Birth Trauma Alix Paget-Brown, MD Division of Neonatology, Department of Pediatrics, University of Virginia

Outline Overview of birth injuries Discussion of specific traumatic birth injuries Cases (with treats)

Birth injuries Incidence Risk factors 6-8:1000 live births <2% of neonatal deaths/stillbirths From 1970 – 1985, 88% decrease in mortality resultant from birth trauma (to 7.5:100,000) Risk factors Primigravida Prolonged or precipitous labor Size discrepancies (LGA, small pelvic outlet…) Instrumentation Oligohydramnios

Outline Epidemiology, diagnosis, prognosis of: Scalp injuries Subgaleal hemorrhage Cephalhematoma Caput succedaneum Intracranial hemorrhage Subdural hemorrhage Neurologic injuries (NOT hypoxic-ischemic encephalopathy) Brachial plexus injuries Spinal cord injuries Orthopedic injuries Clavicular fractures Long bone fractures Intra-abdominal injuries Liver/splenic rupture Adrenal hemorrhage

Outline Epidemiology, diagnosis, prognosis of: Scalp injuries Subgaleal hemorrhage Cephalhematoma Caput succedaneum Intracranial hemorrhage Subdural hemorrhage Neurologic injuries (NOT hypoxic-ischemic encephalopathy) Brachial plexus injuries Spinal cord injuries Orthopedic injuries Clavicular fractures Long bone fractures Intra-abdominal injuries Liver/splenic rupture Adrenal hemorrhage

Subgaleal Hemorrhage Incidence/pathology 1.5:10,000 live births Neonatal emergency 90% of subgaleal hematomas have history of vacuum delivery 40% associated with underlying head trauma (skull fracture/intracranial hemorrhage) Occurs due to tearing of emissary veins connecting dural sinuses and scalp veins Accumulation of blood (up to 260ml) between the galeal/epicranial aponeurosis of the scalp and the periosteum

Subgaleal Hemorrhage Diagnosis/Presentation Boggy, enlarging posterior (predominantly occipital) mass starting at delivery – 72 hours Crosses suture lines, can obscure fontanelles Dropping hematocrit (quickly!!!), shock, hypovolemia, seizures… Head CT

Subgaleal hemorrhage

Subgaleal Hemorrhage cont’d Work up Physical exam, serial hematocrit, serial bilirubin, coags, consider head CT, coagulopathy evaluation Treatment Supportive Blood transfusion, FFP and cryoprecipitate as needed, anti-epileptic medications as needed Prognosis Mortality up to ~ 25% Neurological outcome dependent on the presence of shock, intracranial pathology

Cephalhematoma Hematoma Common (vaginal +/- instrumentation) Diagnosis: Sub-periosteal bleeding overlying one cranial bone (usually parietal, sometimes occipital) Does not cross suture lines 5-20% have underlying skull fractures (usually linear) No workup needed (usually)

Cephalhematoma Hematoma Complications: Anemia, hypovolemia, hyperbilirubinemia, infection Treatment: Observation Treatment of hypovolemia, hyperbilirubinemia as needed Do NOT aspirate (increased risk of infection) Resolves in 2 weeks – 6 months Occasionally leaves residual calcifications

Cephalhematoma Hematoma

Caput succedaneum Very common, occurs in vaginal deliveries Edema in presenting part of the scalp, sometimes with bleeding/petechiae/bruising Workup None Treatment Resolution Several days

Caput succedaneum

Locations of scalp hematomas

Outline Epidemiology, diagnosis, prognosis of: Intracranial hemorrhage Scalp injuries Subgaleal hemorrhage Cephalhematoma Caput succedaneum Intracranial hemorrhage Subdural hemorrhage Neurologic injuries (NOT hypoxic-ischemic encephalopathy) Brachial plexus injuries Spinal cord injuries Orthopedic injuries Clavicular fractures Long bone fractures Intra-abdominal injuries Liver/splenic rupture Adrenal hemorrhage

Subdural Hemorrhage Incidence Diagnosis Work up Treatment Prognosis 2.9:10,000 live births (subdural or intracranial hemorrhage) Usually subsequent to an instrumented delivery or difficult delivery placing extreme stress on the newborn head Diagnosis Physical exam: lethargy, stupor, coma, seizures in the immediate perinatal period Head CT Work up Head CT, EEG (as needed) Blood work/sepsis evaluation Coagulation work up Treatment Neurosurgical consultation, possible need for surgical evacuation Prognosis Guarded Closely related to exam at presentation, rapidity of treatment

Subdural Hemorrhage

Outline Epidemiology, diagnosis, prognosis of: Scalp injuries Subgaleal hemorrhage Cephalhematoma Caput succedaneum Intracranial hemorrhage Subdural hemorrhage Neurologic injuries (NOT hypoxic-ischemic encephalopathy) Brachial plexus injuries Spinal cord injuries Orthopedic injuries Clavicular fractures Long bone fractures Intra-abdominal injuries Liver/splenic rupture Adrenal hemorrhage

Brachial plexus injuries Incidence 0.5-2:1000 live births Only ~ 50% associated with shoulder dystocia Resulting from stretch/avulsion of the C5-T1 nerve roots May have underlying bony injury 5% of brachial plexus injuries have associated phrenic nerve injury

