Approach to birth injury (pediatrics): Clinical sciences

Chapters:

Watch video only

Introduction0:00–0:29

Birth injury refers to any physical harm to a newborn that occurs during labor or delivery. Many birth injuries result from a prolonged labor or a precipitous delivery.
A difficult or instrumental delivery, macrosomia or fetal malpresentation. Common birth related injuries include head injuries, nerve damage, bone fractures and soft tissue injury.

Unstable0:29–1:33

When a pediatric patient presents with a chief concern, suggesting a birth injury first perform an ABCDE assessment to determine if they are stable or unstable.
If unstable, stabilize their airway breathing and circulation and consider intubation for ineffective respirations or apnea.
Next, obtain intravenous access or perform an umbilical venous catheterization and consider starting IV fluids or transfusing packed red blood cells, then place your patient on continuous vital sign monitoring and provide supplemental oxygen if needed.
Once youve initiated acute management, perform a focused history and physical examination. The history might reveal risk factors such as preterm delivery, prolonged labor or instrumental delivery.
As far as the physical exam goes, youll often notice an altered level of consciousness and tachycardia. These findings should make you consider the possibility of a hemorrhage.
Proceed with your evaluation by assessing the scalp for progressive edema. If progressive edema is present, consider a subgaleal hemorrhage.

Subgaleal hemorrhage1:33–2:28

In this case, birth history often reveals that the delivery required vacuum assistance. The physical exam will reveal a boggy scalp with edema that crosses the suture lines that manifests in the first few hours after birth and moves posteriorly to the level of the ears, often pushing the ears outward and extending to the nape of the neck.
The occipital frontal head circumference will also be increased. Now, due to the potential for massive blood loss.
In addition to tachycardia, these patients often develop tachypnea and hypotension as well as pallor and eventually jaundice to confirm the diagnosis, obtain a CBC and head ultrasound.
If the hemoglobin and hematocrit are low and imaging reveals bleeding between the periosteum and the aponeurosis of the scalp diagnose subgaleal hemorrhage.
On the other hand, if there is no progressive scalp edema, consider the possibility of an intra cranial hemorrhage. In this case, the history often reveals risk factors like prolonged labor and instrumental delivery and the neonate may present with seizures, apnea or irritability.

Intracranial hemorrhage2:28–3:10

Meanwhile, the physical examination might reveal a concavity of the skull that resembles an indented pingpong ball, which is highly suggestive of a depressed skull fracture.
Less commonly, there might be signs suggesting a basilar fracture like bloody drainage from the nose or ears. With these findings.
Your next step is to obtain a head ultrasound or CT scan to look for an intracranial hemorrhage. Now, let's look at imaging results if ultrasound or CT reveals a hyperdense crescent shaped lesion in the subdural space, diagnose subdural hematoma, which is the most common intracranial injury seen in newborns.

Subdural3:10–3:34

Here's a clinical pearl. Keep in mind that any subdural hematoma beyond the immediate newborn period should make you suspect abusive head trauma.

Subarachnoid3:34–4:15

However, if imaging identifies a hyperdense layering along the convexity of the cerebral cortex, diagnose subarachnoid hemorrhage.
Although infants with subarachnoid hemorrhage often have no clinical symptoms. In rare cases, those with an underlying arteriovenous malformation can develop a catastrophic intracranial hemorrhage.
Here's another clinical pearl. Other types of intracranial hemorrhage that can occur in newborns include epidural hematoma retinal hemorrhage and intraventricular hemorrhage.
However, intraventricular hemorrhage is more closely associated with prematurity and very low birthweight and its not usually caused by birth trauma.
Ok. Now, let's return to the ABCDE assessment and discuss some stable patients begin with a focused history and physical examination.

Stable4:15–4:54

The history will often reveal risk factors for birth injury such as prolonged labor, instrumental delivery, malpresentation, macrosomia, shoulder dystocia and preterm delivery.
The physical exam might demonstrate scalp edema or focal neurologic deficits while the skin exam may reveal ecchymoses or abrasions also look for signs suggesting a fracture such as palpable crepitus deformity or swelling.
First, let's assess the scalp for the presence of edema. If scalp edema is present, assess its relationship to the suture lines, lets look at scalp edema that does not cross the suture lines.

Scalp edema4:54–5:02

Does not cross suture lines5:02–5:24

If you see a well circumscribed fluctuant area of ecchymosis and edema that develops over the first few hours of life. Diagnose cephalohematoma which is caused when blood vessels beneath the periosteum rupture.
The bleeding doesn't cross suture lines since the bleeding is confined to a single cranial plate. Now, let's look at scalp edema that crosses the suture lines.

Crosses suture lines5:24–6:12

In this case, you'll usually see diffuse, fluctuant, ecchymosis and edema at the time of delivery. This indicates caput succedaneum where edema composed of blood and serum accumulates above the periosteum just below the skin.
Here's another clinical pearl. While caput succedaneum and subgaleal hemorrhage, both present with scalp edema that crosses suture lines.
Newborns with caput succedaneum are generally well appearing and hemodynamically stable. In contrast, those with subgaleal hemorrhage lose a substantial amount of blood into the subgaleal space, which can lead to hypovolemic shock due to the high mortality associated with this condition.
Early recognition is crucial. Now, once your scalp assessment is complete, move on to assess for focal nerve deficits.

