Birth Trauma and CP Flashcards
Discuss birth trauma
-Incidence (2)
-Risk factors (7)
- Incidence
6-8:1000 live births - Risk factors
-LBW
-LGA
-Prematurity
-Prolonged / rapid labour
-Instrumental deliveries
-Vaginal breech
-Abnormal traction during delivery
Discuss cephalhaematoma
-Pathophysiology (4)
-Presentation (5)
-Management (2)
- Pathophysiology
-Subperiosteal collection of blood.
-Doesn’t cross suture lines so is self contained
-Relatively common
-Associated with prolonged labour or instrumental delivery - Presentation
Parietal usually.
Can be bilateral
Largest on second day.
Boggy mass 48-72 hrs post delivery
Exaccerbates jaundice - Management
Resolves in days to months
Rarely needs drainage
Discuss subgaleal haemorrhage
-Pathophysiology
-Presentation
-Management
- Pathophysiology
-Occurs between galea aponeurosis and periosteum
-Associated with prematurity, ventouse (90%), may have underlying coagulopathy
-40% associated with skull fracture, Intracranial haemorrhage
Can hold up to 250mL (Almost all 3kg baby’s blood volume) - Presentation
-Boggy appearance and pitting skull oedema
-Anterior displacement of the ears
-Flick sign (Thrill or crepitus)
-Fetal irritability
-Periorbital oedema
-Hypovolemic shock - Management
-Blood transfusion
-FFP and coagulation factors
-Phototherapy if Jaundice
Discuss cephalhaematoma
-Pathophysiology (4)
-Presentation (5)
-Management (3)
- Pathophysiology
-Subperiosteal collection of blood.
-Doesn’t cross suture lines so is self contained
-Relatively common
-Associated with prolonged labour or instrumental delivery - Presentation
Parietal usually.
Can be bilateral
Largest on second day.
Boggy mass 48-72 hrs post delivery
Exaccerbates jaundice - Management
Resolves in days to months
Rarely needs drainage
Photo therapy if jaundice
Discuss subgaleal haemorrhage
-Pathophysiology (5)
-Mortality rate (1)
-Incidence (2)
-Risk factors
- Pathophysiology
-Occurs between galea/epicranial aponeurosis and periosteum
-Potential space that can accommodate 250mL (90mL/kg babies blood volume)
-Results from rupture of the emissary veins
-40% associated with skull fracture, Intracranial haemorrhage - Mortality rate
-12-25% - Incidence
-0.6:1000 deliveries
-6:1000 ventouse deliveries - Risk factors
-60-90% from ventouse deliveries
-Nulliparity OR 4
-Poor cup placement - over to one side, Not over flexion point
-Failed vaccum extraction OR 16
Discuss facial palsy
-Pathophysiology
-Presentation
-Management
- Pathophysiology
-Unilateral facial weakness.
-Can be bilateral but then likely congenital cause
-Associated with forceps delivery or pressure on maternal ischial spine - Presentation
-Unilateral facial weakness with ipsilateral eye remaining open - Management
-Eye drops if eye permanently open
-Resolves in 1-2 weeks
Discuss facial palsy
-Pathophysiology (3)
-Presentation (1)
-Management (2)
- Pathophysiology
-Unilateral facial weakness.
