The day finally arrived. Jess was in active labor with her husband, Mike, at her side. Her OB assured her that things were looking good, despite Jess having gestational diabetes. According to her doctor, Jess was concerned because her infant was large. That meant that there might be some problems as the baby came down the birth canal
It was a long and difficult labor. The baby’s head wedged against Jessica’s pelvic bone. The OB used forceps to move the baby’s head away from the pelvis and down the birth canal.
Their baby girl was sluggish to cry but was doing well at the 5-minute Apgar. Jess and Mike were thrilled to become a family finally.
But wait. There was something wrong with her face. Only the right side of her mouth was down as she was crying. She had a large bruise on her scalp. Concerned, they asked their OB what had happened to her. He suggested that they wait until the baby’s doctor examined her and answered all their questions.
The following morning, their baby’s pediatrician came ready with answers to all their questions. He first discussed the bruise on her head. He told them it was a cephalohematoma, meaning a small amount of clotted blood in the outer layer of the skull from bursting blood vessels. It occurs in around one of every forty deliveries and resolves within a few weeks.
He then discussed their baby’s face. She had facial paralysis. This happens in between one in 100 to one in 200 live births, frequently when forceps are required. The forceps put pressure on the side of the face as the OB moves the head through the birth canal. While disturbing to look at, it usually heals in less than a month.
Jess and Mike were relieved to learn that both problems would get better. Their doctor let them know that the rest of their baby girl’s exam was fine, and there was no evidence of long-term problems.
How Often Do Birth Injuries Happen?
According to the Paediatr Perinat Epidemiol. 2010 article, birth trauma in the US ranged between 0.2 and 37 birth traumas per 1000 births. There are many reasons for the trauma to occur. These include problems with the mother’s ability to deliver, issues with the infant’s size or position in the birth canal, and the methods used to assist delivery.
What is the Most Common Birth Injury?
Birth injuries are most often due to the natural forces of labor and delivery. The most common area of birth injury is not surprisingly the head which comes out first. The different types of head injuries are these:
Bruising or forceps marks – Bruising is common, especially when the baby’s face is pushing against the mother’s pelvis during labor. Forceps marks occur due to the pressure needed to move the head into a better position for delivery.
Caput succedaneum is a swollen scalp area due to the head pushing against the mother’s pelvis during labor. The swelling can also occur with vacuum delivery.
Subconjunctival hemorrhage – During labor and delivery, the baby’s head and face receive a great deal of pressure leading to small eye blood vessels breaking. There will be a red band in the white part of one or both eyes. While happening frequently, it doesn’t damage the eyes, which get back to normal within two weeks.
Cephalohematoma – As noted above, this is a small amount of clotted blood under the scalp that occurs from blood vessels breaking. It is not a problem and will get better within a few weeks.
Subdural Hematoma – A subdural hematoma is due to bleeding within the skull. Occurring 2.9 infants in every 100,000 live birth, it is the most common intracranial hemorrhage in newborns. Difficulty with labor and delivery and forceps/vacuum use are factors. This injury has the risk of later brain-based problems.
Intraventricular Hemorrhage – This type of bleed occurs within the brain’s ventricles. It occurs mainly in premature infants. On rare occasions, it can occur in term babies due to other pressures such as forceps or vacuum. This injury has the risk of later brain-based problems.
Subarachnoid Hemorrhage – This is the second most common intracranial hemorrhage in neonates. Many newborns acquire an asymptomatic subarachnoid hemorrhage (SAH) during birth. The hemorrhage resolves after several days.
Epidural Hematoma – Epidural hematoma, rare in neonates, is caused by injury to the middle meningeal artery. Most cases also involve a corresponding linear skull fracture. This injury has the risk of later brain-based problems.
What about nerve injuries during labor or delivery?
Injuries to nerves are the second most common injury type. There are two common nerve injuries, facial and brachial plexus.
Facial injuries occur most often when the OB uses forceps during delivery. The trauma occurs with pressure on the side of the head while moving down the birth canal. The infant’s face can show drooping of the eyelid on one side, lack of movement of the muscles around the nose and cheek and drooping of the mouth muscles. Symptoms resolve in about a month.
Brachial plexus injuries involve the muscles of the arm and hand. These occur in 0.5 to 2.5 per 1,000 live births. There are several risk factors for this occurring:
- Shoulder dystocia – long or difficult delivery of the shoulder
- Macrosomia – infant’s birth weight of over 9 pounds
- An overall difficult delivery
- Breech presentation and
- Instrumented deliveries
Physical therapy is ordered to improve arm and hand use when there is an injury to the brachial plexus. After three months, an orthopedic physician is consulted for possible surgery if there are still problems.
What about broken bones during labor or delivery?
Clavicle – This is the most common broken bone during delivery. Between 1 and 1.5% of babies will break their clavicle during delivery. Risk factors are:
- use of vacuum and forceps,
- shoulder dystocia,
- higher birth weight,
- increased maternal age
This injury does not require any medical interventions most of the time. The use of acetaminophen helps with discomfort.
The humerus or the femur may rarely break. These bones could break due to issues such as a large infant, breech position, twin births, prematurity, and for the femur, the baby having diffuse osteoporosis.
Skull fractures – Occurring in 1-2% of births, two types of skull fractures are linear and depressed. Depressed skull fractures have an incidence of 3.4 per100,000 births. These fractures are caused by forceps, vacuum, or even normal vaginal deliveries due to pressure against the maternal pelvic bones. Most of these fractures are monitored if there isn’t any compression to the brain or any bleeding.
Having a baby is exciting and worrisome at the same time. There are always risks of injuries during labor and delivery. It is essential to talk over the possible complications ahead of time to understand better why different choices are made to help deliver your child.
Paediatr Perinat Epidemiol . 2010 Mar;24(2):116-24. doi: 10.1111/j.1365-3016.2009.01077.x.
Hughes CA, Harley EH, Milmoe G, Bala R, Martorella A. Birth Trauma in the Head and Neck. Arch Otolaryngol Head Neck Surg. 1999;125(2):193–199. doi:10.1001/archotol.125.2.193
Birth Injuries in Neonates, Pediatrics in Review, Vol. 37 No. 11 NOVEMBER 2016
Hankins GD, Clark SM, Munn MB. Cesarean section on request at 39 weeks: impact on shoulder dystocia, fetal trauma, neonatal encephalopathy, and intrauterine fetal demise. Semin Perinatol. 2006 Oct;30(5):276-87. doi: 10.1053/j.semperi.2006.07.009. PMID: 17011400.
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