Paediatrics: Birth trauma

2021-04-15 11:20 AM

LGA, cephalic–pelvic disproportion, malpresentation, precipitate delivery, instrumental delivery, shoulder dystocia, prematurity.

Birth trauma

Risk factors

LGA, cephalic–pelvic disproportion, malpresentation, precipitate delivery, instrumental delivery, shoulder dystocia, prematurity.

Head

  • Caput succedaneum: oedema of the presenting scalp. Can beparticularly large following ventouse delivery (chignon). Rapidly resolves.
  • Cephalhaematoma: common fluctuant swelling(s) due to subperiostialbleed(s). Most often occur over parietal bones. Swelling limited by suture lines. Resolves over weeks.
  • Subaponeurotic haematoma: rare; bleeding not confined by skullperiostium, so can be large and life-threatening. Presents as fluctuant scalp swelling, not limited by suture lines.

Skin

  • Traumatic cyanosis: bruising and petechiae of presenting part.
  • Lacerations: caused by forceps, ventouse cap, scalp electrodes, scalppH sampling, or scalpel wounds during CS. Close with Steri-Strips® or suture if required.

Nerve palsies

  • Brachial plexus: commonest is Erb’s palsy (C5–C6 nerve routes). Mayresult from difficult assisted delivery (e.g. shoulder dystocia); the arm is flaccid with pronated forearm and flexed wrist (waiter’s tip position). Complete recovery occurs within 6wks in two-thirds of cases. X-ray clavicle to exclude fractures. Refer to physiotherapy for assessment and follow-up.
  • Facial nerve palsy: follows pressure on face from either maternal ischialspine or forceps. Presents as facial asymmetry that is worse on crying (affected side shows lack of eye closure and lower facial movement; mouth is drawn to normal side). Majority recover in 1–2wks. May require eye care with methylcellulose and specialist referral.

Fractures

  • Clavicle (commonest).
  • Long bone fractures: usually lower avulsion fractures of the femoral ortibial epiphyses, or mid-shaft fractures of the femur or humerus. Infant presents as unsettled, with affected limb pseudo-paralysis, or obvious deformity or swelling. Confirm by X-ray.
  • Skull fracture: associated with forceps delivery and usually require notreatment unless depressed in which case neurosurgical referral is required.
  • Treatment: analgesia; limb immobilization (arm inside baby-grow), oftendo not require orthopaedic intervention, healed in a few weeks. Rapid healing and remodelling usually occur.

Soft tissue trauma

  • Sternocleidomastoid tumour: overstretching of muscle leads tohaematoma. Subsequent contraction of muscle results in non-tender ‘tumour’ and torticollis (head turns away from affected muscle). Physiotherapy almost always curative. Possible indication of malposition in-utero—consider increased risk of developmental dysplasia of the hip (DDH).
  • Fat necrosis Tender, red, subcutaneous swelling caused by pressure over bony prominences, e.g. forceps. It usually resolves spontaneously. May be extensive with risk of Rise Ca2+ and so there is a need to monitor serum level.