Learning Objectives
By the end of this section, you will be able to:
- Describe maternal, newborn, and environmental risks that predispose infants to birth injuries
- Identify and prioritize birth-related complications in the newborn
- Compare and contrast the head injuries caput succedaneum, subgaleal hemorrhage, and cephalohematoma
- Compare and contrast the nerve injuries brachial plexus injury, Erb-Duchenne paralysis, facial paralysis, and phrenic nerve paralysis
Any physical injury to a newborn caused by labor and delivery is a birth injury or birth trauma (Collins & Popek, 2018). Most birth injuries are minor and resolve on their own, others require immediate and possibly long-term treatment, and a few can be fatal. The evidence-based practice of limiting the use of forceps or vacuum extraction during delivery and the increased use of cesarean surgery for birth have decreased the number of birth injuries (Gupta & Cabacungan, 2021). However, in some instances, particularly during long labor or if the fetus is in an abnormal presentation for delivery, injury is unavoidable. The nurse’s role is to know the signs and symptoms of these injuries in the newborn, detect them early, and care for those who need treatment (Table 25.1).
| Type of Injury | Physical Symptoms |
|---|---|
| Caput succedaneum, subgaleal hemorrhage, and cephalohematoma | Scalp and underlying tissue (Caput succedaneum crosses suture lines; a cephalohematoma does not) |
| Subdural hematoma and skull fracture | Intracranial and skull damage |
| Clavicle fracture | Clavicle |
| Brachial plexus injury | Brachial plexus (upper extremity) involving nerves C5 to T1 |
| Erb-Duchenne paralysis | Flaccid arm and adducted shoulder, nerves C5 to C6 |
| Klumpke palsy | Lower arm is flaccid with an absent grasp reflex, nerves C8 to T1 |
Risk factors for birth injuries include those of the person giving birth and those of the fetus (Table 25.2). Increased risk for birth trauma is found in persons giving birth who are over 35 or under 16; are primigravida; or experience uterine dysfunction, prolonged or precipitous labor, preterm or postterm labor, and cephalopelvic disproportion (Cavazos-Rehg, et al., 2015). Increased risk for birth trauma is also associated with dystocia, a result of anatomic conditions of either the birthing person or the fetus.
| Affected Person | Risk Factors |
|---|---|
| Birth parent |
|
| Infant |
|
Head Injury
The three most common extracranial birth injuries of the head are caput succedaneum, subgaleal hemorrhage, and cephalohematoma. Serious head injuries from birth that lead to intracranial hemorrhage are subdural hematoma and skull fracture. Though each injury has its own manifestation and pathophysiology, the nursing care for all of them is similar.
Caput Succedaneum
Caput succedaneum is the most common birth-related trauma (Collins & Popek, 2018). As the fetal head presents during a vertex delivery, the tissue there becomes swollen, edematous, and full of serous fluid or blood. An important sign of caput succedaneum is swelling that is beyond or crosses the sutures of the skull. Shortly after birth, bruising, petechiae, or ecchymosis can be noted at the site. The provider and nurse reassure the parents that no treatment is needed, and the swelling will go away in a few days. The nurse assesses the area for any changes and documents during each shift the evolution of the swelling.
Cephalohematoma
Cephalohematoma occurs when fetal blood vessels in the head break during labor or delivery. This injury is most common for primiparous birthing people, and risk increases with a forceps or vacuum extraction delivery. The most common area of bleeding is under one or both parietal bones and rarely the occipital or frontal bones. Unlike the caput succedaneum, the swelling or bruising will not extend beyond the suture line, and it usually shows up 2 to 3 days after birth (Figure 25.2). Treatment is not needed for an uncomplicated cephalohematoma, which will resolve on its own in 2 to 3 weeks. These neonates, however, are at higher risk for jaundice due to broken red blood cells spilling bilirubin into the bloodstream and could need phototherapy.
