
Traction on scalp that shears the emissary veins between the scalp & intracranial venous sinuses
:partly_sunny: Risk factors
M/C — Difficult Vacuum or Forceps extraction
:earth_americas: Incidence
Overall 1 : 2,000
:apple: PE
Boggy fluid collections with Ballotable fluid wave at
beneath the scalp & bleeding extend to above the eyes and back to insertion of Trapezius ms
:green_apple: Complications
Acute blood loss & hypovolemia — life threatening emergency :warning:
:evergreen_tree: Mx
Serial Hct & BP monitoring closely
Scalpel lacerations
:fried_egg:
:earth_americas: Incidence
:arrow_up: in C/S
:apple: PE
Head or Face
:evergreen_tree: Mx
may need tapes, suturing, plastic surgical referral
Skull Fx
:fried_egg:
:boat:Types
Linear
Depressed
:earth_americas: Incidence
usu. forceps delivery (tho normal delivery ก็เจอได้)
Usu. parietal bone
:zap: Dx
Plain skull films (confirm test)
CT if suspect Depressed Fx that assoc. with Intracranial bleeding
:evergreen_tree: Mx
Rarely do Sx as baby bone usu flexible
Intracranial hemorrhages
:fried_egg:
:boat: Types
Epidural
Subdural
Subarachnoid
Intraventricular (less common)
Intracerebral (less common)
Intracerebellar (less common)
:hotsprings:S&S
Symptoms appears
within 24 hrs of birth
Focal/Generalized seizure activity
Altered level of consciousness (AOC)
Irritability
Focal neurological signs dictated by Location of the bleeding
:zap: Dx
Repetitive clinical examinations
Serial Hct — to assess blood loss
CT brain for Epidural, subdural, or subarachnoid blood
:evergreen_tree: Mx
:crown: Concept
Regconition
Monitoring
Rx of serious consequences
Continuous cardiorespiratory
monitoring
Apnea
Periodic breathing
Hypotension
Heart rate irregularities
Serial neuro. exams
focus on
Level of consciousness
Evidence of focal ms weakness
Brainstem / Cranial nerves signs
Evidence of seizure activity
Develop signs of :arrow_up: intracranial pressure fr Subdural hemorrhage or Epidural collections ➯ require
Acute surgical drainage of blood
Seizures ➯ Phenobarbital
:green_apple: Outcomes
Subarachnoid bleeding & Convexity subdural hemorrhages ➯ Develop normally
without future seizure problems
Posterior fossa subdural blood collections ➯ Death related to Brainstem compression, Hydrocephalus and Long term
neurodevelopmental
sequela among survivors
Should monitor closely for Attainment of developmental milestones
:car:2.
Traumatic nerve & Spinal cord injuries
Brachial plexus injuries
:bulb:
:world_map:Incidence
0.5 - 2.5 per 1,000 live births
:sunflower: Cause:
stretchung of cervical nerve roots fr traction on neck during delivery
:partly_sunny: Risk factors
Macrosomia
Difficult delivery
Shoulder dystocia
Breech position
Multiparity
Assisted deliveries
:white_flower: S&S
assoc. with Damage to the nerve roots —that form Phrenic nerve & controls diaphragmatic func
Tachypnea
Asymmetric chest motion during respiration
Diminished breath sounds on Side of paralysis
Assoc. with Damage to Sympathetic outflow (via nerve root T1)
can result in an associated
Horner’s syndrome
Miosis
Ptosis
Enophthalmos
:lion_face: Types
:star:m/c injury 1. Erb-Duchenne palsy (Erb’s palsy)
Cause:
Damage to 5th & 6th cervical nerve roots
Clinical:
Waiter’s tip position
Klumpke paralysis (Klumpke’s palsy)
Clinical:
isolated lower arm palsy
supinated hand, wrist extended, finger clawed
Loss of grasp reflex
Cause:
injury to 8th cervical & 1st thoracic n.
