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CHAPTER 35

Birth Injuries

Auwal M. Abubakar
Johanna R. Askegard-Giesmann
Brian D. Kenney

Introduction suggests child abuse rather than birth injury, especially if the bones
The majority of birth injuries are minor and often unreported. involved are those other than the ones commonly affected in birth
Occasionally, though, birth injuries may be so severe as to be fatal or injuries. Dislocations following birth trauma are generally rare.
leave the child with a permanent disability. They may occur because Clavicle
of inappropriate or deficient medical skills or attention, but they also The clavicle is the most common fracture in the newborn, following
can occur despite skilled and competent obstetrical care. Birth inju- from difficulty with delivery caused by shoulder dystocia. Many times,
7
ries are mostly iatrogenic, and the legal implications of these should the fracture is noticed only when callous formation begins. It is usu-
be noted. Most of these injuries can be managed nonoperatively, but ally a green stick fracture and occasionally is associated with brachial
prompt identification of those that will need surgical intervention plexus injury. Fracture of the clavicle requires no treatment.
is essential.
Long bones
Demographics Fracture involving the long bones is not common. The femur may be
The incidence of significant birth injuries in the United Sates is 6–8 involved during a difficult breech delivery when traction is applied to
per 1,000 live births, accounting for less than 2% of perinatal mortal- extract the foetus; usually the midshaft is involved. This fracture is treat-
8
1
ity. In Africa, statistics on birth injuries are lacking. However, a sur- ed by skin traction or splinting with a spica cast. Fracture of the humerus
vey of rural Egyptian birth attendants in different regions revealed an is encountered during a difficult delivery of the shoulder in a vertex pre-
overall prevalence of birth injuries at 7%, and up to 17% in the Aswan sentation. Humeral fractures may be associated with Erb’s or radial nerve
2
region. Autopsy studies on stillbirths from Accra, Ghana, also esti- palsy. These fractures are treated by restricting the baby’s movements by
mate the incidence of perinatal deaths due to birth trauma as 5.4%. 3 bandaging the arm to the chest for a period of 1 to 3 weeks.
Aetiology Skull
The risk factors for birth injuries are as follows: Linear fracture, especially of the parietal bone, is the most common
4–6
injury seen; it needs no treatment. Depressed skull fractures may
1. primigravida;
require elevation, depending on severity. Closed elevation of a so-
2. maternal age younger than 16 or older than 35 years;
called “ping-pong” fracture can be achieved by the use of the vacuum
3. high neonatal birth weight; extractor. Open elevation will be required if there is increased intracra-
4. maternal parity >6; nial pressure, neurological deficit, or when bony fragments are project-
ing into cerebral tissue.
5. prolonged or precipitate delivery;
6. cephalopelvic disproportion; Cephalhaematoma
Cephalhaematoma is a subperiosteal haemorrhage, which is limited
7. foetal presentation (face, breech);
to one cranial bone by surrounding cranial sutures (Figure 35.1). It
8. type of delivery (forceps, vacuum); appears on the second day of life; this is an important feature distin-
9. prematurity; guishing it from caput succedaneum. There may be a linear fracture of
10. postmaturity; the underlying bone. Most cephalhaematomas are resorbed within 2
weeks to 3 months of age. A massive cephalhaematoma may require
11. organomegaly and mass lesions in the abdomen; and
blood transfusion. Aspiration or incision of the swelling is contraindi-
12. coagulopathy. cated. Calcification of the haematoma may require surgical excision.
Injuries are sustained as a result of mechanical impact on the Neurological Injuries
foetus during birth due to pressure in the birth canal or to traction
and pressure produced by manipulations during delivery. The risk of Brachial plexus
injury to infants during breech delivery is about twice that with vertex The most common neurological injury is brachial plexus injury. Infants
delivery. Birth injuries can also occur, however, in spontaneous, full- with brachial plexus injuries are typically large, with a difficult labour
term, apparently uncomplicated deliveries. and frequent shoulder dystocia or breech presentation. The predominance
Clinical Presentation and Management of the right plexus injury is related to the common left occipito-anterior
presentation that leaves the right shoulder against the pubic arch. Erb-
Fractures Duchenne paralysis results if the upper roots (C5, C6) are involved. The
Most fractures following birth trauma heal spontaneously. Nonunion arm appears adducted and internally rotated, and the forearm is pronated.
is almost unknown. The most common bones involved are the The Moro reflex on the ipsilateral side is also absent. The hand muscles,
clavicle, femur, humerus, and skull. Calcification of these fractures is however, are intact and without sensory deficit. The phrenic nerve is
evident by the second week of life. The absence of such calcifications involved in 5% of cases, and should always be ruled out.