Management of birth injuries

Mechanical Birth Injuries: A Comprehensive Five-Year Analysis From a Tertiary Care Hospital

BACKGROUND

Birth injury or birth trauma refers to physical damage or trauma that occurs to a newborn during the birthing process. To ensure continuous care and improve neonatal outcomes, it is crucial to know the incidence, types, relation to the mode of delivery, and their management.

METHODOLOGY

This is a retrospective cohort study conducted at Aga Khan University Hospital, Pakistan from January 2018 to December 2022. Neonates aged from birth to 28 days of life identified to sustain any form of mechanical birth injuries were included. Data analysis was done using SPSS version 19 (IBM Corp., Armonk, NY).

RESULTS

In the last five years, 51 mechanical birth injuries were found among 27,854 deliveries, which accounts for one in 546 births with an overall prevalence of 0.001%. Out of the total mechanical birth injuries, 12 (23.5%) were noticed in spontaneous vaginal delivery, six (11.8%) had instrumental delivery, and 33 (64.7%) patients had cesarean sections. More birth injuries were noticed in emergency cesarean section as compared to vaginal deliveries. There were 40 babies (78%) with soft tissue injuries, seven (14%) had musculoskeletal injuries/fractures, two (4%) babies had intracranial bleeding, and two (4%) had fractures along with intracranial bleeding. There was no mortality reported among these neonates.

CONCLUSION

The overall rate of birth injuries was significantly lower as compared to other low and middle-income countries. Most of the birth injuries were soft tissue injuries in patients with cesarean sections. The rate of birth injury did not show any association with the time of delivery. More frequent obstetric emergency drills would improve complications associated with shoulder dystocia.

Is There a Role for Isolated Closed Reduction in the Emergency Department Without Fixation for Displaced Proximal Humerus Fractures in Adolescents?

OBJECTIVE

Pediatric proximal humerus fractures (PHFx) are uncommon and makeup ~2% of all pediatric fractures. Traditionally, most cases are treated nonoperatively with closed reduction (CR) or immobilization with no reduction (INR) with excellent outcomes. Indications for CR without fixation remain unclear as immobilization in the position of reduction (shoulder abduction and external rotation) is not practical. We aim to determine the need for CR among adolescents with displaced PHFx treated nonoperatively.

METHODS

We conducted an IRB-approved prospective multicenter study involving 42 adolescents aged 10 to 16 years, treated for displaced PHFx across 6 institutions between 2018 and 2022. CR was performed under conscious sedation in the emergency department, with data collected during follow-up visits at 6 weeks and 3 months. Radiographic measurements, range of motion, and patient-reported outcomes, including the Patient-Reported Outcomes Measurement Information System Upper Extremity and Physical Function, Shoulder Pain and Disability Index, and QuickDash scores, were compared between the INR and CR groups.

RESULTS

Among 42 fractures, 23 (55%) were treated with INR and 19 (45%) with CR, followed by placement in a hanging arm cast or sling. Of the cases, 62% were high-energy injuries. Radiographic alignment and range of motion were similar between groups at preoperative, 6 weeks, and 3 months with no significant differences noted.Patient-Reported Outcomes Measurement Information System Upper Extremity, Physical Function, QuickDash, and Shoulder Pain and Disability Index scores at 6 weeks and 3 months showed no significant differences between cohorts. Significant improvement was observed between 6 weeks and 3 months for every patient-reported outcome in both cohorts.

CONCLUSIONS

For displaced PHFx treated nonoperatively, our data suggests INR has a similar radiographic and clinical outcome when compared with CR. Our results question the necessity of performing CR in this group of patients.

LEVEL OF EVIDENCE

Level II-therapeutic studies: prospective cohort study.

PM2.5-related neonatal encephalopathy due to birth asphyxia and trauma: a global burden study from 1990 to 2019