Subgaleal Hemorrhage
Subgaleal hemorrhage occurs when there is bleeding within the subgaleal space. The subgaleal space is under the tendinous sheath that connects the frontal and occipital muscles and is the inner surface of the scalp. Bleeding is caused by a shearing injury during the compression and dragging of the fetal head through the pelvis. Delivery with forceps or vacuum extraction increases the risk of this injury. The bleeding extends beyond the skull bones and can continue after birth. Nursing care includes taking serial head circumference measurements and evaluating for a firm mass on an examination of the head and neck. A boggy, fluctuant mass over the scalp that crosses suture lines and moves when the newborn is repositioned is an early hallmark sign of the injury. Other symptoms include those related to blood loss, e.g., tachycardia and pallor; the effects of the swelling; and the forward lateral position of the ears. Possible testing includes computed tomography (CT) or magnetic resonance imaging (MRI) to confirm assessment diagnosis. Obtaining an MRI on a young infant can be challenging. Obtaining a head ultrasound prior to an MRI may be beneficial, as ultrasound scans are easily obtained at the bedside. Replacement of blood by transfusion or administration of clotting factors may be needed for treatment. Continuing to monitor the infant for changes in level of consciousness and anemia is paramount in determining treatment. Ultimately, serum bilirubin may increase as the hematoma resolves and the blood collection is absorbed.
Neuromusculoskeletal Injuries
A fracture is a break in a bone. Many different types of fractures exist, though in newborns very few occur due to the birth process. In this chapter, the focus is on fractures caused by birth trauma. The goal in treatment is to allow the bones to heal in a functional position. In the newborn, casting is not the primary treatment modality as it is in older patients who have fractures that need time and support to heal.
Skull Fractures
The skull of the neonate is flexible and can significantly change shape throughout the process of labor and delivery. Two types of fractures are found to occur in the skull bones of the newborn, linear and depressed fractures. Linear fractures are most often seen in the parietal bones and are benign, requiring no intervention. The pressure of the parietal bone moving through the pelvis or the use of forceps can result in depressed fractures. These require a CT scan to both diagnose and evaluate for bone fragments or underlying damage. These fractures heal over time without intervention. The most common cause of a skull fracture is forceful assistance during birth.
Clavicle Fracture
Clavicle fractures are the most common fracture sustained during labor and delivery (Stanford Medicine Children’s Health, 2023). These fractures are most often present in the middle third of the bone. Difficult delivery of the shoulders during a vaginal birth or extension of the arms in a breech birth can result in a fracture. Infants who are born via vacuum or forceps-assisted birth, are macrosomic (weight over 4,000 grams), or have birthing persons with a higher weight (BMI 30 or greater) or diabetes have increased risk for clavicle injury (Hashmi et al., 2021). Any large-for-gestational-age infant, particularly those weighing over 4,500 grams and delivered vaginally, is at risk for a clavicle fracture, and the nurse will evaluate for the injury when completing a head-to-toe assessment (Rehm et al., 2020). Signs and symptoms include limited movement of the arm, crepitus over the clavicle, and absence of the Moro reflex on the fractured side. The signs and symptoms and x-ray are diagnostic. Treatment includes gentle handling of the affected side because it will heal on its own without the need for immobilization.
Link to Learning
A helpful resource for purposes of family support, this link explains injuries that most commonly occur from birth and differentiates between birth injuries and birth defects.
Nerve Injuries
Nerve injuries caused by birth trauma can be direct damage done during delivery, or they can be a secondary injury related to swelling or compression of tissue around or near the affected nerve. The nurse assesses the newborn for intact reflexes (see Chapter 23 Newborn Assessment) and equal bilateral movement with smooth full range of motion to evaluate for any nerve-related injury. The injured or compressed nerve is identified by the signs and symptoms. Treatment consists of allowing time (weeks to months) for the injury to heal as the underlying damage is repaired by the body. Finding an abnormality or unexpected movement in a newborn can be alarming and stress inducing in the new parent or caregiver. The role of the nurse is to both find the nerve injury early and educate the family about the treatment and prognosis with empathy.