-Can be bilateral but then likely congenital cause
-Associated with forceps delivery or pressure on maternal ischial spine - Presentation
-Unilateral facial weakness with ipsilateral eye remaining open - Management
-Eye drops if eye permanently open
-Resolves in 1-2 weeks
Discuss brachial plexus injury
-Types (2)
-Nerves affected in each type
-Incidence of each type
-Management
-Prognosis
- Types
-Erbs palsy C5-6
-Klumpke’s palsy C7-T1 - Incidence of each type
-Erbs >90%
-Klumpke’s <1% - Management ad prognosis
-Most heal without treatment in 3-4 months
-Physiotherapy
-Erbs 90% resolve
-Klumpke’s 40% resolve
Discuss cerebral palsy
-Incidence (1)
-Definition (3)
-Cause (2)
- Incidence
-2:1000 lie births - Definition
-Group of disorders characterised by motor and postural dysfunction
-Permanent and non progressive
-Commonly associated with cognitive impairment - Causes
-Many usually unidentified factors
-More likely due to delivery event if preterm
Discuss the correlation of apgar scores and development of CP
-5 minute APGAR <7 increased risk CP
-10 minute APGAR <4 - 5% of babies develop CP
-75% of babies who develop CP have normal APGARS
Discuss risk factors for cerebral palsy
-Fetal (3)
-Obstetric (4)
-Neonatal (3)
- Fetal risk factors
-PTB <34/40 - 5%
-LBW <1500g
-Multiple pregnancy 5% of triplets 1% of twins - Obstetric risk factors
-Chorioamnionitis
-Antepartum haemorrhage
-Placental insufficiency
-Perinatal asphyxia - Neonatal
-Intraventricular haemorrhage
-Periventricular leucomalacia
-HIE (Biggest RF)
Discuss the correlation of APGAR scores and development of CP
-5 minute APGAR <7 increased risk CP
-10 minute APGAR <4 - 5% of babies develop CP
-75% of babies who develop CP have normal APGARS
Discuss the correlation of APGAR scores and development of CP (3)
-5 minute APGAR <7 increased risk CP
-10 minute APGAR <4 - 5% of babies develop CP
-75% of babies who develop CP have normal APGARS
Discuss cerebral palsy presentation
- 95% have mild/moderate symptoms
-Associated with muscle issues and movement, spacity, weakness and balance issues
-Increased problems with cognition, social interactions, ADHD, anxiety
-Becomes more obvious at school age
-50% need additional educational assistance - 5% have severe impairment
-Difficulty living independently - 92% live to >20
Discuss hypoxic ischemic encephalopathy
-Definition (3)
-Causes (1)
-Clinical manifestation (4)
-Incidence (1)
- Definition
-No universal definition
-Is a subset of neonatal encephalopathy
-Requires evidence of hypoxia on cord gases, low apgars and early evidence of cerebral oedema on imaging. - Causes
-Results from intrapartum hypoxia and acidosis
-Not all metabolic acidotic babies develop HIE - Clinical manifestations
-Abnormal level of conscience
-Seizures
-Difficulty with breathing - initiating and maintaining
-Depression of tone and reflexes - Incidence
-1.5:1000 live births
Discuss hypoxic ischemic encephalopathy
-Grades
-Characteristics of each grade
-Prognosis of each grade
- Grade 1 - mild
-Hyper alterness
-Irritability
-Jittery
-Normal EEG - Grade 2 - moderate
-Obtundation
-Hypotonia
-Strong distal flexion
-Multifocal seizures
Prognosis:
-20-30% death or major neurological sequalae - Grade 3 - severe
-Coma
-Frequent seizures
Prognosis:
Majority of cases = death or severe neurological sequalae - Overall prognosis
-14% of HIE develop CP
Discuss diagnosis for HIE (3)
- EEG
-Do son after birth to look for seizure activity
-Of prognostic value - Cranial USS
-Use to detect cerebral oedema
-Can show brain lesions associated with CP (periventiricular leukomalacia, IVH) - MRI
-Gold standard
-Early imaging before 96 hr helps to show cause of hypoxia
-MRI around 10days shows full extent of brain injury
-Good for prognosis
Discuss cooling as management of HIE
-Method of cooling
-Who should be cooled
-Pathophysiology behind management
-Efficacy of cooling
- Method of cooling
-Reduce temp to 34 degrees within 6hrs of birth and maintain for 72hrs with slow rewarming - Who should be cooled
-Moderate or severe HUE
- >36/40
-Evidence of acidosis pH <7 BE >16
-APGAR <5 - Pathophysiology behind management
-Ischemia causes primary neuronal death
-Upon re-establishment of circulation there can be secondary neuronal death in a zone around the initial neuronal death.
-Cooling aims to avoid / decrease this secondary neuronal death - Efficacy
-NNT in moderate HIE = 6
-NNT in severe HIE = 7
What are the poor prognostic markers for HIE (6)
- Persistent seizures
- Persistent abnormal neurological exam
- Poor feeding by 2 weeks of age
- Limited evidence of recovery on EEG
- Abnormal MRI findings suggesting basal ganglia changes or cerebral atrophy
- Poor postnatal head growth
Outline the steps of neonatal resus
- Assess infant for tone, breathing, crying
- Dry and take to resus site - resusitare
- Keep warm
- If poor breathing effort or HR <100 start positive pressure ventilation with room air
Discuss subgaleal haemorrhage
-Presentation (7)
-Management ()
- Presentation
-Mean onset 1-6hrs post delivery
-Diagnosis is clinical. Don’t delay for imaging
Generalised signs:
-associated with blood loss and low 5 min apgar in setting of no asphyxia
Localised signs:
-Generalised skull swelling and scalp laxity, pitting oedema infront of ears
-Ballotable lesion that crosses suture lines
-Anterior displacement of the ears and periorbital oedema
-Crepitius or fluid thrill - flick test +
-Hypovolemic shock - Management
-Medical emergency.
