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Obstetrics Simplified - Diaa M. EI-Mowafi

Foetal Birth Trauma

HEAD INJURIES

Fracture Skull

Usually occurs due to difficult forceps delivery. It may be:

  • Vault fracture:
    • usually affecting the frontal or parietal bone.
    • It may be linear or depressed fracture.
    • It needs no treatment unless there is intracranial haemorrhage.
  • Fracture base:
    • usually associated with intracranial haemorrhage.

Cephalhaematoma

  • It is a subperiosteal haematoma most commonly lies over one parietal bone.
  • It may result from difficult vacuum or forceps extraction.

Diagnosis and Differential Diagnosis

Cephalhaematoma Caput Succedaneum
Develops hours or days after birth. Present at birth.
Localised haematoma to one bone limited by sutures at its edges. Diffuse tissue oedema overlying more than one bone.
Well-defined edges. Ill-defined edges.
Elastic, does not pit on pressure. Soft , pits on pressure.
Disappears within few weeks. Disappears within 1-2 days.

Management

  • It usually resolves spontaneously.
  • Vitamin K 1 mg IM is given.

Intracranial Haemorrhage

Causes

  • Sudden compression and decompression of the head as in breech and precipitate labour.
  • Marked compression by forceps or in cephalopelvic disproportion.
  • Fracture skull.

Predisposing factors

  • Prematurity due to physiological hypoprothrombinaemia, fragile blood vessels and liability to trauma.
  • Asphyxia due to anoxia of the vascular wall .
  • Blood diseases.

Sites

  • Subdural: results from damage to the superficial veins where the vein of Galen and inferior sagittal sinus combine to form the straight sinus.
  • Subarachnoid: The vein of Galen is damaged due to tear in the dura at the junction of the falx cerebri and tentorium cerebelli.
  • Intraventricular: into the brain ventricles.
  • Intracerebral: into the brain tissues .

Subdural and subarachnoid haemorrhage is usually due to birth trauma, in Intraventricular and Intracerebral haemorrhage the foetus is usually a premature exposed to hypoxia.

Clinical picture

  • Altered consciousness.
  • Flaccidity.
  • Breathing is absent, irregular and periodic or gasping.
  • Eyes: no movement, pupils may be fixed and dilated.
  • Opisthotonus, rigidity, twitches and convulsions.
  • Vomiting.
  • High pitched cry.   
  • Anterior fontanelle is tense and bulging.
  • Lumbar puncture reveals bloody C.S.F.

Investigations

  • Ultrasound is of value.
  • CT scan is the most reliable.

Prophylaxis

  • Vitamin K: 10 mg IM to the mother in late pregnancy or early in labour.
  • Episiotomy: especially in prematures and breech delivery.
  • Forceps delivery: carried out by an experienced obstetrician respecting the instructions for its use.

Treatment

  • Minimal handling, warmth and oxygen to the baby.
  • No oral feeding for 72 hours.
  • IV fluids.
  • Vitamin K 1mg IM.
  • Lumbar puncture: is diagnostic and therapeutic to relieve the intracranial tension if the anterior fontanelle is bulging.
  • Sedatives for convulsions.
  • 60 cc. of 10% sodium chloride per rectum to relieve brain oedema.
  • 1 cc of 50% magnesium sulphate IM to relieve brain oedema and convulsions.
  • Antibiotics: to guard against infections particularly pulmonary.

BONE INJURIES

These usually occur during difficult breech delivery.

Vertebral Column Injuries

These are fatal if associated with spinal cord transection above C4 due to diaphragmatic paralysis.

Femur, Humerus and Clavicle

Managed by splint to the long bone and a sling for clavicular fracture.

NERVE INJURIES

Facial Palsy (Bell’s palsy)

  • It is usually due to pressure by the forceps blade on the facial nerve at its exit from the stylomastoid foramen or in its course over the mandibular ramus.
  • It appears within 1-2 days after delivery due to resultant oedema and haemorrhage around the nerve.
  • Manifestations: There is paresis of the facial muscles on the affected side with partially opened eye and flattening of the nasolabial fold. The mouth angle is deviated towards the healthy side.

Brachial Plexus Palsy

It is due to over traction on the neck as in:

  • Shoulder dystocia.
  • After-coming head in breech delivery.

Erb's palsy

  • It is the common, due to injury to C5 and C6 roots.
  • The upper limb drops beside the trunk, internally rotated with flexed wrist (policeman’s or waiter’s tip hand).

Klumpke’s palsy

  • It is less common, due to injury to C7 and C8 and 1st thoracic roots.
  • It leads to paralysis of the muscles of the hand and weakness of the wrist and fingers' flexors.

Treatment

  • Support to prevent stretching of the paralysed muscles.
  • Physiotherapy: massage, exercise and faradic stimulation.

MUSCLE INJURIES

Sternomastoid injury due to exaggerated lateral flexion of the neck leading to torticollis and swelling in the muscle. It is usually improved within 2 weeks but permanent torticollis may continue.

VISCERAL INJURIES

Liver, spleen and kidney may be injured in breech delivery which should be avoided by holding the foetus from its hips.

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