STATE ESTABLISHMENT «DNEPROPETROVSK MEDICAL ACADEMY OF MINISTRY OF HEALTH UKRAINE »
“Сonfirmed;”
at methodical meeting
of hospital pediatrics №1 department
Сhief of department professor ______V. A. Kondratyev
“______” ______2013 y.
METHODICAL INSTRUCTIONS
FOR STUDENTS` SELF-WORK
WHILE PREPARING FOR PRACTICAL LESSONS
Educational discipline / pediatricsmodule № / 2
Substantial module № / 8
Theme of the lesson / Birth trauma
Course / 5
Faculty / medical
Dnepropetrovsk, 2013
Neonatal birth trauma
1. Actuality of the topic:
Injuries of organs and tissues which occur during the birth can cause further function disorders of corresponding organs and systems. The most essential is the injury of Central Nervous System. Early diagnostic and treatment as well as adequate rehabilitation considerably enhance the prognosis.
2. Specific aims:
А. A student should know:
1. Definition of term “birth injury.”
2. Causes of birth traumas.
3. Classification of birth injuries.
4. Clinical signs of birth injuries of different localization:
А. Fracture of clavicle.
B. Trauma of muscle sternocleidomastoideus.
C. Cephalohematoma.
D. Intracranial birth injury.
E. Trauma of spine.
5. Additional diagnosing methods in patients with birth traumas.
6. Main complications which occur during birth traumas.
7. Phases of course in patients with birth CNS injury.
8. Principles of treatment of new-born after birth trauma depending on location.
9. Principles of rehabilitation after birth injuries.
В. A student should be able:
1. To determine clinical signs of birth injury.
2. To detect and analyze anamnesis factors which could have promoted birth injury during the birth.
3. To carry out differential diagnosing between traumatic and other injuries of organs and systems.
4. To formulate diagnosis of birth trauma.
6. To draw up a plan of the new-born baby with birth trauma.
7. To draw up a plan of treatment for infants with birth injury:
А. Fracture of clavicle.
Б. Injury of muscle sternocleidomastoideus.
C. Cerebral hemorrhage.
D. Spine injury.
8. To determine signs of complications for the child with birth trauma.
9. To draw up a plan of rehabilitation for children with birth injury.
3. Tasks for self work while preparing for the lesson.
3.1. List of main terms, parameters, characteristics a student has to master while preparing for the lesson:
Term / DefinitionBirth trauma of infants / Injury of organs and tissues of a fetus which happens during the birth. The most severe injuries are those with cerebral hemorrhage and they require special treatment
Birth tumor / Gathering of serous-blood fluid subcutaneously, outside periosteum, with badly delineated edges; it can spread through linea media and through stitch lines and is usually related to compression of fetus head during the birth
Cephalohematoma / Periosteum hemorrhage in infant’s skull area
Interbrain traumatic hematoma / Gathering of blood in brain matter which appears due to traumatic hemorrhage and can cause brain compression. Being in the white matter of brain it can create a cavity
Hemorrhage / Gathering of blood in tissues or body cavities due to increase of penetrability or disorders in blood vessel integrity
Paralysis of diaphragm nerve (СЗ, 4 or 5) / It is a result of overstraining of lateral cervical muscles. It is practically always one-sided and it is often connected with injuries of plexus brachialis
Fracture of clavicle / Most often it is neonatal orthopedic injury. An infant has pseudoparalysis on the injured side, crepitation, bone displacement, spasm of muscle sternocleidomastoideus. Bone breaks (not complete) can be without signs
Paralysis of Erb / Injury of the fifth and sixth cervical spinal nerves. The injured arm is brought into motion and makes a rotation with straightened elbow, forearm remains in prone position, wrist is arcuated. Morpho, biceps, radiocarpal reflexes on the injured side are absent. Grasp reflex is normal
Intraventricular hemorrhage / It happens more often with pre-term children as a result of hypoxic influences and small gestation age. Acute adynamy, tonic cramps are typical, tremor of high magnitude, hypertension syndrome, strabismus, vertical nystagmus, thermoregulation disorders, abnormal breath rhythm and cardiac activity are present, congenital and tendinous reflexes, sucking, swallowing are suppressed
Subdural hemorrhage / Birth injury which happens most often during prolonged or fast birth and causes displacement of brain ventriclesи, liquor ways, increase of intracranial pressure. One of main death causes of infants is compression of vital centers in medulla
Subarachnoid hemorrhage / Birth injury which occurs in children during prolonged birth, especially in case of obstetrician interventions; most often in pre-term babies and it is accompanied by anxiety, clonic-tonic cramps, manifested vegetative-visceraldisorders, increase of muscular tone and tendious reflexes, bulging of fontanel, Gref-s symptome, strabismus, horizontal nystagmus; typical changes in spinal liquid: xanthochromia, blood presence, cytosis up to 1,000 and more, lymphoid cells, strongly positive Pandy’s reaction, general protein 0.3 – 1.3 g/l
Adiponecrosis / Focal necrosis of subcutaneous fat, well-defined solid nodes 1-5 cm in diameter in subcutaneous layer of buttocks, back, shoulders, extremities. It develops at the age of 1-2 weeks old
Neurosonography / Ultrasound brain study of an infant with a sensor in fontanel major
Computer tomography / An X-ray method (unlike plain X-ray), which provides us with the opportunity to get the screen of a specific cross-section of a human body. The body can be studied by layers with the step of 1 mm
Magnetic-resonant tomography. / This method with the use of electric-magnetic waves gives us a chance to visualize brain, spinal cord and other internal organs with high quality