Long-term exposure to fine particulate matter (PM_2.5) may increase the risk of neonatal encephalopathy due to birth asphyxia and trauma. However, little is known about the trends of PM_2.5-related neonatal encephalopathy burden under different levels of social and economic development. We studied the burden of PM_2.5-related neonatal encephalopathy due to birth asphyxia and trauma measured by the age-standardized mortality rate (ASMR) and the age-standardized disability-adjusted life years rate (ASDR), and its trends with the socio-demographic index (SDI) in 192 countries and regions from 1990 to 2019. This is a retrospective study using the Global Burden of Disease Study 2019 (GBD2019) database. The age-standardized mortality rate (ASMR) and age-standardized disability-adjusted life years rate (ASDR) are used to measure the burden of PM_2.5-related neonatal encephalopathy in different countries and regions. The mortality rate (per 100 thousand) is used to evaluate the differences of PM_2.5-related neonatal encephalopathy burden in sex and age. The annual percentage changes (APCs) and the average annual percentage changes (AAPCs) are used to reflect the trends of PM_2.5-related neonatal encephalopathy burden over years (1990-2019) and are calculated using a Joinpoint model. The relationship of the socio-demographic index with the ASMR and ASDR is calculated using Gaussian process regression. In summary, the global burden of PM_2.5-related neonatal encephalopathy increased since 1990, especially in boys, early neonates, and regions with low-middle SDI. Globally, the ASMR and ASDR of PM_2.5-related neonatal encephalopathy burden in 2019 were 0.59 (95% CI: 0.40, 0.83) per 100,000 people and 52.59 (95% CI: 35.33, 73.67) per 100,000 people, respectively. From 1990 to 2019, the ASMR and ASDR of PM_2.5-related neonatal encephalopathy increased by 44.39% and 44.19%, respectively. The global average annual percentage changes of ASMR and ASDR were 1.3 (95% CI: 1.0, 1.6). The relationship between the socio-demographic index and the burden of PM_2.5-related neonatal encephalopathy presented negative correlation when the socio-demographic index was more than 0.60. Middle, high-middle, and high SDI regions had decreasing trends of PM_2.5-related neonatal encephalopathy, of which the AAPCs for both ASMR and ASDR ranged from - 0.3 to - 3.1. Besides improving the progress in national policy and the coverage rate of maternal and neonatal health care and facility-based delivery, air pollution control may also be a better way for countries with large and increasing amounts of exposure to PM_2.5 pollution to reduce neonatal encephalopathy. And our results also suggest that low and low-middle SDI countries should appropriately pay more attention to early newborns and boys.

Modified Velpeau Sling Application for the Treatment of Fractures Around Shoulder in Infants

BACKGROUND

Fractures around the shoulder region in infants are treated by arm-chest bandaging, adhesive strapping, or sling application. These conventional treatment methods are associated with issues like skin irritation, excoriation, movement of bone fragments causing muscle spasm, and difficulty in nursing care. We describe the technique of modified Velpeau sling application and reviewed its efficacy at a long-term follow-up.

METHODS

A retrospective study was conducted with 19 infants who presented between 2009 and 2018 to a tertiary care center in western India with either clavicle or humerus fracture. Inclusion criteria was any infant with humerus or clavicle fracture that underwent modified Velpeau sling application and had a minimum follow-up of 2 years. Patients were followed at weekly intervals until sling discontinuation based on the fracture healing. At further follow-up, children were assessed for the presence of angular or rotational malalignment and limb length discrepancy. Functional outcome was measured by the Paediatric Adolescent Shoulder Survey at the final follow-up.

RESULTS

Seven clavicle and 12 humerus fractures were treated with this technique. The mean age at presentation was 50 days (range, 1 d to 7 mo). The average follow-up was 6 years (range, 2 to 10 y). Two infants had underlying osteogenesis imperfecta. Infants without underlying pathology had no angular/rotational malalignment or limb length discrepancy, while both infants with underlying osteogenesis imperfecta had a varus alignment and shortening of the humerus. Infants without underlying pathology demonstrated good functional outcomes measured by the Paediatric Adolescent Shoulder Survey questionnaire, while those with pathology had functional limitations.

CONCLUSIONS

The modified Velpeau method is an effective way of treating fractures around the shoulder region in infants without underlying pathology. Several advantages such as accessibility of sling material, easy application, inexpensive material, and absence of skin-related complications make this an effective treatment.

LEVEL OF EVIDENCE

Level IV-therapeutic study.

Brachial Plexus Birth Palsy: Practical Concepts for Radiologists

Brachial plexus birth palsy (BPBP) is classified as a preganglionic or postganglionic injury based on the site of injury. Most patients recover spontaneously and are followed up with clinical evaluation; however, permanent sequelae are not uncommon. For patients with persistent neurologic deficits, clinical and radiologic evaluation is crucial. Untreated BPBP can progress to significant sequelae, such as muscle contractures and glenohumeral dysplasia (GHD). Timely characterization of these entities based on different imaging modalities is a high priority for optimal patient outcomes. We describe the anatomy and pathogenesis, as well as the different imaging modalities involved in the evaluation and classification of BPBP and GHD.

