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Traumatic Birth Injury Adam A. Rosenberg Neoreviews 2003;4;e270 DOI: 10.1542/neo.4-10-e270

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Article trauma

Traumatic Birth Injury
Adam A. Rosenberg, MD*

Objectives
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After completing this article, readers should be able to:

Describe the delivery conditions that increase the risk for birth trauma. Explain why subgaleal hemorrhage can be a medical emergency. Delineate the commonpresenting findings of traumatic intracranial bleeding. Describe the risk factors for brachial plexus palsy. Differentiate facial nerve palsy from congenital palsies and hypoplasia of the depressor anguli oris muscle.

Introduction
Birth injuries are sustained during the labor and delivery process. They can be divided into those due to physical trauma during the birth process (traumatic birth injury)and those due to lack of oxygen (hypoxic-ischemic injury). These types of injuries can occur separately or in combination. This review focuses on the diagnosis and management of traumatic birth injuries. Traumatic injuries often are the result of a discrepancy between the size or position of the fetus in relation to the birth canal or an unusually rigid pelvis that has not adapted to the size ofthe fetal head. The reported rate of birth trauma from a 7-year review published in 1990 was 3.2%. Some injuries are avoidable, and with improvements in obstetric care, the frequency of birth injury as a cause for perinatal mortality has decreased over the past 25 years. Predisposing factors for traumatic birth injury are listed in Table 1. Macrosomic fetuses, including those from poorlycontrolled diabetic pregnancies, represent a particularly high-risk group for birth injury. However, predicting which macrosomic infants will be injured during the birth process is difficult. Injuries also are more frequent with instrumented vaginal deliveries. Use of forceps has been associated with facial nerve and brachial plexus injuries, skull and facial fractures, and intracranial hemorrhages.Ocular injuries, including fracture of the base of the orbit, intraorbital hemorrhage, corneal laceration, and breaks in Descemet’s membrane with corneal opacification, as well as dislocated nasal septum and fractured nasal bones have been reported. Vacuum extractions are associated with cephalohematoma, skull fracture, scalp lacerations, intracranial hemorrhage, subgaleal hemorrhage, and retinalhemorrhage. The frequency of injury is increased by a longer duration of application, multiple applications, and a paramedian cup placement. Cesarean section does not eliminate the possibility of birth trauma, especially when prior attempts have been made at delivery with vacuum extraction or forceps. A comprehensive listing of birth injuries is presented in Table 2. Reported frequencies of injuries(excluding bruising and minor scalp trauma) are greatest for clavicular fractures, followed by facial nerve injuries, brachial plexus palsy, intracranial hemorrhage, humerus fracture, diaphragmatic paralysis, spinal cord injury, and depressed skull fracture. Many injuries, such as soft-tissue trauma, are minor, but others, such as liver laceration, subgaleal hemorrhage, or large subdural blood...