78: Traumatic Delivery

I. PROBLEM

An infant is noted to have severe bruises after birth, and a nurse observes that the infant is not using his right arm. The birth was noted to be traumatic, and the nurse calls you to evaluate the infant. Birth injuries are injuries that occur during the birth process. The incidence is ∽6–8 per 1000 live births (higher rates for infants >4500 g). Birth injuries occur from both vaginal and cesarean deliveries. Infants delivered by cesarean section are at risk for different types of birth trauma than infants delivered vaginally. Infants delivered by cesarean have a decreased risk of all birth trauma due to the decreased risk of clavicle fractures, brachial plexus, and scalp injuries.

II. IMMEDIATE QUESTIONS

1. Are there any risk factors for a birth injury? Certain factors predispose the infant to birth injuries. These include fetal macrosomia, prima gravida, small maternal stature, prolonged or very rapid labor, precipitous delivery, difficult fetal extraction, abnormal presentation (especially breech), vaginal breech delivery, cephalopelvic disproportion, maternal pelvic abnormalities, oligohydramnios, nuchal cord, very low birthweight infant, very large fetal size, fetal anomalies (osteogenesis imperfecta), use of forceps or vacuum extraction, and prematurity.

2. Is the injury so serious that it requires immediate attention? The majority of birth injuries are not serious and do not require urgent treatment. Significant injuries requiring immediate intervention, such as abdominal organ injuries that present as shock and require surgery, need to be identified early.

3. Was forceps or vacuum extraction used during the delivery? Studies suggest that the use of mid-forceps and vacuum extraction may increase the infant's risk of fractures and paralysis.

III. DIFFERENTIAL DIAGNOSIS (BASED ON SITE OF INJURY)

1. Skin

   1. Petechiae. Small (<3 mm) bruises that do not blanch on pressure. In birth trauma, petechiae are usually localized (eg, on the head, neck, upper chest area, and lower back). There is no associated bleeding, and no new lesions appear. If petechiae are diffuse, suspect thrombocytopenia or other systemic disease. If there is bleeding from venipuncture sites, suspect coagulation disorders or other diseases.

   2. Ecchymosis. A >1 cm bruise beneath the skin. Bruising can occur after a traumatic delivery, especially when labor is rapid or the infant is premature.

   3. Abrasions or lacerations. These can occur secondary to the use of a scalpel during a cesarean delivery. They usually occur on the buttocks, scalp, or thigh. Sometimes suturing is necessary.

   4. Forceps injury. Frequently, reddish linear marks are seen across both sides of the face.

   5. Scalp electrode injury. The site of insertion of the scalp electrode can sometimes become infected (1% of cases) and in premature infants can rarely cause severe bleeding.

   6. Subcutaneous fat necrosis. Typically involves the shoulders and the buttocks with a well-circumscribed lesion of the skin and underlying tissue. It usually appears between 6 and 10 days of age. Lesion size is 1–10 cm, it can be irregular and hard, and the overlying ...