Clavicular Fractures in Newborns: What Happens to One of the Commonly Injured Bones at Birth?

Introduction The clavicle is one of the most commonly injured bones during the birth process. The objective of this study was to determine the frequency and outcome of fractured clavicle amongst neonates born in a five-year period at a Secondary Hospital setting and to determine the Maternal and Neonatal Characteristics involved in such cases and compare them with a control group and determine the significance of any factors. Methods All cases of fractured clavicle were retrospectively reviewed in a Secondary care hospital setting during a five-year period from July 2015 to June 2020. Maternal and neonatal factors were determined and then compared to a control group. Results Out of 21,435 live births at our center during the study period, 92 infants were diagnosed to have clavicle fractures, giving an incidence of 4.29 per 1,000 live births (0.43%). 89% cases (n=82) were detected before discharge and 11 % cases (n=10) on routine follow-up visit after discharge. Physical examination identified 77% cases (n=71) whereas 23% cases (n=21) were recognized incidentally on X-ray. All babies with fracture including 3 with Erb's palsy recovered completely without any complications. On logistic regression analysis, spontaneous vaginal delivery, prolonged second stage, vertex presentation, vitamin D deficiency in mothers, birthweight, macrosomia, all were significant risk factors. Conclusion Neonatal clavicular fracture appears to be a transient yet unpredictable and unavoidable event with an overall good prognosis. Only the birth weight was identified as the common risk factor affecting clavicular fracture. Parental concerns and anxiety can be decreased with proper counselling and reassurance.

Neonatal Birth Trauma: Analysis of Yearly Trends, Risk Factors, and Outcomes

OBJECTIVE

To evaluate the trends, proportions, risk factors, resource utilization, and outcomes of neonatal birth trauma in the US.

STUDY DESIGN

This cross-sectional study of in-hospital births used the Nationwide Inpatient Sample for 2006-2014. We divided the cases by type of birth trauma: scalp injuries and major birth trauma. Linear regression for yearly trends and logistic regression were used for risk factors and outcomes. A generalized linear model was used, with a Poisson distribution for the length of stay and a gamma distribution for total spending charges.

RESULTS

A total of 982 033 weighted records with neonatal birth trauma were found. The prevalence rate increased by 23% from (from 25.3 to 31.1 per 1000 hospital births). Scalp injuries composed 80% of all birth traumas and increased yearly from 19.87 to 26.46 per 1000 hospital births. Major birth trauma decreased from 5.44 to 4.67 per 1000 hospital births due to decreased clavicular fractures, brachial plexus injuries, and intracranial hemorrhage. There were significant differences in demographics and risk factors between the 2 groups. Compared with scalp injuries, major birth trauma was associated with higher odds of hypoxic-ischemic encephalopathy, seizures, need for mechanical ventilation, meconium aspiration, and sepsis. Length of stay was increased by 56%, and total charges were almost doubled for major birth trauma.

CONCLUSIONS

Neonatal birth trauma increased over the study period secondary to scalp injuries. Major birth trauma constitutes a significant health burden. Scalp injuries are also associated with increased morbidity and might be markers of brain injury in some cases.

Liver laceration presented as intraabdominal bleeding in a newborn with hypoxic-ischemic encephalopathy

Objectives

Birth injuries usually occur with two different mechanisms: trauma due to mechanic stress during labor and hypoxic-ischemic injury. Sometimes these two mechanisms can occur at the same time with a complex clinical picture.

Case presentation

The baby girl was born at 372/7 weeks after a prolonged second stage of labor, weighing 3,725 g, and was admitted to the Neonatal Intensive Care Unit with the diagnosis of hypoxic-ischemic encephalopathy. During follow up she developed multiorgan failure and severe anemia. On the third postnatal day, abdominal bleeding was detected. Laceration in the liver capsule was found and appeared to be the source of bleeding.

Conclusions

Abdominal bleeding secondary to mechanical laceration of the liver is hard to diagnose and may coexist with perinatal asphyxia.

