What is Birth Injury?
Birth injury is damage sustained during the birthing process, typically occurring while the infant passes through the birth canal.
Why Do Birth Injuries Occur?
A difficult delivery - with injury to the infant - may occur if the birth canal is too small or the fetus is too large (such as if the mother has Gestational Diabetes or the pregnancy is post-date). Injury is more likely to occur if the fetus is in an abnormal position in utero and presents for delivery buttocks first (breech position), rather than head first. The rate of birth injuries overall is much lower now than in previous decades thanks to the advances in prenatal assessment using ultrasonography, and because in certain circumstances, a cesarean delivery may be performed.
Types of Birth Injuries:
Head and Brain Injury - in most births, the head is the first part of the infant to enter the birth canal, and experiences much of the pressure during delivery. Swelling of the scalp and bruising are common - and not a serious complication - in infants and usually resolve within a couple of days to a week after birth.
Intercranial Hemorrhage (bleeding in the brain) is caused by a rupture of a blood vessel within the skull. Bleeding in the spaces around the brain is caused by deformity of the skull bones during delivery or a lack of oxygen. Brain bleeds are far more common in premature infants; resulting from inadequate blood flow to the brain or a diminished amount of oxygen in the blood.
While bleeding in the brain can cause sluggishness, poor feeding, and seizures, most infants do not exhibit symptoms.
There are several possible locations within the skull that a bleed can occur:
Subarachnoid Hemorrhages - are the most common type of intercranial hemorrhage, and usually occur in full-term (not premature) infants. These hemorrhages are located below the innermost of the two membranes that cover the brain. While newborns with subarachnoid hemorrhages may have seizures initially, they tend to do well over time.
Subdural hemorrhages - occur between the outer and inner layers of the brain membranes. These types of hemorrhages are much less common now, thanks to improved birthing techniques. Subdural hemorrhages can increase pressure on the surface of the brain. Infants with subdural hemorrhages may develop seizures or have high bilirubin levels in the blood. Subdural hemorrhages are treated surgically.
Intraventricular hemorrhages - occur within the normally-fluid filled spaces (the ventricles) of the brain. Intraparenchymal hemorrhages are hemorrhages in the brain tissue. These types of hemorrhages occur most often in very premature infants and are usually the result of an underdeveloped brain, rather than a birth injury.
Infants who have a hemorrhage, no matter what type, all receive supportive measures. These measures include warmth, IV fluids, and other treatments as necessary to maintain body functions until the infant recovers.
Blood - blood may collect below the thick covering of the skull bones (called the "periosteum"); this is known as a cephalohematoma. Cephalohematomas feel soft to the touch and may increase in size initially after birth. They do not require treatment, as the body reabsorbs the blood, and disappear within the first few months of the infant's life.
Skull Fracture - in rare instances, one of the skull bones may fracture. Usually it heals quickly and without treatment. If the fracture becomes indented (depressed fracture), it may require treatment.
Bone Fractures - In very rare cares, during a difficult delivery, a bone may break. Fractures of the clavicle (collarbone) are the most common, although the humerus (upper arm bone) or femur (upper leg bone) may break, depending on the force exerted on the infant, and its position in the birth canal during delivery. These types of fractures are very unusual, and typically heal quickly. Treatment for a fracture in a newborn is to limit movement of the affected area as much as possible with a sling or a cast.
Soft Tissue Injuries - The most common soft tissue injury in newborns is bruising. Bruises can occur as the infant is squeezed through the birth canal, either from the pressure of the contractions, or from being pressed against the mother's pelvic bones. If forceps or vacuum extraction are used to assist with delivery, scalp bruising or small lacerations (cuts) may occur.
Sometimes the small blood vessels in the eyes can break, causing a subconjunctival hemorrhage. The iris of the eye (or both eyes) may have a bright red band around it. This does not cause damage to the eye(s), and the redness is absorbed within a week to ten days.
Nerve Injury - Nerve injuries may occur in rare cases. Areas that may be affected are the face, arms, diaphragm or spinal cord.
