Chapter 33 Trauma During Birth, Haemorrhage and Convulsions
Trauma to skin and superficial tissues
Skin
Damage to the skin may result from forceps blades, vacuum extractor cups, scalp electrodes and scalpels.
Superficial tissues
Trauma to soft tissue involves oedematous swellings and/or bruising. The oedema consists of serum and blood (serosanguineous fluid).
Caput succedaneum
This is an oedematous swelling under the scalp and above the periosteum (Fig. 33.1 and Box 33.1). A ‘false’ caput succedaneum can also occur if a vacuum extractor cup is used; the resulting oedematous deformity is known as a ‘chignon’.
Other injury
When the face presents, it becomes congested and bruised, and the eyes and lips become oedematous. In a breech presentation the fetus will develop bruised and oedematous genitalia and buttocks.
Uncomplicated oedema and bruising usually resolve within a few days of life. However, if there is significant trauma during a vaginal breech birth, there can be serious complications such as:
Muscle trauma
Injuries to muscle result from tearing or from disruption of the blood supply.
Torticollis
Excessive traction or twisting can cause tearing to one of the sternomastoid muscles during the birth of the anterior shoulder of a fetus with a cephalic presentation, or during rotation of the shoulders when the fetus is being born by vaginal breech. A small lump can be felt on the affected sternomastoid muscle. It appears painless for the baby. The muscle length is shortened; therefore the neck is twisted on the affected side.
The management of torticollis involves stretching of the affected muscle, achieved under the guidance of a physiotherapist. The swelling will usually resolve over several weeks.
Nerve trauma
Commonly, there is trauma to the facial nerve or to the brachial plexus nerves.
Facial nerve
Damage to the facial nerve usually results from its compression against the ramus of the mandible by a forceps blade, resulting in a unilateral facial palsy. The eyelid on the affected side remains open and the mouth is drawn over to the normal side. If the baby cannot form an effective seal on the breast or teat, there may be some initial feeding difficulties. Spontaneous resolution usually occurs within 7–10 days.
Brachial plexus
Trauma to this group of nerves usually results from excessive lateral flexion, rotation or traction of the head and neck during vaginal breech birth or when shoulder dystocia occurs. These injuries can be unilateral or bilateral. There are three main types of injury:
Erb’s palsy. There is damage to the upper brachial plexus involving the fifth and sixth cervical nerve roots. The baby’s affected arm is inwardly rotated, the elbow is extended, the wrist is pronated and flexed, and the hand is partially closed. This is commonly known as the ‘waiter’s tip position’. The arm is limp, although some movement of the fingers and arm is possible.
Klumpke’s palsy. There is damage to the lower brachial plexus involving the seventh and eighth cervical and the first thoracic nerve roots. The upper arm has normal movement but the lower arm, wrist and hand are affected. There is wrist drop and flaccid paralysis of the hand with no grasp reflex.
Total brachial plexus palsy. There is damage to all brachial plexus nerve roots with complete paralysis of the arm and hand, lack of sensation and circulatory problems. If there is bilateral paralysis, spinal injury should be suspected.
All types of brachial plexus trauma will require further investigations such as X-ray and ultrasound scanning (USS), and assessment of the joints. Passive movements of the joints and limb can then be initiated under the direction of a physiotherapist. At approximately 1 month of age, magnetic resonance imaging (MRI) can offer specific data on nerve damage.
Spontaneous recovery within days to weeks is expected for most babies. Follow-up is recommended. Babies with no functional recovery by 6 months of age may require surgical repair.
Haemorrhage
Blood volume in the term baby is approximately 80–100 ml/kg and in the preterm baby 90–105 ml/kg; therefore even a small haemorrhage can be potentially fatal.
Haemorrhage due to trauma
Cephalhaematoma
A cephalhaematoma is an effusion of blood under the periosteum that covers the skull bones (Fig. 33.2 and Box 33.2). During a vaginal birth, if there is friction between the fetal skull and the maternal pelvic bones, such as in cephalopelvic disproportion or precipitate labour, the periosteum is torn from the bone, causing bleeding underneath. Cephalhaematomas can also be caused during vacuum-assisted births. More than one bone may be affected, causing multiple cephalhaematomas to develop (Fig. 33.3).