Unusual Presentations of Birth Related Cervical Spinal Cord Injury

Neonatal spinal cord injury is a rare complication of birth trauma by difficult delivery. The typical manifestations are often catastrophic, include decreased or absent movement, loss of reflexes, apnea or periodic breathing, and a lack of response to painful stimulation. The outcome is usually fatal or severe, with long-term sequelae of respiratory insufficiency, limb weakness, or even paralysis of the limbs. We described a male neonate with a C2 spinal cord injury who was born smoothly by vaginal delivery and was unnoticed initially due to unusual subtle symptoms. He presented with a hoarse voice, swallowing dysfunction, decreased movement of upper limbs, and hypercapnia. After receiving corticosteroid therapy and rehabilitation, he recovered much except that he still needed ventilator support at night.

Birth Injury: Birth Asphyxia and Birth Trauma

Injury to a fetus or neonate during delivery can be due to several factors involving the fetus, placenta, mother, and/or instrumentation. Birth asphyxia results in hypoxia and ischemia, with global damage to organ systems. Birth trauma, that is mechanical trauma, can also cause asphyxia and/or morbidity and mortality based on the degree and anatomic location of the trauma. Some of these injuries resolve spontaneously with little or no consequence while others result in permanent damage and severe morbidity. Unfortunately, some birth injuries are fatal. To understand the range of birth injuries, one must know the risk factors, clinical presentations, pathology and pathophysiology, and postmortem autopsy findings. It is imperative for clinicians and pathologists to understand the causes of birth injury; recognize the radiographic, gross, and microscopic appearances of these injuries; differentiate them from inflicted postpartum trauma; and work to prevent future cases.

An unusual cause of neonatal shock: a case report

The authors present a premature male neonate who developed subcapsular hematoma of the liver (SHL) secondary to birth trauma during the delivery process. During cesarean section, it was discovered that the infant had suffered birth trauma to the abdomen that caused intra-abdominal hemorrhage, resulting in hypovolemic shock. It was diagnosed as SHL upon abdominal ultrasound. This premature newborn infant presented with hypotension and metabolic acidosis secondary to internal hemorrhage. He was managed with volume replacement including packed red blood cells (pRBC), fresh frozen plasma and cryoprecipitate transfusions. The infant’s clinical condition improved gradually, and he went home without any problems at 36 weeks of corrected gestational age. On follow-up visits, he was found to be growing and developing appropriately. High index of suspicion, appropriate work-up and prompt treatment of shock were the key steps in the management of this infant.

A Unique Type of Birth Trauma Mistaken for Abuse

Pediatric abusive head trauma is a challenging subject across many disciplines. Of particular importance is the identification of mimics of abuse, so cause and manner of death can be properly assigned. We present the case of suspected child abuse involving an infant who presented unresponsive to the hospital with hypoglycemia, hypothermia, and bilateral parietal fractures. An autopsy revealed fractures associated with organizing scalp hemorrhage and gross leptomeningeal congestion and hemorrhage. The fractures were circular with external displacement, rounded margins, and subperiosteal new bone formation indicative of healing. Birth records revealed vacuum assist and cesarean section delivery. Although vacuum extraction-related injuries are typically cephalohematomas and/or linear fractures, the outbending and circular morphology of the fractures are consistent with vacuum extraction. Moreover, microscopic neuropathological examination revealed hemorrhagic purulent leptomeningitis. This unique case demonstrates the importance of considering birth trauma in the determination of cause and manner of death of an infant.

Brain Computed Tomography Compared with Facial 3-Dimensional Computed Tomography for Diagnosis of Facial Fractures

OBJECTIVES

To compare the detection of facial fractures and radiation dose between brain computed tomography (CT) and facial 3-dimensional (3D) CT in pediatric patients who have experienced a trauma.

STUDY DESIGN

Four hundred pediatric patients who experienced a trauma and underwent immediate brain CT and facial 3D CT between January 2016 and June 2016 were included in this retrospective study. Two reviewers independently analyzed and determined the presence of the facial fractures of 8 anatomic regions based on brain CT and facial 3D CT over a 1-week interval. Suggested treatment decisions for facial fractures seen on brain CT and facial 3D CT were evaluated by one physician. The facial 3D CT scans, interpreted by a senior radiologist, were considered as the reference standard. Diagnostic performance, radiation dose, and interobserver agreement of the CT scans were evaluated.