-Involve senior paeds immediately
-Serial head measures may be useful but shouldn’t be considered reassuring
-Blood transfusion and aggressive fluid resus
-FFP and coagulation factors
-Phototherapy if Jaundice
Discuss prevention strategies for subgaleal haemorrhage
-Appropriate patient selection (3)
-Proper technique (10)
-Medical prophylaxis (1)
- Appropriate patient selection
-Absolute contra-indication if <34/40
-Relative contraindication if <36/40
-Absolute contra-indication in infants with bleeding disorders - Proper technique
-Should be done by someone with adequate training or with supervision
-Cup should be placed on flexion point
-Cup should be /3cm (ideally 6cm) from anterior fontanelle
-Cup should be placed evenly across sagittal suture
-Steady traction with contractions and maternal effort only
-Good decent of head
-Avoid prolonged traction
-Abandon if time longer than 20mins and not delivered (consider changing tact after 15mins)
-Abandon if more than 3 pulls and head not yet on perineum (Can do more if birth imminent)
-Abandon if > 3 pop offs - Medical prophylaxis
-IM Vit K for all neonates with instrumental delivery
Discuss neonatal surveillance for subgalial haemorrhage
-Levels of neonatal surveillance (3)
-Indication for monitoring at each level (3)
-What each level requires in terms of surveillance
- Intensity of surveillance should be based on perceived risk of SGH
- Level 1 neonatal surveillance
Indaction:
Minimum surveillance level for all infants delivered by instrumental or second stage CS
Monitoring
-Baseline obs and activity at 1 hr of age
-Structural assessments at 1-6hrs then at 24hrs post birth
-Avoid hats so changing head size and appearance can be noted
-If signs of SGH then escalate to level 2 surveillance
-If concern secondary to neonatal behaviour (irritable, poor feeding, pallor) escalate to level 2 - Level 2 neonatal surveillance
Indication:
-Total extraction time >20mins, >3 pulls, >2 pop offs
-5 min apgar <7
-At clinical request
-Level one surveillance causing concern
Monitoring:
-Take cord bloods
-Check Haemocrit and plts
-Continue formal neonatal SGH obs for 12 hrs - hrly x 2 then 2 hrly - Level 3 neonatal surveillance
Indications:
-Clinical suspicion following delivery
-Abnormalities noted on level 2 surveillance
Monitoring:
-Review by paeds with consideration for admission to NICU for ongoing investigation and management
Discuss responsibility of neonatal resus
-Who should attend low risk births (3)
-Who should attend high risk births (3)
-Who decides who should be there
- Who should attend low risk births
-There should always be someone who is trained in neonatal resus
-Staff members trained in basic neonatal resus
(Resus steps up to CPR)
-Health practitioners with advanced resus skills should be available but not required at the birth - Who should attend high risk births
-Health practitioners with advanced resus skills (Intubation, vascular cannulation, use of drugs and fluids)
-The health practitioner should only be responsible for care of the baby (not the mother)
-More than one experienced health practitioner with training should be at the birth. - Who decides who should be there?
-The responsibility falls to the accoucher managing the birth to decide based on RF
Discuss the responsibilities of medical practitioners at neonatal resus
-Who decides on skill level required
-What should skill levels requirement be based on
-What should happen if ongoing care is needed post resus
- Who decides
Requirement for staff skilled in advanced resus is at the discretion of the medical staff - Things to consider for need of skills
-Fetal risk factors
-Maternal risk factors
-Intrapartum risk factors
-Whether a skilled practitioner can be there urgently if required. If not then should be in attendance as a precaution or tx woman - Ongoing care post resus
-The responsible clinician should be free from other responsibilities
-There should be a clear hand over of duty and information
What are the criteria which suggests intrapartum CP (6)
- Low apgar scores
- High umbillical arterial lactates / low pH <7.0 BE >12
- Early onset of HIE grades 2 and 3
- Early imaging supporting an acute non-focal cerebral anomaly
- Spastic quadraplegic or dykinetic CP
- No other reason for CP