Duchenne-Erb Palsy Most common brachial plexus injury Injury of C5-C6 Presentation The extremity lies adducted, prone, and internally rotated. Moro, biceps, and radial reflexes are absent on the affected side. Grasp reflex is usually present. Work up Chest and extremity radiographs to evaluate the presence of bony trauma/phrenic nerve injury

Duchenne-Erb Palsy Treatment Prognosis Goal: prevent contractures (return of function happens ‘by itself’) 1st week – tie the infant’s sleeve to the shirt across the chest 2nd week – begin range of motion to prevent contractures Controversial – nerve graft to replace injured segment Prognosis 88% recovery at 4 months; 92% at 12 months; 93% at 48 months

Duchenne-Erb Palsy

Klumpke palsy Very rare, usually following vaginal breech delivery C7-T1 nerve roots affects Weakness of the intrinsic muscles of the hand in the newborn period Classically, it produces flexion and supination of the elbow, extension of the wrist, hyperextension of the metacarpophalangeal joints, and flexion of the interphalangeal joints with the “claw hand” posture beyond the neonatal period Frequently associated with Horner syndrome (ipsilateral ptosis and pupil constriction) when the cervical sympathetic fibers at T1 are involved

Klumpke

Phrenic nerve injury Part of the complex of brachial plexus injuries Associated with higher brachial complex damage (C3, 4, 5…) More frequent with difficult breech deliveries 80% involve the right side, 10% are bilateral Presentation with abdominal breathing, cyanosis, respiratory failure

Phrenic nerve injury Diagnosis Treatment Prognosis Pathognemonic chest radiograph, arterial blood gases showing hypoxemia/ventilatory failure, fluoroscopy/ultrasound showing diaphragmatic paresis Treatment Supportive Possible need for diaphragmatic plication, pacing Prognosis Mortality ~ 50% for bilateral lesions, 10-15% for unilateral lesions Recovery in 6-12 months

Phrenic Nerve Injury

Spinal cord injuries Incidence Cause Unknown, possibility of some still-births resulting from upper cervical spinal injury Cause from excessive traction (breech deliveries) or torsion (vaginal deliveries) May happen in-utero Cause Hemorrhage, stretch, transection of the cord

Spinal cord injuries Presentation Upper c-spine Lower c-spine T-spine Paralysis, severe respiratory depression Lower c-spine Hypotonia, some respiratory compromise T-spine Paraplegia, urinary and respiratory compromise

Spinal cord injuries Management Diagnosis Prognosis Supportive measures No role for laminectomy/surgery Possible role for methylprednisolone Diagnosis MRI X-ray of the cervical and thoracic spines Prognosis Very poor, dependent on the level/severity of the lesion

Outline Epidemiology, diagnosis, prognosis of: Orthopedic injuries Scalp injuries Subgaleal hemorrhage Cephalhematoma Caput succedaneum Intracranial hemorrhage Subdural hemorrhage Neurologic injuries (NOT hypoxic-ischemic encephalopathy) Brachial plexus injuries Spinal cord injuries Orthopedic injuries Clavicular fractures Long bone fractures Intra-abdominal injuries Liver/splenic rupture Adrenal hemorrhage

Clavicular fracture Common, can complicate normal atraumatic deliveries Diagnosis Physical exam, chest x-ray Suspect in infant with pain reaction Can present as ‘pseudoparalysis’ MUST rule out other nerve/spinal damage

Clavicular fracture Treatment Prognosis Aimed at pain reduction Pin sleeve to chest May require surgical intervention if fractured ends don’t approximate well Prognosis Excellent Initiation of callus formation in 7-10 days

Clavicular fracture

Long bone fracture Complication associated with prolonged labor, difficult delivery Diagnosis First sign may be cracking felt by obstetrician Loss of motion of the extremity, pain on passive motion, swelling X-ray of affected extremity Rule out radial nerve compression in humeral head fractures

Long bone fracture Treatment Prognosis Splinting May require open reduction only in cases of non-approximation Prognosis Great Healing to cease immobilization sufficient in 8-10 days, complete recovery in 2-4 weeks

Outline Epidemiology, diagnosis, prognosis of: Scalp injuries Subgaleal hemorrhage Cephalhematoma Caput succedaneum Intracranial hemorrhage Subdural hemorrhage Neurologic injuries (NOT hypoxic-ischemic encephalopathy) Brachial plexus injuries Spinal cord injuries Orthopedic injuries Clavicular fractures Long bone fractures Intra-abdominal injuries Liver/splenic rupture Adrenal hemorrhage

Liver/Splenic rupture Very rare but deadly Presents from immediately postpartum – several days postpartum Risk factors Pre/post dates, hepatomegaly, significant resuscitative efforts, difficult delivery requiring traction (breech, c-section) Presentation Pallor, shock, vascular collapse, anemia, abdominal distention May be insidious or fulminant Hepatic bleed usually after rupture of hepatic hematoma (>4-5cm)

Liver/Splenic rupture Diagnosis Abdominal ultrasound showing free fluid Paracentesis Treatment Aggressive fluid/colloid resuscitation, coagulation correction (FFP, cryoprecipitate, platelets as needed) Surgical repair

Adrenal hemorrhage Increased risk with prematurity, asphyxia, neonatal neuroblastoma Presentation Pallor, hypotension, shock, vomiting, diarrhea, fever, tachypnea, flank mass Diagnosis Ultrasound, cortisol level (not diagnostic if low…) Treatment Red cell transfusion, i.v. steroids