RESULTS

Brain CT showed a high sensitivity (94.1%-96.5%), high specificity (99.7%-100%), and high accuracy (98.8%-99.0%) in both reviewers, and performed as well as did facial 3D CT (P ≥ .25). The suggested treatment decision was not different between the brain CT and facial 3D CT findings. The agreements between the reference standard and the reviewers, and between reviewers 1 and 2 were excellent (k = 0.946-0.993). The mean effective radiation doses used in brain CT (3.6 mSv) were significantly lower than those in brain CT with facial 3D CT (5.5 mSv) (P < .001).

CONCLUSIONS

Brain CT showed acceptable diagnostic performance and can be used as the first-line imaging tool in the workup of pediatric patients with suspected facial fractures.

Bilateral congenital pseudoarthrosis of the clavicles in a newborn

Bilateral congenital pseudoarthrosis of the clavicles is extremely rare. We report a case of this entity presenting in the neonatal period. We highlight the importance of the differential diagnosis when clavicular fracture shows no evidence of healing or occurs bilaterally.

Iatrogenic injury and unexpected hospital death in the newborn

Neonates are unusually vulnerable to iatrogenic injury due to small body size, delicate tissues, and immature immune systems. Investigation of an unexpected neonatal death in the hospital should begin with a review of the medical record and discussion with medical staff involved in the patient׳s care. Postmortem investigation should include a complete and well-documented autopsy. Additional investigations, such as microbiological studies and chemical and toxicological studies of postmortem and antemortem fluid samples, may be crucial in arriving at a diagnosis. Causes of iatrogenic injury include birth trauma, medication errors and adverse drug effects, hospital-acquired infection, and medical device malfunction, incorrect placement, and misuse. Autopsy is an important tool for understanding the cause of an unexpected death, improving the quality of care, and providing closure to parents and family.

Intracranial hemorrhage in infants with cephalohematoma

BACKGROUND

Intracranial hemorrhage (ICH) is a rare birth injury in term infants. Newborn infants with cephalohematoma (CH) associated with ICH, however, have frequently been found incidentally at Kyungpook National University Hospital; many of them had no neurological symptoms. The aim of this study was to evaluate the clinical manifestations of ICH in newborn infants with CH.

METHODS

Newborn infants with CH in the neonatal intensive care unit were retrospectively evaluated. During period I (5 years), neuroimaging (brain computed tomography and magnetic resonance imaging) was performed when intracranial abnormalities were suspected. During period II (36 months) neuroimaging was performed when CH > 5 cm in diameter was present.

RESULTS

During period I, seven out of 19 infants who underwent neuroimaging had ICH (36.8%) including two epidural hemorrhages (EDH). During period II, 18 out of 27 infants who underwent neuroimaging had ICH (66.7%), including two EDH. There was no significant difference in the clinical manifestations between infants with and without ICH. In 10 cases of CH accompanied with a linear skull fracture, nine had ICH, including all cases of ICH that needed intervention.

CONCLUSIONS

The association of ICH appears to be common in newborn infants with CH; particularly in infants with CH accompanied with a skull fracture, the rate of ICH was very high, and all cases of EDH requiring intervention were associated with skull fracture. Therefore, evaluation of accompanying skull fracture should be required in infants with CH, and, in cases of skull fracture, neuroimaging should be considered.

Three-dimensional humeral morphologic alterations and atrophy associated with obstetrical brachial plexus palsy

BACKGROUND

Obstetrical brachial plexus palsy (OBPP) is a common birth injury, resulting in severe functional losses. Yet, little is known about how OBPP affects the 3-dimensional (3D) humeral morphology. Thus, the purpose of this study was to measure the 3D humeral architecture in children with unilateral OBPP.

METHODS

Thirteen individuals (4 female and 9 male patients; mean age, 11.8 ± 3.3 years; mean Mallet score, 15.1 ± 3.0) participated in this institutional review board approved study. A 3D T1-weighted gradient-recalled echo magnetic resonance image set was acquired for both upper limbs (involved and noninvolved). Humeral size, version, and inclination were quantified from 3D humeral models derived from these images.

RESULTS

The involved humeral head was significantly less retroverted and in declination (medial humeral head pointed anteriorly and inferiorly) relative to the noninvolved side. Osseous atrophy was present in all 3 dimensions and affected the entire humerus. The inter-rater reliability was excellent (intraclass correlation coefficient, 0.96-1.00).