3.2. Theoretical topics for the lesson:
1. Definition of term ”birth injury " (BI).
2. Frequency of BI among other infant’s diseases.
3. Causes of BI development.
4. Conditions impacting BI appearance.
5. Localization of BI.
6. Pathogenesis of different BI forms.
7. Clinical symptoms typical for BI of different location: muscle BI, bone BI, brain BI, spine BI , BI of peripheral nervous system.
8. Value of additional methods while diagnosing BI.
9. Classification of birth injuries in nervous system.
10. Complications of BI .
11. Principles of therapy and rehabilitation of children with BI.
12. Prophylaxis of BI and their complications.
13. Outcomes of BI.
3.3. Practical skills (tasks) mastering during practical lesson:
1. To collect complaints, case history and personal (life) history
2. To inspect the child consistently
3. To reveal early symptoms of the birth trauma
5. To evaluate the condition of the child and available clinical symptoms. 6. To evaluate the results of the additional methods of investigation
7. To make the clinical diagnosis according to classification.
8. To make the treatment plan.
9. To make recommendations of dispensary supervision.
4. Maintenance of the subject:
Definition of the term "birth trauma" (BT).
The birth trauma is a damage of the baby owing to the action of mechanical forces (such as compression or traction) at the time of delivery. Damages can occur at the antenatal period, during resucsitation, or delivery.
Prevalence of birth trauma.
Modern obstetrics technique considerably reduced mortality from birth trauma which now occurs with the prevalence of 3,7 per 100000 live-born. Mortality depends upon the type of birth trauma. Cephalohematoma is the most common BT. More serious traumas are seen from 2 to 7 on 1000 live-born.
Causes of BT.
Process of the birth is set of such phenomena, as a squeezing, compression, contraction and pulling. When it is associated with abnormal fetal size, position, and/or delay in the development of nervous system, labor activity can lead to the tissue damage, edema, hemorrhages or fractures at the newborn. The usage of obstetric instruments can enhance the action of these forces, or cause damage independently. Appropriate use of obstetric instruments can reduce asphyxia occurance. Though foot position leads to the greatest risk and damage, extraction by Cesarean section doesn't guarantee that the baby won't be damaged.
Features that predispose to the birth trauma
First labor
Small mother`s height
Pelvic anomalies at mother
Overdue or prompt childbirth
Long standing of prelying part of the fetus in one plane
Lack of waters
Wrong fetal position (for example, sciatic)
Use of forceps or vacuum extractor
Turn and fetal extraction
The infant with very low weight at the birth or deep prematurity
Fetus with the big head
Anomalies of fetal development
BT localization.
Classification of BT according to the classification: BT of soft tissues (muscles, subcutaneous fatty cellulose, cephalohematoma), cerebral BT (injury of the skull bones, intracranial hemorrhage: subdural, subarachnoid, intracerebral (parenchymatous), intraventricular), BT of bones (fractures of the clavicle, tubular bones - humeral, femoral), BT of the spinal cord, BT of peripheral nervous system (damage of the posterior nerve roots, peripheral nerves).
Patogenesis of different forms of BT.
Causes of soft tissue damage: actual damage throughout the birth process, a squeezing at the time of delivery, owing to fetal monitoring (plasing of electrodes on hairy part of the head), a squeezing of the fetal head at the time of delivery, use of obstetric tools.
Damage of sterno-cleudo-mastoideus muscle (SCM). It is considered that SCM-damages to childbirth can be the cause of the congenital muscular torticollis.
Injury of skull bones. Compressional fractures are usually caused by the use of forceps at the time of delivery. Fractures of the occipital bone are often caused by the difficult labour at sciatic presentation and have poor prognosis. Forces which lead to the skull fractures, can also cause closed injuries of the brain or ruptures of blood vessels that leads to subcutaneous or intracranial bleedings. Fractures can be located below the level of cephalohematoma and can lead to the attacks of hypotension or death.
Damage of the spinal cord is possible if the fetus has a big head. Children who have sciatic presentation, are also belong to the risk group if have vaginal labor. The low estimation by Apgar scale can display damage of the brain stem and/or a spinal cord. Epidural hemorrhage is the most frequent injury of the brain which results in brain edema and temporary denervation.