Total arm paralysis
Cause:
damage to all nerve roots
:male-scientist::skin-tone-4:Inx
CXR: Elevated hemidiaphragm
U/S: demon. lack of or paradoxi diaphragmatic movement
:green_apple:Outcomes
As swelling around nerve roots resolves ➯most nerve palsie
resolve spontaneously
75 - 90% of pt — achieve complete recovery
arm function resolves completely over several days to 4 wks
:evergreen_tree: Mx
Diaphragmatic paralysis infants:
O2 supplementation or Mechanical ventilation
Infants that remain ventilator-dependent for 6-8 wks ➯
Surgical diaphragm plication should be considered
Facial nerve injury
:bulb:
:star:
M/C neonatal
traumatic n. Injury (up to 1% of livebirths)
:sunflower: Causes
Pressure on facial n. Fr sacral promontory
or
Fetal shoulder as infant passes thru birth canal or by forceps application
:white_flower: S&S
Loss of motion on affected side with Open eye
Drooping mouth
Lack of expression
Inability to wrinkle the brow
Must
ddx from
Congenital hypoplasia of the depressor anguli oris muscle—control mouth ➯ so when close eyes(close ดี) but
one
drooping side of mouth
:evergreen_tree: Mx
Liquid tears or Lid closure to preserve moisture in the affected side eyes
:green_apple: Outcomes
(90% of infants
recover within 4 wks of birth
)
Spinal cord injuries
:bulb:
Rare!
:partly_sunny: Risk factors
Mid-forceps rotations & Difficult breech extractions ➯ Excessive longitudinal or lateral traction or rotation of SC
Upper cervical injuries — assoc. with rotations fr Cephalic position
Thoracolumbar injuries occurs with Breech presentation
:white_flower: S&S
Stillbirth / Rapid neonatal death
Respi. Failure
Generalized weakness
Paralysis & areflexia of Lower extremities with Variable upper extremity involvement
Distended bladder
Patulous anus
:male-scientist::skin-tone-5: Lab inx
Radiographs to R/O vertebral Fx or Dislocation
Bedside U/S to identify swelling & hemorrhage in cord
MRI (definite dx
& R/O potentially
treatable lesion
—such as Occult dysraphism
Suspects SC injury in infant? ➯ If yes, stabilized & referred to Tertiary center for further evaluation + Mx
Initial stabilization including
adequate oxygenation & perfusion using Mechanical ventilation
volume infusion if needed
Decompressed bladder with
indwelling catheter
➯ spine is stabilized
& infant sedated
:green_apple:Outcome
Often result in death/paralysis with dependence on Long term care
Prog is better for lesions below T4
Disability correlates with Timing of onset of respiratory effort, Extibstion, and rare of motor recovery over the first 3 months after birth
:car: 3.
Bone and Soft-tissue injuries
Bone injuries
:hotdog:
Types :cat:
Fx humerus
:star:
m/c long bone Fx
If nondisplaced ➯ Fx can be asymptomatic
Fx clavicle
:world_map: Incidence
0.5-1.5% of live births
:arrow_up: in presence of Shoulder dystocia & Breech extractions
:star:
m/c bone to fx during delivery
:white_flower: S&S
Crepitus
Swelling
Pain on movement
:arrow_down:Limb movement
Deformity
:deciduous_tree: Mx
Limits mobility
Splint to reduce pain
:green_apple: Outcome
Fx of clavicle & humerus are
rarely displaced
Most commonly
resolved w/o fixed immobilization
Soft tissue injuries
:meat_on_bone:
:star:
m/c form of Traumatic birth injury
Includes
Petechiaes
Common sites: Usu. present over
head, neck and upper thorax
Present
after birth
,
no progresses
, Not associated with other bleeding
Bruising
Breech deliveries usu see
severe vaginal or scrotal edema
Usu. resolves spontaneously
Subcutaneous fat necrosis
Def: A localized area of induration of Red or Purple discoloration
due to local ischemia fr Trauma
Usu. presents
Late during 1st postnatal week
Common sites — cheeks, shoulders, buttocks, thighs, calves
Complication
m/c: Hypercalcemia
:green_apple:Outcomes
Resolves by 6-8 wks
Superficial soft-tissue injuries resolves with the only sequelae being Localized infection and Neonatal bilirubinemia
Subcutaneous fat necrosis ➯ can cause symptomatic hypercalcemia at 3-4 wks
:car: 4.
Intra-abdominal trauma
Types :cake:
Solid organ injury
(related to Downward rib pressure & traction on supporting ligaments
Liver Fx & Rupture of subscapular hematomas
S&S: shock, pallor, anemia, abd distention and bluish discoloration
Splenic rupture
S&S: shock, pallor, anemia, abd distention and Palpable mass in LUQ
Adrenal hemorrhage
other RFs for this
Hypoxia
Shock
-Septicemia
Neonatal stress
adrenal tumor
Intravascular coagulation
:green_heart:
Mx
Supportive with
Volume infusions
Blood & Clotting factors replacement
Surgical intervention as needed