Birth Injuries

Birth trauma (injury) is physical injury sustained by a neonate during labor and birth. It remains an important source of neonatal morbidity. Most birth injuries are avoidable, especially with careful assessment of risk factors and appropriate planning of the birth. The use of fetal ultrasonography allows antepartum diagnosis of certain fetal conditions that may be treated in utero or shortly after birth. Elective cesarean birth can be chosen for some pregnancies to prevent significant birth injury. A small percentage of significant birth injuries such as in especially difficult or prolonged labor or an abnormal fetal presentation are unavoidable despite skilled and competent obstetric care. Some injuries cannot be anticipated until the specific circumstances are encountered during childbirth. Emergency cesarean birth may provide a last-minute salvage, but in these circumstances the injury may be unavoidable. The same injury might be caused in several ways (e.g., a cephalhematoma could result from an obstetric technique such as forceps birth or vacuum extraction or from pressure of the fetal skull against the maternal pelvis).

Many injuries are minor and resolve readily in the neonatal period without treatment. Other trauma requires some degree of intervention; few are serious enough to be fatal. The nurse’s contributions to the newborn’s welfare begin with early observation of his or her transition. Promptly reporting signs that indicate deviations from normal permits early initiation of appropriate therapy. Table 25-1 provides an overview of neurologic birth injuries and the sites in which they occur.

Care Management

When the newborn is born, the nurse makes a rapid inspection and physical assessment to determine whether there are any life-threatening conditions that require immediate medical or surgical attention. A comprehensive physical assessment of the newborn is performed after the parents have had the opportunity to interact with their new baby. Because evidence of some birth injuries may not be apparent at the initial examination, assessment continues during each contact with the neonate.

Soft-tissue injuries that commonly occur at birth (i.e., caput succedaneum and cephalhematoma) are discussed in Chapter 22.

Skeletal Injuries

The newborn’s immature, flexible skull can withstand a great degree of deformation (molding) before fracture results. Considerable force is required to fracture it. Two types of skull fractures typically identified in the newborn are linear and depressed fractures. The location of the fracture and involvement of underlying structures determine its significance.

If an artery lying in a groove on the undersurface of the skull is torn as a result of the fracture, increased intracranial pressure (ICP) follows. Unless a blood vessel is involved, linear fractures, which account for 70% of all fractures for this age-group, heal without special treatment. The soft skull may become indented without laceration of either the skin or the dural membrane. These depressed fractures, or Ping-Pong ball indentations, may occur during difficult births from pressure of the head on the bony pelvis. They can also occur as a result of injudicious application of forceps.

The clavicle is the bone most often fractured during birth. Generally the break is in the middle third of the bone (Fig. 25-1). Dystocia, particularly shoulder impaction, may be the predisposing problem. Limited arm motion, crepitus over the bone, and absence of the Moro reflex on the affected side are often present. Except for use of gentle rather than vigorous handling and containment of the limb against the chest, no accepted treatment for fractured clavicle of the newborn exists, and the prognosis is good. The humerus and femur are other bones that may be fractured during a difficult birth. Fractures in newborns generally heal rapidly. Immobilization is accomplished with slings, splints, swaddling, and other devices.

The parents need support in handling these infants because they often are afraid of hurting them. They are encouraged to practice handling, changing, and feeding the affected neonate under the guidance of nursery personnel. This increases their confidence and knowledge and facilitates attachment. A plan for follow-up therapy is developed with the parents so the times and arrangements for therapy are acceptable to them.

Peripheral Nervous System Injuries

Plexus injury results from forces that alter the normal position and relationship of the arm, shoulder, and neck. Erb palsy (Erb-Duchenne paralysis) is caused by damage to the upper plexus and usually results from a stretching or pulling away of the shoulder from the head such as might occur with shoulder dystocia or a difficult vertex or breech birth. The less common lower-plexus palsy, or Klumpke palsy, results from severe stretching of the upper extremity while the trunk is relatively less mobile.