Focal nerve deficit6:12–6:18

Face6:18–6:41

Let's start with facial nerve deficits. These are most noticeable while the newborn is crying.
In this case, the exam might demonstrate ptosis, reduced contractility of one side of the face. A loss of the nasolabial fold or drooping of the mouth.
Any of these findings confirms facial nerve injury which is often caused by trauma to the facial nerve during forceps delivery.
Ok. Now, let's discuss upper arm nerve deficits.

Upper arm6:41–7:59

In this case, the exam will reveal unilateral arm weakness and they may hold their arm in a single position. With these findings, you can make a clinical diagnosis of brachial plexus injury.
The most common type of brachial plexus injury is Herb Duchenne palsy, which involves the C five and C six nerve roots. These newborns hold their arm in an adducted and internally rotated position and keep the elbow pronated and the wrist flexed while the grasp reflex remains intact.
In contrast, clumpy palsy is caused by injury to the C eight and T one nerve roots which results in lower arm paralysis and an absent grasp reflex.
Patients with clumpy palsy often have ipsilateral Horner syndrome due to involvement of cervical sympathetic nerves within the first thoracic root.
These patients also present with ptosis, meiosis and enophthalmos. Here's a high yield fact, in rare cases, brachial plexus injury involving nerve root C three through C five causes damage to the phrenic nerve.
These infants have impaired movement of the diaphragm on the affected side and present with intermittent episodes of cyanosis and respiratory distress.
All right. Let's look at the case when the nerve assessment is complete.

Skeletal abnormalities7:59–8:04

Your next step is to assess for skeletal abnormalities. Let's first discuss abnormalities involving the clavicle, which is the most common site for a skeletal injury in the newborn.

Clavicle8:04–9:02

Here. The physical exam often reveals tactile crepitus tenderness and pete over the clavicle as well as decreased arm movement on the affected side.
In addition, a bony callus may form at 7 to 10 days of life. With these findings, consider a clavicle fracture, then obtain an X ray.
If the imaging shows a fracture of the clavicle with or without displacement, youve confirmed a clavicle fracture. Here's a high yield fact, macrosomia, shoulder dystocia and breech delivery are significant risk factors for clavicle fractures and brachial plexus injuries.
In these cases, injury is caused by traction to the head and neck or by manipulation of the arms or clavicle during delivery.
Next, let's look at skull abnormalities. These patients may present with fussiness and you'll typically find crepitus or mild swelling over the skull.

Skull9:02–9:32

These findings should lead you to consider a skull fracture, then obtain a CT scan of the head. If imaging demonstrates lines and strips of decreased density, diagnose a linear skull fracture, its important to note that this form of skull fracture is not usually associated with an underlying intracranial hemorrhage.
Ok. Now, let's move on to abnormalities involving the extremities.

Extremities9:32–10:19

In this case, you might notice a long bone deformity with tenderness or swelling as well as decreased limb movement at 7 to 10 days of life.
A bony callus may become apparent at the site of injury. These findings should lead you to consider a long bone fracture and obtain an xray if radiographs demonstrate a fracture of a long bone such as the humerus or femur, possibly with overriding bony fragments, diagnose a long bone fracture.
Heres another clinical pearl whenever you identify a long bone fracture after an uncomplicated delivery, consider the possibility of osteogenesis, imperfecta or any condition characterized by underlying bony fragility.
Finally, once you've completed assessment for skeletal abnormalities, your next step is to assess for soft tissue changes.

Soft tissue injury10:19–11:16

Look for abrasions or swelling of the ears, lips, and nose as well as lacerations, pete or ecchymoses. In some cases, you might see a well circumscribed indurated and erythematous patch of fat necrosis.
Any of these findings indicates a soft tissue injury. These injuries can result from normal labor and delivery but are more frequently seen after a face presentation, instrumental delivery or an injury caused by a scalpel, fetal scalp, electrode or fetal scalp, blood sampling.
One last high yield fact, newborns born with face presentation can develop significant edema and facial bruising, especially on the eyelids and lips.
Severe facial bruising can even be mistaken for central cyanosis. All right.

Review11:16–12:01

As a quick recap when evaluating a birth injury of an unstable patient, provide acute management and assess for life threatening injuries, progressive scalp edema suggests subgaleal hemorrhage.
While unstable newborns without progressive scalp edema might have an intracranial hemorrhage such as subdural hematoma or subarachnoid hemorrhage.
On the other hand, most stable newborns with scalp edema have cephalohematoma or caput succedaneum, focal nerve deficits typically result from facial nerve injury or brachial plexus injury.
While common skeletal injuries include clavicle, skull and long bone fractures. Finally, common soft tissue injuries include abrasions, ecchymoses and fat necrosis.
Approach to birth injury (pediatrics): Video | Osmosis