Facial Nerve Injury - caused either by instruments, such as forceps, used to help with delivery or by the infant's head being pressed against the mother's pelvis during delivery. Injury to the facial nerve causes weakness in the muscles of one side of the face. When the newborn cries, one side of the face is paralyzed and the eye cannot be closed. This type of injury usually resolves on its own, without treatment, within 2 to 3 months. However, if the nerve was torn, instead of only bruised, surgery may be needed.
Brachial Palsy - sometimes occurs during the delivery of a large infant, when there is difficulty delivering the infant's shoulder. The group of nerves that controls the arms and hands (the brachial plexus) is compressed, causing the infant to lose flexibility as well as mobility in the arm. Some cases resolve quickly without treatment; others may require splints or therapy to aid in healing, and may take months to resolve. If the nerve was torn, surgery may be required.
In some cases, if the infant is showing signs of brachial palsy, s/he may have damage to the nerve that controls the diaphragm, the muscle that assists the lungs with breathing, and separates them from the stomach and intestines. In this instance, the diaphragm may be paralyzed on the same side as the affected arm, and the infant may have difficulty breathing. The injury to the diaphragmatic nerve usually resolves concurrently with the injury to the brachial plexus.
Spinal Cord Injury - in extremely rare cases, the spinal cord can be overstretched during delivery, resulting in paralysis below the site of the injury. Unfortunately, damage to the spinal cord may be permanent.
Perinatal Asphyxia - occurs when the newborn has been deprived of oxygen at some point during the birthing process. Oxygen deprivation could be due to either insufficient oxygen in the blood or insufficient blood flow to the infant's tissues. Causes of perinatal asphyxia may include:
- Pressure on the umbilical cord
- Blood clot in the vessels of the umbilical cord
- Inadequate placental function (the placenta cannot provide enough oxygen to the baby during labor)
- Rapid blood loss
- Genetic abnormality
- Exposure to certain drugs prior to birth
Newborns with perinatal asphyxia are pale, appear lifeless, breathing weakly or not at all, and have an extremely slow pulse. No matter the cause, newborns with perinatal asphyxia all receive supportive measures, such as warmth, IV fluids, as well as breathing and circulation support as needed. If a specific cause for the asphyxia can be identified, (eg, infection or rapid blood loss), the newborn will be treated with appropriate additional measures (eg, antibiotics or blood transfusion).
Affected newborns may have damage to one or more organ systems. They may experience impaired neurological function, lethargy, seizures or coma. Breathing difficulties, as well as inadequate kidney function may occur.
Some newborns recover completely; others will have long-term neurologic damage, which may include mild learning disorders, developmental delays or cerebral palsy. In the most severe cases, of perinatal asphyxia, the newborn will not survive.
Risks Associated with Birth Injury Occurrence:
Quite simply put, big babies + small birth canals = possible birth injuries. If the baby is too big to pass through the birth canal easily, birth injuries may occur. Additional risks include:
- abnormal or breech birthing presentation;
- prematurity (born before 37 weeks) - premature babies are more fragile and therefore more susceptible to injury;
- prolonged labor;
- cephalopelvic disproportion - the size and/or shape of the mother's pelvis does not allow the baby to pass into the birth canal;
- compression of the umbilical cord.
Diagnosis of Birth Injuries:
Diagnosis of the birth injury depends upon the type of injury sustained. It can be readily apparent, as with fractures or bruising, or it may be harder to spot, as with a brain hemorrhage. Blood tests, MRIs, or CT scans may be ordered to assist with diagnosis.
Treatment of Birth Injuries
Treatment of the birth injury is tailored to the type of injury sustained. Some minor injuries (bruising) may not require treatment at all. Others may require surgical intervention. In most all cases, newborns are provided with warmth and IV fluids, and any other supportive measures (breathing assistance, blood transfusions) that may be required to help the newborn's body function while it heals.
Additional Resources for Birth Injuries
The Merck Manual Home Health Handbook provides detailed information regarding birth injuries, problems in newborns, and other children's health topics.
BirthInjury.org is a non-profit organization that provides support and resources to families affected by birth injuries.
United Brachial Plexus Network provides education about, and resources for, brachial plexus injuries at all ages, newborns to adults.
March of Dimes - a national organization committed to improving the health and lives of babies.
Federation for Children with Special Needs - provides information, support, and assistance to parents of children with disabilities.