The clinical manifestations of Erb palsy are related to the paralysis of the affected extremity and muscles. The arm hangs limp alongside the body. The shoulder and arm are adducted and rotated internally. The elbow is extended, and the forearm is pronated with the wrist and fingers flexed; a grasp reflex may be present because finger and wrist movement remains normal (Carlo, 2011b) (Fig. 25-2). In lower-plexus palsy the muscles of the hand are paralyzed, with consequent wrist drop and relaxed fingers. In a third and more severe form of brachial palsy, the entire arm is paralyzed and hangs limp and motionless at the side. The Moro reflex is absent on the affected side for all of the forms of brachial palsy. Total plexus is the second most common type of plexus injury.

Treatment of the affected arm is aimed at preventing contractures of the paralyzed muscles and maintaining correct placement of the humeral head within the glenoid fossa of the scapula. Complete recovery from stretched nerves usually takes 3 to 6 months. However, avulsion of the nerves (complete disconnection of the ganglia from the spinal cord that involves both anterior and posterior roots) results in permanent damage. For injuries that do not improve by 3 months, surgical intervention may be needed to relieve pressure on the nerves or repair the nerves with grafting (Carlo, 2011b).

Nursing care of the newborn with brachial palsy is concerned primarily with proper positioning of the affected arm. The affected arm should be abducted 90 degrees with external shoulder rotation, forearm supination, and extension at the wrist with the palm facing the infant’s face. Passive range-of-motion exercises of the shoulder, wrist, elbow, and fingers are initiated in the latter part of the first week. Wrist flexion contractures may be prevented with the use of a wrist splint with padding in the fist. In dressing the infant, preference is given to the affected arm. Undressing begins with the unaffected arm, and redressing begins with the affected arm to prevent unnecessary manipulation and stress on the paralyzed muscles. Instruct parents to use the football position when holding the infant and avoid picking the child up from under the axillae or pulling on the arms.

Pressure on the facial nerve (cranial nerve VII) during birth may result in injury to it. The primary clinical manifestations are loss of movement on the affected side such as an inability to completely close the eye, drooping of the corner of the mouth, and absence of wrinkling of the forehead and nasolabial fold (Fig. 25-3). Facial palsy or paralysis is most noticeable when the infant cries. The mouth is drawn to the unaffected side, the wrinkles are deeper on the normal side, and the eye on the involved side remains open. Often the condition is temporary, resolving within hours or days of birth. Permanent paralysis is rare unless the nerve fibers were torn, in which case surgical intervention may be necessary.

Nursing care of the infant with facial nerve paralysis involves helping the infant suck and the mother with feeding techniques. The infant may require gavage feeding to prevent aspiration. Breastfeeding is not contraindicated, but the mother needs additional assistance to help the infant grasp and compress the areolar area.

If the eyelid on the affected side does not close completely, artificial tears can be instilled daily to prevent drying of the conjunctiva, sclera, and cornea. The eyelid is often taped shut to prevent accidental injury. If eye care is needed at home, the parents are taught the procedure for administering eyedrops before the infant is discharged.

Phrenic nerve paralysis results in diaphragmatic paralysis as demonstrated by ultrasonography, which shows paradoxical chest movement and an elevated diaphragm. Initially radiography may not demonstrate an elevated diaphragm if the neonate is receiving positive-pressure ventilation (Volpe, 2008). The injury sometimes occurs in conjunction with brachial palsy. Respiratory distress is the most common and important sign of injury. Because injury to the phrenic nerve is usually unilateral, the lung on the affected side does not expand, and respiratory efforts are ineffectual. The infant is positioned on the affected side to facilitate maximum expansion of the uninvolved lung. Breathing is primarily thoracic; cyanosis, tachypnea, or complete respiratory failure may be seen. Pneumonia and atelectasis on the affected side may also occur.

The infant with phrenic nerve paralysis requires the same nursing care as any infant with respiratory distress. As with other birth injuries, the family’s emotional needs are similar to those discussed for soft-tissue injury (see Chapter 22). Follow-up is also essential because of the extended length of recovery.