Paralysis of the diaphragmal nerve (C3, 4 or 5) can be result of overstretching of lateral neck muscles. It is usually unilateral and often caused by the damage of the humeral plexus (75% of patients).
Damage of the humeral plexus can be at traction of the head, neck, hands or trunk. Hypotonic infants are especially sensitive to an excessive divergence of the segments of bones and to the excessive extension.
Injury of bones. Changes are most often observed at sciatic presentation or the transverse fetal position at infants with macrosomia, but can sometimes be observed after Cesarean section. Usually it is caused by the traction and rotation of extremities.
Clinical symptoms
For the confirmation of the birth trauma careful medical examination of the infant should be carried out with the consultation of neurologist. It is necessary to evaluate symmetry of the structure and function, integrity and amplitude of movements of the joints and to perform research of craniocerebral nerves.
Birth trauma of soft tissues.
Cephalohematoma ICD X code – X: Р 12.0
Cephalohematoma is a subperiosteal hemorrhage, hence always limited to the surface of one cranial bone. No discoloration of the overlying scalp occurs, and swelling is not usually visible until several hours after birth because subperiosteal bleeding is a slow process. An underlying skull fracture, usually linear and not depressed, is occasionally associated with cephalohematoma. Most cephalohematomas are resorbed within 2 wk–3 mo, depending on their size. They may begin to calcify by the end of the 2nd wk. Сephalohematomas require no treatment, although phototherapy may be necessary to ameliorate hyperbilirubinemia. Incision plus drainage is contraindicated because of the risk of introducing infection in a benign condition. A massive cephalohematoma may rarely result in blood loss severe enough to require transfusion.
The subaponeurotic hematoma is located in the space between a skull periosteum and the tendinous helmet with distribution from eyebrow arches and to the occipital region. This hematoma can extend through the skullcap Its growth can be not visible for hours or days, or be manifested as hemorrhagic shock and, even, death. The hairy part of head skin can have excavations like edema; round eyes and auricles there can be bruises.
Caput succedaneum is a diffuse, sometimes ecchymotic, edematous swelling of the soft tissues of the scalp involving the portion presenting during vertex delivery. It may extend across the midline and across suture lines. The edema disappears within the first few days of life. Analogous swelling, discoloration, and distortion of the face are seen in face presentations. No specific treatment is needed, but if extensive ecchymoses are present, hyperbilirubinemia may develop. Molding of the head and overriding of the parietal bones are frequently associated with caput succedaneum and become more evident after the caput has receded, but they disappear during the first weeks of life.
Adiponekroz (focal necrosis of subcutaneous fatty cellulose) – well located dense knots, infiltrates of 1-5 cm in size in subcutaneous fatty cellulose of buttocks, backs, shoulders, extremities. Occurs on 1-2 week of life. Skin over infiltrate or isn't changed, or cyanotic, violet-red or red color. The general condition of the child is satisfactory, temperature is normal.
Etiology of the disorder: local trauma, штекфnatal hypoxia, cooling. Prognosis favorable. Infiltrates disappear independently without treatment in some weeks, sometimes-3-5 months. Treatment usually should not be administered, sometimes thermal procedures are prescribed (Sollyux, dry bandages with cotton wool), at widespread process vitamin E can be administered.
Damage of the sterno-cleido-mastoideus muscle (SCM)
MKB code – X: Р 15.2
SCM can be affected during delivery. Induration of SCM can be palpated at the birth or (most often) can develop after the first 2-3 weeks of life.
Erythema, abrasions, ecchymoses, and subcutaneous fat necrosis of facial or scalp soft tissues may be noted after forceps or vacuum-assisted deliveries. Their location depends on the area of application of the forceps. Ecchymoses may be seen after manipulative deliveries and occasionally in premature infants for no discernible reason.
Birth trauma of bones.
Fracture of a clavicle. MKB-H code: Р 13.4
This bone is fractured during labor and delivery more frequently than any other bone; it is particularly vulnerable with difficult delivery of the shoulder in vertex presentations and the extended arms in breech deliveries. The infant characteristically does not move the arm freely on the affected side; crepitus and bony irregularity may be palpated, and discoloration is occasionally visible over the fracture site. The Moro reflex is absent on the affected side, and spasm of the sternocleidomastoid muscle with obliteration of the supraclavicular depression at the site of the fracture can be noted. Infants with greenstick fractures may not have any limitation of movement, and the Moro reflex may be present. Fracture of the humerus or brachial palsy may also be responsible for limitation of movement of an arm and absence of a Moro reflex on the affected side. The prognosis is excellent. Treatment, if any, consists of immobilization of the arm and shoulder on the affected side. A remarkable degree of palpable callus develops at the site within a week and may be the initial evidence of the fracture.