Birth trauma

Question 1

What is the difference between caput succadeum, cephalhaematoma, and subgaleal haemorrhage?

Answer 1

Caput
- is the result of pressure on the babies head during vaginal birth, and can be exaggerated by the chignon created for ventouse delivery. It is a serosanguinous collection above the level of the epicranial aponeurosis and does not cause harm.

Cephalhaematoma
- occurs beneath the periosteum of the skull bones, resulting in a well demarcated fluctuant swelling. It may progressive’s over 12-24hours, but rarely ever requires medical intervention.

Subgaleal haematoma
- is a collection between the periosteum and epicranial aponeurosis. It is caused by shearing forces on the the babies head resulting in rupture of the emissary veins which provide communication between the dural venous sinuses and scalp veins. It is a potentially life threatening complication.

Question 2

What is the rate of subgaleal haemorrhage after NVB, venous and forceps?

Answer 2

The vast majority occur after ventouse delivery (60-89%).

Ventouse = 5/1000 (roughly 1/200-300)
- though likely underestimation (when Malaysia study set up an observation program, rates of SGH 21%)

NVB = 0.4/1000 (roughly 1/2000)

Question 3

How can subgaleal haemorrage present?

Answer 3

Generalised signs due to blood loss:

• APGAR <7 at 5 mins in the absence of birth asphyxia; higher index of suspicion if following vnetouse
• Anaemia and pallor
• Haemodynamic instability
• Coagulopathy
• Irritable or poor tone/ reduced activity

Localised signs:

• scalp swelling, poorly defined
• crosses suture lines and can extend from orbital ridges to ear and occiput
• pitting oedema, fluctuant, fluid thrill or crepitus
• Fluid dependent
• periorbital oedema (puffy eyes)or peri-auricular oedema (displaced earlobes)
• Head circumference increasing
• neonatal irritability and pain response on head handling

Question 4

What monitoring is required for babies at risk of subgaleal haemorrhage?

Answer 4

Level 1 monitoring:

• For all babies after instrumental
• Full obs at birth and after 1 hour
• No hats

Level 2 monitoring

• For babies after difficult instrumental (>3 pulls,>20 mins, second instrument etc); 5 min APGAR <7, at accoucheurs request, or concerns after level 1 monitoring
• Cord blood for: pH/lactate, Haematocrit, platelets
• Full obs and scalp monitoring for first 12 hours after birth
• No hats

Level 3 monitoring

• If clinical suspicion for SGH at birth, or after level 1 or 2 monitoring
• Senior paediatric review
• Admission to neonatal unit
• Cord blood for: pH/lactate, Haematocrit, platelets
• Full obs and scalp monitoring
• No hats

Question 5

How is subgaleal haemorrhage managed?

Answer 5

• Urgent senior paediatric review
• Admission to neonatal unit
• Cord blood for: pH/lactate, Haematocrit, platelets
• Give IM vitamin K
• Full obs and scalp monitoring
• No hats
• Aggressive fluid resuscitation and Blood products to manage hypovolemia
• Correction of acidemia
• Correction of coagulopathy

Question 6

What birth injuries are associated with forceps? And ventouse?

Answer 6

Forceps:

• Facial bruising
• Conjunctival laceration
• Facial nerve palsy
• shoulder dystocia and its sequelae
• skull fracture / intracranial haemorrhage
• c-spine injury ( higher risk with rotational forceps)

Ventouse:

• Caput
• cephalhaematoma
• SGH
• retinal haemorrhage
• shoulder dystocia and its sequelae
• skull fracture / intracranial haemorrhage

Question 7

What are the risks to the newborn after shoulder dystocia?

Answer 7

Brachial plexus injury (2.3-16%)
Permanent brachial plexus injury (<10% BPI are permanent)
Clavicular fracture
Humeral fracture
HIE
Death

Question 8

How can SGH be prevented?

Answer 8

• Avoiding ventouse delivery; preferentially using forceps
• Do not use ventouse if: <34wks, ideally not <36wks, thrombocytopenia or bleeding diathesis, osteogenesis imperfecta
• Correct cup placement over flexion point (3cm from post fontanelle, symmetrically over sagittal suture)
• Pull with maternal effort and contractions only
• Pull in a continuous motion, avoid rocking/shearing forces

Only continue:

• If evidence of progress
• For maximum 3 contractions
• Maximum 20 minutes
• Maximum 2 pop-offs (some allow 3)

Question 9

What nerves roots are affected and how does each brachial plexus injury present?
For erb’s, klumpke’s and total brachial plexus injury.

Answer 9

Erb’s:

• C5, C6
• Caused by exaggerated lateral flexion of head and neck
• Numbness in C5/6 distribution
• Wasting of deltoid, biceps and brachioradialis
• ‘Waiters tip’ arm - arm adducted and medially rotated, forearm extended and pronated
• Unable to: abduct shoulder, flex at shoulder or elbow, supinate forearm

Klumpke’s

• C8, T1
• Exceptional traction used on arm when extended above head (e.g. in delivery of poster arm)
• Numbness in C8, T1 dermatome
• Wasting and weakness of thenar and hypothenar eminences and small muscles of hand (interossei) and flexors of wrist and fingers (flexor digitorum profundis and flexor carpi ulnaris)
• ‘Claw hand’ - supination of forearm, extension of wrist, flexion of fingers

Total brachial plexus:

• C5-8, T1
• numbness affecting C5-T1 dermatomes
• Wasting and weakness of whole arm