Sepsis (the presence of microorganisms or their toxins in the blood or other tissues) continues to be one of the most significant causes of neonatal morbidity and mortality. Maternal immunoglobulin M (IgM) does not cross the placenta. IgG levels in term infants are equal to maternal levels; however, in preterm infants the amount of IgG is directly proportional to gestational age. IgA and IgM require time to reach optimum levels after birth. Neonatal neutrophils are present in term infants but have decreased functional capabilities; response to infections is sluggish. Phagocytosis is less efficient. Serum complement levels are low in term infants and even lower in the preterm infant; serum complement (C1 through C6) is involved in immunologic reactions, some of which kill or lyse bacteria and enhance phagocytosis. The gut mucosal barrier is initially immature in both term and preterm infants; this barrier is enhanced by the ingestion of human colostrum, which contains antiinfective properties. Dysmaturity seen with intrauterine growth restriction (IUGR) and preterm and postdate birth further compromises the immune system of the neonate.

Table 25-3 outlines risk factors for neonatal sepsis. Special precautions for preventing infection and prompt recognition when it occurs are necessary for optimal newborn care. Neonatal infections may be acquired in utero, at birth or shortly thereafter, and as a health care–associated infection (HAI).

Neonatal bacterial infection is classified into two patterns according to the time of presentation. Early-onset or congenital sepsis usually manifests within 24 to 48 hours of birth, progresses more rapidly than later-onset infection, and carries a mortality rate as high as 50%. Early-onset sepsis is acquired in the perinatal period; infection can occur from direct contact with organisms from the maternal GI and genitourinary tracts. The most common infecting organisms are Escherichia coli and group B streptococcus (GBS) (Stoll, Hansen, Sanchez, et al., 2011). E. coli, which may be present in the vagina, accounts for approximately half of all cases of sepsis caused by gram-negative organisms. GBS is an extremely virulent organism in neonates, with a high (50%) death rate in affected infants. Other bacteria noted to cause early-onset infection include Haemophilus influenzae, Citrobacter and Enterobacter organisms, coagulase-negative staphylococci, and Streptococcus viridans. Other pathogens that are harbored in the vagina and may infect the infant include gonococci, Candida albicans, herpes simplex virus (HSV) type 2, and chlamydia. Early-onset sepsis is associated with a history of obstetric events such as preterm birth, prolonged rupture of membranes (more than 18 hours), maternal fever during labor, and chorioamnionitis. Early-onset infection is also inversely related to infant birth weight (Polin and AAP Committee on Fetus and Newborn, 2012).

Late-onset sepsis, occurring approximately at 7 to 30 days of age, is considered primarily to be an infection acquired in the hospital or community; the offending organisms are usually staphylococci, Klebsiella organisms, enterococci, E. coli, and Pseudomonas or Candida species (Stoll, 2011). Coagulase-negative staphylococci, considered to be primarily a contaminant in older children and adults, are commonly found to be the cause of septicemia in extremely low–birth-weight (ELBW) and VLBW infants. Additional infections of concern include methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and multidrug-resistant gram-negative pathogens. Bacterial invasion can occur through sites such as the umbilical stump; the skin; mucous membranes of the eye, nose, pharynx, and ear; and internal systems such as the respiratory, nervous, urinary, and GI systems.

Perinatally acquired infections may cause miscarriage, stillbirth, intrauterine infection, congenital malformations, and acute neonatal disease. Other viral infections such as respiratory syncytial virus (RSV), rotavirus, herpes simplex, influenza, and varicella may occur in the neonatal intensive care unit (NICU). These pathogens also may cause chronic infection, with subtle manifestations that may be recognized only after a prolonged period. It is important to recognize the manifestations of infections in the neonatal period to be able to treat the acute infection, prevent HAIs in other infants, and anticipate effects on the infant’s subsequent growth and development.

Fungal infections are of greatest concern in the immunocompromised or preterm infant. Occasionally fungal infections such as thrush are found in otherwise healthy term infants.

