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Birth Injuries 229

ate postnatal period. The infants who survive with spinal injury may
have permanent neurological abnormalities due to the damage to the
spinal cord or the vertebral arteries. The mechanism of injury to the
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spinal cord involves application of strong traction when the spine is
hyperextended or when the direction of pull is lateral. It may also occur
with a forceful longitudinal pull when the head is firmly engaged. The
most common part of the spinal cord involved is the upper cervical C4
with cephalic presentation. Affectation of vertebra above C4 is usu-
ally fatal due to compromised respiration because the vital centres in
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the upper cervical cord and brain stem may be involved. In addition,
lower cervical cord injuries (C5–C7) may occur with breech deliver-
ies. Neurological signs may be produced by haemorrhage or oedema.
Plain radiography is not very helpful because cord transection can
occur without vertebral fractures. Ultrasonography (US) and magnetic
resonance imaging (MRI) are best to characterise the site and extent of
injuries and are usually confirmatory.
The mainstay of treatment is supportive, with physiotherapy,
urology, orthopaedics, and psychology involved. This supportive
treatment may mean endotracheal intubation for artificial respiration
in the upper cervical injury group. Therefore, great emphasis is placed
on prevention.
Intracranial trauma
This trauma is usually intracranial haemorrhage and can be subdural,
subarachnoid, or intracerebral. Intracranial trauma usually follows
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Figure 35.1: The rare occipital cephalhaematoma in an infant. vacuum extraction of the foetus.
Subdural haemorrhage
Acute subdural haemorrhage is a recognised cause of increased head
In the Déjerine-Klumpke palsy, the lower part of the brachial plexus circumference and anaemia soon after birth. The haemorrhage is from
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(C8, T1) is involved, causing wrist drop with associated paralysis of the dural sinuses or the major cerebral veins. The clinical features are those
hand. Horner’s syndrome is frequently associated with this injury. This of a focal neurological deficit, hemiparesis, unequal pupils, or deviation
has a worse prognosis than Erb-Duchenne paralysis. of the eyes. Other symptoms include bulging anterior fontanelle, pal-
Patients are followed up closely with both active and passive lor, vomiting, irritability, and seizures. The diagnosis is suggested by a
exercises. Most patients make a complete recovery on this conservative subdural tap. Computed tomography (CT) scan and MRI are required to
management. Persistence of deficit for 3 months is an indication for confirm the diagnosis. The treatment is by repeated tap of the subdural
surgical intervention, but this is rare. space by using a size 20G needle.
Neurolysis, end-to-end anastomosis, and nerve grafting are some Subarachnoid haemorrhage
of the surgical procedures employed. Primary surgery for brachial Subarachnoid haemorrhage results from damage to the veins travers-
plexus lesions with modern microsurgical techniques is an emerging ing the subrachnoid space. It is the most common form of intracranial
surgical option, with the prospect of improving functional recovery haemorrhage related to the trauma of birth. Subarachnoid haemorrhage
in carefully selected patients who would otherwise be faced with is suspected on lumbar puncture with frank blood or a tinge of blood.
lifelong impairment and secondary skeletal deformities. Grafting and There is no treatment required, as it resolves spontaneously.
extraplexal neurotisation are the procedures most commonly involved. Intracerebral haemorrhage
Donor nerves include the intercostal nerves, phrenic nerve, spinal Intracerebral haemorrhage is the least common intracranial trauma. The
accessory nerve, and contralateral C7 root. 9–10 clinical presentation is that of increased intracranial pressure. Serial
Facial nerve US, CT, and MRI are needed to monitor the regression.
Facial nerve injury may follow forceps delivery for face presentation Solid Abdominal Visceral Injuries
or may arise from pressure from the birth canal during labour. Facial Solid abdominal visceral injuries are the most serious complications of
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nerve injury is of the lower motor neurone lesion in most cases; it usu- birth trauma, but, fortunately, they are comparatively rare. The liver
ally recovers with nonoperative treatment. In facial nerve paralysis, is the most common organ involved, followed by the adrenal gland,
care of the exposed cornea is important. This is done by instillation of spleen, and kidney, in that order. The presenting symptoms are severe
methylcellulose into the conjunctival sac. 11 shock and abdominal distention. These patients may appear normal
Phrenic nerve for the first 3 days, however; therefore, a high index of suspicion is
The phrenic nerve is rarely involved; this nerve affects diaphragmatic required to make an early diagnosis. Refusal of feeds, listlessness, and
function. It needs to be differentiated from congenital diaphragmatic rapid respiration in the presence of a rapidly developing anaemia should
hernia or eventration of the diaphragm. Chest infections are a serious alert the physician to the possibility of internal bleeding. The presence
complication of this injury. Spontaneous recovery is expected in 1–3 of scrotal haematoma is an indication of haemoperitoneum usually in
months. After 3 months without recovery, operative intervention is a patient with persistence of the processus vaginalis. Abdominal para-
indicated. Imbrication or prosthetic replacement of the diaphragm is centesis will confirm haemoperitoneum. Abdominal ultrasound will
usually carried out. 12 confirm the injury and is also used in monitoring patients where non-
operative treatment is used. Coagulopathy and hypoxia are contributing
Spinal cord factors to injuries.
Spinal cord injury is one of the most devastating injuries because in In bilateral injuries involving the adrenal gland, acute adrenal
the very severe cases, the babies may be stillborn or die in the immedi- insufficiency characterised by pyrexia, convulsions, coma, hypoglycaemia,