DISCUSSION

This study showed that both humeral atrophy and bone shape deformities associated with OBPP are not limited to the axial plane but are 3D phenomena. Incorporating information related to these multi-planar, 3D humeral deformities into surgical planning could potentially improve functional outcomes after surgery. The documented reduction in retroversion is an osseous adaptation, which may help maintain glenohumeral congruency by partially compensating for the internal rotation of the arm. The humeral head declination is a novel finding and may be an important factor to consider when one is developing OBPP management strategies because it has been shown to lead to significant supraspinatus inefficiencies and increased required elevation forces.

Birth-related injury to the head and cervical spine in neonates

Birth-related injury is defined as any traumatic or ischemic event sustained during the process of delivery. Perinatally acquired disease processes secondary to birth-related injury can be traumatic or ischemic in nature. In this article, the authors focus on traumatic/mechanical injuries. Other diseases of the perinatal time period, including germinal matrix hemorrhages and hypoxic-ischemic encephalopathy, are beyond the objective of this review.

Birth fracture of the clavicle

Birth fracture of the clavicle occurs in approximately 0.4% to 10% of vaginal births. The most common symptom is decreased movement of the ipsilateral arm. A high index of suspicion is necessary in infants presenting without any symptoms. Although displaced clavicular fractures are relatively easily diagnosed clinically, nondisplaced fractures may be apparent only after callus formation, or if all neonates are subjected to radiography or ultrasonography, or multiple physical examinations by trained examiners. We present a case of an infant delivered with vaginal labor with a fracture of the right clavicle diagnosed after apparent callus formation and discuss the current evidence of associated factors and obstetrical care.

Intrauterine rectovaginal tear during a manual attempt to rotate a neonate

Intrauterine rectovaginal tears in neonates are a rare and life-threatening complication of abnormal presentation during labor. Two previous cases have been presented in the literature, of which one had a fatal outcome. The authors present a third case of a severe rectovaginal intrauterine tear that had a favorable outcome.

Neonatal spinal cord injury after an uncomplicated vaginal delivery

Neonatal spinal cord injury has been reported after traumatic births and as a consequence of underlying lesions in the spinal cord. This report describes an infant who was born with bilateral flaccid paralysis of the upper extremities after an atraumatic, noninstrumented vaginal delivery. The infant was otherwise neurologically intact. The infant was initially thought to exhibit bilateral brachial plexus injury. However, magnetic resonance imaging demonstrated an upper cervical spinal cord hemorrhage, with no underlying lesions of the spinal cord or surrounding vasculature. This case highlights the importance of thoroughly evaluating any neurologic deficit in the newborn, and suggests that normal mechanical forces of labor and delivery may be sufficient to cause damage to the newborn spinal cord.

A neonate with asymmetric arm movements

Abnormal arm posture or movements in a neonate may cause significant concern in a pediatric emergency department. This can be secondary to osteomyelitis, which may rarely present with asymmetric arm movements in the neonatal period. The diagnosis of osteomyelitis is difficult to establish in a neonate because systemic signs may not be present at this age. We report an infant with upper limb weakness and asymmetric movements 3 weeks after delivery.

Sagittal craniosynostosis combined with ossified cephalhematoma--a tricky and demanding puzzle

INTRODUCTION

Four cases of sagittal synostosis combined with ossified cephalhematoma prompted the authors to present the data and to discuss the implications. Large cephalhematoma of the vertex at birth with subsequent ossification occurred in all with final sizes of 6.5-10 by 4.0-5.5 by 0.8-1.8 cm. At surgery with 2-6 months, the mean skull index was 64.75, sagittal suture completely closed, and a disfiguring bony mass present in all.

DISCUSSION

In three of the original cohort of 106 sagittal synostoses, ossified cephalhematoma was removed in one piece together with the suture. In contrast to pathogenesis of common parietal cephalhematomas, cephalhematoma in sagittal synostosis is rather induced by periosteal detachment of the midline by strong shearing forces because molding is hindered in the lateral direction. Frequent and fast complete ossification is possibly directed by the same local factors (e.g., Noggin) which lead to premature fusion of cranial sutures. Some treatment principles of ossified cephalhematoma in sagittal synostosis may be applied to surgery of common types.

Head trauma after instrumental births

Instrumental vaginal delivery involves the use of the vacuum extractor or obstetric forceps to facilitate delivery of the fetus. It is associated with substantial risk of head injury, including hemorrhage, fractures, and, rarely, brain damage or fetal death. This review article describes the different types, etiology, pathophysiology, risk factors, and clinical features of head trauma after instrumental birth, along with their management and prevention strategies.