Septicemia refers to a generalized infection in the bloodstream. Pneumonia, the most common form of neonatal infection, is one of the leading causes of perinatal death. Bacterial meningitis occurs in approximately 0.2 to 0.4 cases per 1000 live births, with a higher rate in preterm infants. Gastroenteritis is sporadic, depending on epidemic outbreaks. Local infections such as conjunctivitis and thrush occur commonly.

Care Management

Review the prenatal record for risk factors associated with infection and the signs and symptoms suggestive of infection. Maternal vaginal or perineal infection may be transmitted directly to the infant during passage through the birth canal. Psychosocial history and history of sexually transmitted infections (STIs) may indicate possible human immunodeficiency virus (HIV), hepatitis B virus (HBV), herpes (type 2), or cytomegalovirus (CMV) infection.

Perinatal events should also be reviewed. Premature rupture of membranes (PROM) may be caused by maternal or intrauterine infection. Ascending infection may occur after prolonged PROM, prolonged labor, or intrauterine fetal monitoring. In some cases infection may occur with intact membranes or contribute to early rupture. A maternal history of fever during labor or the presence of foul-smelling amniotic fluid may also indicate infection. Antibiotic therapy initiated during labor should be noted. The neonate’s gestational age, maturity, birth weight, and gender affect the incidence of infection. Sepsis occurs about twice as often and results in a higher mortality in male than in female infants. Assess the neonate for respiratory distress, skin abscesses, petechial rashes, and other indications of infection.

During the postnatal period note the time of onset of suspicious clinical signs. Onset within the first 48 hours of life is more often associated with prenatal or perinatal predisposing factors; onset after 2 or 3 days more often reflects an HAI.

The earliest clinical signs of neonatal sepsis are characterized by a lack of specificity. The nonspecific signs include lethargy, poor feeding, poor weight gain, and irritability. The nurse or parent may simply note that the infant is not doing as well as before. Differential diagnosis may be difficult because signs of sepsis are similar to signs of noninfectious neonatal problems such as hypoglycemia and respiratory distress. Additional clinical and laboratory information, including cultures, supplement the findings described. Table 25-4 outlines the clinical manifestations associated with neonatal sepsis.

Laboratory studies are important. Specimens for cultures include blood, cerebrospinal fluid (CSF), stool, and urine. A complete blood cell count with differential is performed to determine the presence of bacterial infection or increased or decreased white blood cell count (the latter is an ominous sign). The total neutrophil count, immature-to-total (I/T) neutrophil ratio, absolute neutrophil count, platelet count, procalcitonin, and C-reactive protein may be used to determine the presence of sepsis. It is important to note that these tests are often adjuncts for the confirmation of neonatal sepsis; a combination of these tests and clinical signs often alert the practitioner to the need for treatment. Additional diagnostic tests that may be used to identify or exclude neonatal sepsis include sedimentation rate, interleukins (IL-8, IL-2, IL-6, and IL-1β), and nucleic acid amplification testing (NAAT). Antepartum infection can now be treated successfully with a number of antiviral medications to decrease viral replication and fetal transmission of disease; neonates may also be treated with antiviral medications such as acyclovir and ganciclovir. In high risk infants with significant illness, antiviral or antibiotic treatment may begin once cultures are obtained. Once the pathogen is identified, antibiotic, antiviral, or antifungal therapy may be modified.

Vigilant assessment continues during and after treatment. Prolonged administration of antibiotics to ELBW neonates without positive cultures in the first week of life is associated with an increased incidence of necrotizing enterocolitis (NEC), mortality, and late-onset infection; therefore careful use of antibiotics and close observation of such infants are recommended (Cotten, Taylor, Stoll, et al., 2009; Kuppala, Meinzen-Derr, Morrow, et al., 2011). The newborn continues to be assessed for sequelae to septicemia, which include meningitis, disseminated intravascular coagulation (DIC), NEC, pneumonia, and septic shock. Septic shock results from the toxins released into the bloodstream. The most common signs include decreasing oxygen saturation, poor perfusion (prolonged capillary refill, cool extremities, mottling), tachycardia, respiratory distress, and hypotension.

