Chapter 7: Birth Injuries

SCOPE

DISEASE/CONDITION(S)

Newborn care.

GUIDELINE OBJECTIVE(S)

All newborns are at risk for birth-related injuries. Pediatricians and neonatologists involved in newborn care should be familiar with the presentation and management of common birth injuries.

BRIEF BACKGROUND

Birth injuries are a common reason for neonatology consultation. The overall incidence is decreasing with early identification of risk factors and improving obstetrical techniques. The most common risk factors are fetal macrosomia, maternal obesity, abnormal fetal presentation, and operative deliveries (forceps or vacuum-assisted).

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

Routine newborn care should include assessment for, and management of, common birth injuries. Review of the pregnancy and delivery can reveal important risk factors for injury, and physical examination can detect important signs and symptoms.

PRACTICE OPTIONS

Risk factors, presentation, and management of common birth injuries are presented next by injury type.

Practice Option #1: Musculoskeletal and Soft Tissue Injuries

Fracture

Introduction. Several risk factors for birth-related fractures have been identified. In addition to those known to be associated with increased risk for all birth injuries, prematurity in particular is an important risk factor for fracture. Of note, premature infants are also at increased risk for multiple fractures, with ribs being the most common site.

Clavicular Fracture

Background

• Most common birth-related fractures, with a 0.4−4.4% incidence overall

• Risk increases with instrumented delivery, birth weight >4 kg, shoulder dystocia

Presentation

• Displaced fractures are more likely to be observed in the immediate postpartum period and be accompanied by other physical examination findings (swelling, crepitus, decreased spontaneous arm movement, asymmetrical bone contour, pain with passive motion, asymmetric Moro reflex).

• Nondisplaced fractures are often asymptomatic and may not present for weeks when visible or palpable callus forms, or as an incidental finding on chest radiograph.

Evaluation and management recommendations

• Differential diagnosis includes humeral fracture, shoulder dislocation, and brachial plexus injury.

• Diagnosed by plain radiograph: include chest and upper extremities to evaluate for other associated fractures.

• Most nondisplaced fractures heal spontaneously within 2−3 weeks without sequelae; provide parental reassurance.

• Careful handling to decrease pain; pinning sleeve at 90-degree angle may help with comfort, but is not necessary for healing.

• Repeat radiograph at 2 weeks will delineate proper healing, but callus formation and resolution of tenderness are usually predictive of appropriate healing.

• Significantly displaced fractures should prompt orthopedic consultation.

Humeral Fracture

Background

• Rare, occurring in 0.002−0.005% of births.

• Most are located in the medial 1/3 of the humerus and are transverse and complete.

• Risk increases with shoulder dystocia, macrosomia, breech extraction, cesarean ...