BIRTH TRAUMA

Most birth trauma is associated with difficult delivery, particularly with a large infant, abnormal position, or fetal distress requiring rapid extraction. The most common injuries are soft tissue bruising, fractures (clavicle, humerus, or femur), and cervical plexus palsies, although skull fractures, intracranial hemorrhage (primarily subdural and subarachnoid), and cervical spinal cord injuries can also occur.
Fractures are often diagnosed by the obstetrician, who may feel and hear a snap during delivery. Clavicular fractures may cause decreased spontaneous movement of the arm, with tenderness and crepitus over the area. Humeral or femoral fractures may cause tenderness and swelling over the shaft with a diaphyseal fracture, with limited spontaneous extremity motion in all cases. Epiphyseal fractures are harder to diagnose radiographically owing to the cartilaginous nature of the epiphysis. After 8–10 days, callus appears and is visible on radiographs. Treatment in all cases is gentle handling, with immobilization for 8–10 days: the humerus against the chest with elbow flexed; the femur with a posterior splint from below the knee to the buttock.
Brachial plexus injuries may result from traction as the head is pulled away from the shoulder during delivery. Injury to the C5–C6 roots is most common and results in Erb-Duchenne paralysis. The arm is limp, adducted and internally rotated, extended and pronated at the elbow, and flexed at the wrist (so-called waiter’s tip posture). Grasp is present. If the lower nerve roots (C8–T1) are involved, the hand is flaccid (Klumpke’s palsy). Isolated involvement of these roots is rare. If the entire plexus is injured, the arm and hand are flaccid, with an associated sensory deficit.
Early treatment for brachial plexus injury is conservative, because function usually returns over several weeks. Referral should be made to a physical therapist so that the parents can be instructed on range-of-motion exercises and splinting and for further evaluation if needed. Return of function begins in the deltoid and biceps, with recovery by 3 months in most cases.
Spinal cord injury can occur at birth, especially in difficult breech extractions with hyperextension of the neck, or in midforceps rotations where the body fails to turn with the head. Infants are flaccid, quadriplegic, and without respiratory efforts at birth, although facial movements are preserved. The long-term outlook for such infants is grim.
Facial nerve palsy is sometimes associated with forceps use but more often results from chronic in utero pressure of the baby’s head against the mother’s sacrum. The infant has asymmetric mouth movements and eye closure with poor movement on the affected side. Most cases resolve spontaneously within a few days to 3 weeks.