Breastfeeding (medically stable infants) or feeding the newborn expressed breast milk from the mother is encouraged. Breast milk provides protective mechanisms. Colostrum contains IgA, which offers protection against infection in the GI tract. Human milk contains iron-binding protein that exerts a bacteriostatic effect on E. coli. Human milk also contains macrophages and lymphocytes. The vulnerability of infants to common mucosal pathogens such as RSV may be reduced by passive transfer of maternal immunity in the colostrum and breast milk. There is evidence that early enteral feedings with human milk are beneficial in establishing a natural barrier to infection in ELBW and VLBW infants (Hanson, 2007). Human milk is also thought to provide some degree of protection from NEC.

Administering medications, taking precautions when performing treatments, and following isolation procedures are also interventions to consider in the prevention and treatment of neonatal sepsis.

Monitoring an intravenous (IV) infusion and administering antibiotics are important nursing responsibilities. It is important to administer the prescribed dose of antibiotic within 1 hour after it is prepared to avoid loss of drug stability. If the IV fluid that the infant is receiving contains electrolytes, vitamins, or other medications, the nurse should check with the hospital pharmacy before adding antibiotics. The antibiotic (or other medication) may be deactivated or may form a precipitate when combined with other medications.

Care must be taken in suctioning secretions from any newborn’s oropharynx or trachea. Routine suctioning is not recommended and may further compromise the infant’s immune status, cause hypoxia, and increase ICP. Efforts should also be taken to prevent ventilator-associated pneumonia in infants on mechanical ventilation (see Chapter 40). Isolation procedures are implemented as indicated according to hospital policy. Isolation protocols change rapidly, and the nurse is urged to participate in continuing education and in-service programs to remain up to date.

Maternal Infections

The range of pathologic conditions produced by infectious agents is large, and the difference between the maternal and fetal effects caused by any one agent is also great. Some maternal infections, especially during early gestation, can result in fetal loss or malformations because the fetus’s ability to handle infectious organisms is limited and the fetal immunologic system is unable to prevent the dissemination of infectious organisms to the various tissues.

Not all prenatal infections produce teratogenic effects. Furthermore the clinical picture of disorders caused by transplacental transfer of infectious agents is not always well defined. Some viral agents can cause remarkably similar manifestations, and it is common to test for all of them when a prenatal infection is suspected. This is the so-called TORCH complex, an acronym for:

To determine the causative agent in a symptomatic infant, tests are performed to rule out each of these infections. The O category may involve testing for several viral infections (e.g., HBV, varicella zoster, measles, mumps, HIV, syphilis, and human parvovirus). Bacterial infections are not included in the TORCH workup because they are usually identified by clinical manifestations and readily available laboratory tests. Gonococcal conjunctivitis (ophthalmia neonatorum) and chlamydial conjunctivitis have been reduced significantly by prophylactic measures at birth (see Critical Thinking Case Study and Chapter 22). The major maternal infections, their possible effects, and specific nursing considerations are outlined in Table 25-5.

 Critical Thinking Case Study

Neonate with Chlamydia

An 8-day-old male infant is brought to the pediatric urgent care center on a Sunday morning by Maggie, an 18-year-old single mother, with a complaint of eye drainage for 2 days. Maggie is breastfeeding and states that she was diagnosed and partially treated for a couple of sexually transmitted infections in late gestation; she does not remember the name but says one started with a “C.” The medications made her stomach sick, so she quit taking them after 2 days. The practitioner examines the infant, who has a purulent yellowish discharge from both eyes but otherwise appears healthy; she suspects chlamydial conjunctivitis and orders cultures of the eye drainage. The retrieved medical record from the infant’s birth indicates that eye prophylaxis with erythromycin ophthalmic ointment was administered.

1. Evidence—Is there sufficient evidence to draw conclusions about the cause of the infant’s eye drainage?

2. Assumptions—What assumptions can be made about the following factors:

a. Treatment for neonatal chlamydia infection.

b. Neonatal sequelae of inadequate chlamydia treatment in newborn.

c. The mother’s health status and possible treatment (she is not allergic to penicillin).

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