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230 Birth Injuries

and hyponatraemia are additional forms of presentation. In fact, in the more
severe cases of bilateral adrenal haemorrhage, the diagnosis is usually made
at postmortem examination. Patients should be resuscitated from shock and
steroid replacement, and electrolytes should be administered in cases with
adrenal involvement. Coagulopathy should be corrected.
Liver
One mechanism of injury to the liver is thoracic compression pushing
the liver down and applying a pull on the hepatic ligaments, leading
16
to a tear of these ligaments at their site of attachment. Another is
Figure 35.2: A severe form of perineal injury from repeated vaginal examination
direct pressure on the liver during the passage of the foetus through
16
the maternal pelvis, leading to subcapsular haemorrhage. In breech from the referral hospital. The child was delivered by a caesarian section due to
delayed second stage and breech presentation.
delivery, blood is compressed from the lower parts of the body and
venous return is retarded by the compression on the chest by the uterus,
1
leading to marked congestion of the solid abdominal organs. Therefore, described following the use of suction or endotracheal tubes. Dislocation
23
if pressure is applied on the trunk instead of the pelvis during delivery, of the triangular cartilage of the nasal septum has been described.
any of these organs may be injured. This is the most common form of Evisceration of the bowel through a wide tear of the umbilical cord
hepatic injury encountered—even more so in the premature baby whose during delivery may occur. This may result in bowel injury, requiring
liver is more exposed. resection and anastomosis. If this occurs immediately after birth, it can
The nonoperative approach to correction of liver injury should be be confused with gastroschisis by the inexperienced birth attendant. 24
considered, as described in Chapter 29 on abdominal injuries. In severe Prevention
cases, particularly in haemodynamically unstable infants, surgical
exploration treatment should be undertaken. Topical haemostatic In developed countries, improvements in obstetrics care, particularly
agents such as fibrin glue are more effective than direct suturing or antenatal ultrasonography, have allowed identification of risk factors for
25
17
electrocoagulation of the involved liver surface. In Africa, where these birth trauma and have led to modification in modes of delivery. Also,
more liberal use of caesarian section, decreased use of difficult forceps
agents may not be available, however, the use of the omentum, which
delivery, and centralisation of high-risk services have reduced the inci-
acts as a plug when sutured in place, is advocated.
dence of birth trauma. In developing countries, however, many deliveries
Adrenal gland still take place outside the orthodox centres. This practice is attended by
The right adrenal gland is most commonly involved in birth injuries. a higher incidence of birth injuries and increased perinatal mortality. 2,3,26
The vertebra exposes it to mechanical compression. The presence of a Health education and training of traditional birth attendants and
neuroblastoma is a risk factor that must always be ruled out in adrenal reduction of delivery fees in hospitals in Africa will reduce the perinatal
trauma. Plain abdominal x-ray will show a rim of calcification only in morbidity and mortality associated with birth injuries.
18
adrenal haemorrhage, as different from the diffuse calcification seen in Evidence-Based Research
the diagnosis of the tumour. Biopsy of the adrenal gland should always
be taken at laparotomy in suspicious cases. Table 35.1 presents a case control study of the incidence of birth trauma
27
Nonoperative treatment suffices in most cases of adrenal injuries. using a five-year review.
Haemorrhage into the perinephric fascia arrests spontaneously. Table 35.1: Evidence-based research.
Unilateral adrenalectomy is tolerated, even though steroid replacement Title Birth trauma. A five-year review of incidence and associated
may be necessary. perinatal factors
Spleen Authors Perlow JH, Wigton T, Hart J, Strassner HT, Nageotte MP,
Injury to the spleen secondary to birth trauma is rare. The mechanism Wolk BM
of injury and clinical presentation are similar to those for the liver. The Institution Department of Obstetrics and Gynecology, Christ Hospital
injury can occur alone but is frequently associated with liver injury. and Medical Center, Oak Lawn, Illinois, USA
Preservation of the spleen is a high priority to avoid the problem of Reference J Reprod Med 1996; 41(10):754–760
19
overwhelming postsplenectomy infection. However, spleen-sparing Problem Birth injury.
surgeries are very difficult in the newborn, and splenectomy is fre-
Intervention Case-control study.
quently carried out.
Comparison/ Compares cases with injury to control births without injury
Kidney control to examine the incidence of clavicular fracture, facial nerve
The kidney is rarely involved in birth injuries. Tissue preservation, just (quality of injury, and brachial plexus injury at birth to identify possible
as for the spleen, is paramount. Intravenous urography is indicated to evidence) risk factors.
assess the extent of renal injuries. CT scan is the modality of choice in Outcome/ The injuries are associated with prolonged gestation,
more accurate assessment of these injuries. effect epidural anaesthesia, prolonged second stage of labor,
oxytocin use, forceps delivery, shoulder dystocia,
Genitourinary Injuries macrosomia, low Apgar scores, and a previous maternal
Foetal manipulations in breech delivery have been associated with scro- obstetric history of macrosomia when compared to
controls. Other significantly associated variables include
tal and testicular injuries in boys. In one particular report, an iatrogenic the presence of meconium in labor and neonatal
injury caused castration in a newborn. 20 hyperbilirubinaemia. Despite the presence of multiple
In girls, severe perineal tears have been described following both perinatal factors that are individually associated statistically
breech delivery and caesarian section (Figure 35.2). These injuries with the injured groups, multiple logistic regression analysis
predicted 44.2% of clavicle fractures, none of the facial
require prompt surgical intervention by way of a multilayered closure nerve injuries, and only 19% of the brachial plexus injuries.
to achieve a good outcome. A significant delay was associated with a Historical
21
fatal outcome from overwhelming sepsis. 22 Significance/ Most reports of birth injuries are case studies; this study,
however, tries to examine for risk factors.
Rare (Unusual) Injuries comments
Injuries to the pharynx, trachea, bronchi, or oesophagus have been