Chapter 83: 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. The terms birth injuries and birth trauma are used interchangeably. According to the National Vital Statistics Reports, birth injury is “the impairment of the infant’s body function or structure due to adverse influences that occurred at birth.” Birth trauma is defined as “a physical injury sustained by an infant in the process of birth.” The rate of birth trauma has declined over the past 20 years, and the incidence is unclear, with study estimates ranging from approximately 6 to 8 per 1000 live births. The highest percentage of birth injuries occurs in mothers who were subjected to birthing instruments (eg, vacuum extraction, forceps). African Americans and Hispanics experience lower rates of birth injuries than whites and Asians/Pacific Islanders. 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 and injuries to the brachial plexus and scalp. Birth injuries can range from minor (petechiae) to severe (spinal cord injury resulting in death). The most common birth injuries are brachial plexus palsy (Erb palsy), bone fractures (fracture of the clavicle most common), cephalohematoma, caput succedaneum, intracranial hemorrhage, subconjunctival hemorrhage, facial paralysis, spinal cord injuries, and cerebral palsy. Documentation of injuries (Mongolian spot [now called congenital dermal melanocytosis], rib fractures, clavicle fractures, retinal hemorrhages) is very important at the first physical examination because some of these injuries can be confused with nonaccidental trauma after discharge.

II. IMMEDIATE QUESTIONS

1. Are there any risk factors for a birth injury? Certain factors predispose the infant to birth injuries. Macrosomia and instrumental deliveries are major risk factors.

   1. Risk factors

      1. Maternal: Small maternal stature, primigravida, maternal pelvic abnormalities, maternal obesity, cephalopelvic disproportion, increased maternal age (clavicle fracture), maternal trauma 1 to 2 weeks before delivery (intra-abdominal injuries in infant), twin pregnancy (femur fracture).

      2. Delivery: Prolonged or very rapid labor, precipitous delivery, difficult fetal extraction, abnormal presentation (especially breech by vaginal delivery; 30 per 1000 live births), cephalopelvic disproportion, nuchal cord, oligohydramnios, instrumental deliveries (use of mid-forceps [4-fold increase] or vacuum extraction [3-fold increase]), excessive traction during delivery.

      3. Infant: Macrosomia irrespective of route of delivery The higher the degree of macrosomia the higher is the risk of birth injury (risk is increased by 2-fold with BW of 4000–4500 g, 3-fold with BW of 4500–4900 g, and 4.5-fold with BW >5000 g), very large fetal head, very low BW infant, fetal anomalies (osteogenesis imperfecta), prematurity, male gender (head and neck trauma), shoulder dystocia (brachial plexus injury, clavicular fracture, humerus fracture).

   2. Injuries associated with risk factors...