Penetrating abdominal injury and peritonitis: A rare case of birth Injury

The incidence of birth injuries has decreased considerably because of the identification of risk factors at an earlier stage and taking the decision for caesarian section (LSCS) at proper time. Fractures, nerve palsies and central nervous system injuries comprise the majority of "birth injuries." In this study, we report a newborn that had a birth injury during LSCS. The baby sustained a penetrating abdominal injury by the knife of the surgeon, while performing LSCS. The bowel was injured at two sites, proximal jejunum and descending colon. The baby developed meconeum spillage and peritonitis. Exploratory laprotomy was done and the injuries were identified. The injured portions were resected and bowel continuity was reestablished. The baby had an uneventful recovery.

Does a change in obstetric management influence the incidence of traumatic birth lesions in mature, otherwise healthy newborn infants?

AIM

The incidence of lesions due to birth trauma can be generally regarded as a characteristic of obstetric management; since obstetric management has changed through the years, one might expect a decrease or increase of lesions due to birth trauma in mature newborn infants.

METHODS

In a retrospective study, the incidence of lesions due to birth trauma was recorded in the year 2000. In 1989, an identical study had already been carried out in the same department, employing the same criteria. The new findings were compared with the historical data.

RESULTS

In the year 1989 24.6% and in 2000 13.2% showed lesions due to obstetric trauma. The episiotomy rate and lesions due to birth trauma had significantly decreased. A decline regarding the traumas per se was noticed in caput succedaneum traumas, in hematomas due to birth trauma and in clavicle fracture. The cesarean section rate among the study group increased. The cesarean section rate among the traumatized newborns decreased.

CONCLUSION

Episiotomy does not prevent newborns from traumatic lesions. Gestational age and birthweight have not significantly changed throughout the years; therefore an increase in the cesarean section rate must have contributed to the decrease of birth traumas. Even during abdominal operative delivery, obstetric traumas in newborns do occur. However, an increase in cesarean sections alone can not thoroughly explain the reduction of birth lesion among newborns. Improvement in prenatal diagnostic tools and procedures, respectively, and a goal-oriented use of labor induction might also play a major role.

Peritoneal dialysis in the neonatal intensive care unit. Management of acute renal failure after a severe subgaleal hemorrhage

Acute renal failure is common in the neonatal intensive care unit but is often not recognized in its early phases, when it is potentially reversible. The typical patient with acute renal failure is premature, but many term infants are also at risk. One such group is those with severe bleeding, such as a subgaleal hemorrhage. In these cases, hypovolemia can quickly progress to ischemia, which affects many organs but has profound effects on the kidney. In term infants, acute renal failure is most commonly diagnosed in those with perinatal depression. This article presents a unique case of an infant with subgaleal and intracranial bleeding that resulted in acute renal failure requiring peritoneal dialysis in the hopes of the eventual restoration of kidney function.

A newborn with multiple fractures as first presentation of infantile myofibromatosis

Pathological fractures occur in infancy from a variety of causes, but are a rare condition during neonatal period. We describe the case of a male newborn with a metaphyseal fracture of femur and multiple lytic lesions, diagnosed as infantile myofibromatosis.

Head injuries after instrumental vaginal deliveries

PURPOSE OF REVIEW

The types, mechanisms and clinical manifestations of head injuries (extracranial, cranial and intracranial) after instrumental delivery are described along with current evidence of their prevention and management.

RECENT FINDINGS

Asymptomatic subdural hematomas can occur in up to 6.1% of uncomplicated vaginal deliveries. Maternal nulliparity, incorrect placement of vacuum extraction cup and failed vacuum extraction are predisposing factors to subgaleal hemorrhage. Injuries associated with the vacuum devices may be minimized if the recommended limits for a safe traction force are not exceeded. There is no difference in the incidence of scalp trauma between vacuum deliveries by a rigid plastic cup (Omnicup) and the standard, silastic cup. The use of a metal cup may increase the occurrence of head injuries. Protective covers over forceps reduce the rates of neonatal facial abrasions and skin bruises. There is no difference in the incidence of cephalhematoma comparing a sequential operative vaginal delivery and a caesarean section following a failed vacuum delivery.

SUMMARY

Instrumental vaginal deliveries carry substantial risks. Only practitioners who are adequately trained or are under supervision should undertake instrumental delivery. The mode of intervention needs to be individualized after consideration of the operator's skills and experience and the clinical circumstances.