Brachial Plexus Injury
The most common type of paralysis related to birth is brachial plexus injury (BPI). The paralysis involves muscles of the upper extremity due to trauma of C5 through T1. Any infant weighing over 4,000 grams is at increased risk for this injury, as are infants born breech, with a forceps- or vacuum-assisted birth, or after a prolonged second stage of labor.
Erb-Duchenne paralysis is due to injury of nerves C5 and C6 caused by pulling the head away from the shoulder during a difficult birth. The signs and symptoms are a limp arm that has an adducted shoulder and is internally rotated. The elbow is extended, and the forearm is pronated; however, a grasp reflex can still be present, as the finger and wrist movement is normal (Figure 25.3).
Klumpke palsy, also called Klumpke palsy, is less common than the other two injuries. It is the result of damage to the lower plexus rather than the upper, and it affects the nerves between C8 and T1. The lower arm is flaccid, and the grasp reflex is absent. Klumpke palsy can present in combination with the other two nerve injuries. Treatment starts with immobilization of the affected upper limb with proper positioning, followed by gentle range of motion (ROM) exercises. If hemorrhage or edema is the cause of the nerve damage, full recovery in a few weeks is likely. If a laceration has occurred to the nerve itself and movement is not restored in a few months, surgery may be required. Return of full function is variable.
Educating parents on the progression of their newborn if the child is diagnosed with this injury is the role of the bedside nurse. During head-to-toe assessment, a finding of lower arm flaccidity and loss of grasp reflex (see Chapter 23 Newborn Assessment) could be made by the bedside nurse, leading them to alert the health-care provider and move forward with treatment.
Facial Paralysis
In a neonate, facial paralysis occurs from birth injury to the facial nerve, which is cranial nerve 7 (Cromeens et al., 2020). When under pressure, this nerve may be injured because of its location. Infants who undergo a prolonged second stage of labor or a forceps-assisted delivery are at higher risk for this injury. Signs and symptoms are loss of movement on that side, such as a droopy eyelid, although the eye remains open on the affected side (Figure 25.4). The face is flattened and unresponsive during crying. The forehead will not wrinkle, resulting in a notable presentation during crying. This injury does not need treatment, is usually transitory, and improves spontaneously in hours to days after birth. Some presentations can take weeks to months to heal. Congenital unilateral facial paralysis related to an ipsilateral facial nerve aplasia or hypoplasia is a potential cause that requires surgical intervention. These longer-lasting symptomatic findings point toward an underlying developmental or congenital defect and underscore the importance of MRI in the diagnostic workup (Decraene et al., 2020). Discussing this finding with the parents can relieve unvoiced concerns regarding abnormal facial movement during crying.
Phrenic Nerve Paralysis
Paralysis of the diaphragm is called phrenic nerve paralysis. The injury is usually caused by hyperextension of the neck during delivery. This can occur with breech delivery or a forceps-assisted delivery (Murty & Ram, 2012). Diaphragmatic paralysis almost always occurs with a brachial plexus injury, though brachial plexus injuries are generally a lone injury. Paralysis of the diaphragm is usually unilateral, although it can be bilateral. The same pulling of the shoulder away from the head that causes the brachial plexus injury is the cause of this injury (Rizeq et al., 2020).
Cyanosis and irregular thoracic respirations with no abdominal movement during breathing are the presenting signs of paralysis, which can lead to a medical emergency. These infants will require respiratory support, most commonly mechanical ventilation, for the first few days of life. Due to the lack of diaphragmatic support for their breaths, they are at increased risk for pneumonia. If respiratory distress, a state when the increased efforts of breathing cannot meet ventilation and oxygenation demands, is persistent, the infant requires longer support. Diaphragmatic electrical stimulation, called pacing, or surgical correction may be required for treatment.