Perinatal trauma Flashcards
Identify predisposing factors that increase the risk for birth trauma
LGA - obstruction
SGA - malpresentation
Prolonged labour, maternal exhaustion - depleting reserves, ischemic event
Instrumental delivery - poor palcement, multiple attemps, fetus is high
Shoulder dystocia
Vasa and placenta praevia - asphysia
Caesar - scalpel
Caput succedaneum
Risk factors: Vaginal delivery, prolonged labour, obstructed labour, malposition, vacuum
Physiology: swelling/oedema under the subcut later of the scalp due to the pressure of the head on a less than fully dilated cervix
- can cross suture lines but is typically unilateral
- resolves within a day
- does not require midwifery management
Chignon
Risk factors: Vacuum delivery
Physiology: artificial caput of fluid and smll haemorrhages caused by poor application of the venteuse
- may cross suture lines where vacuum was applied
- resolves within a day
- nil long term complications
Cephalhaematoma
Risk factors: vacuum, forceps
Physiology: collection of blood, effectively a bruise, between the periosteum and skull bone
- does not cross suture lines and is contained
- should resolve spontaneously within weeks
- does not require midwifery intervention
Subconjunctival haemorrhage
Predisposing factor: vaginal delivery
Physiology: Breakage of small vessels during the pressure of vaginal delovery
- frequent finding in normal newborns
- does not affect vision
- spontaneously resolves
- does not require midwifery management
Subdural haemorrhage
Risk factors: traumatic instrumental delivery
Physiology: Collection of blood beneath the dura mater and arachnoid membrane (between skull and brain)
- change in conscious state
- seizures
- other neurological S+S
Midwifery management
Subarachnoid hameorrhage
Risk factors: traumatic instrumental delivery
Physiology: Bleeding between the brain and arachnoid membrane
- Can be more serious
- seizures
- irritability
- poor feeding
Midwifery management:
Subgaleal hameorrhage
Risk factors: Traumatic instrumental delivery, traction, malposition, maternal exhaustion, LGA
Physiology: Collection of blood between the periosteum and galea
- extends from the orbital margain to nuchal bridge to temporal fascia
- this space holds 260mls of blood
- hypovolaemic shock requiring blood transfusion and extensive management
Midwifery management:
- treat shock
- maintain fluid balance and electrolytes
- restore circulating blood volume
- control bleeding with clotting factors, encourage vit K
- measure head circumference
- IV access and pathology (including group and hold)
- assess for jaundice
- symptomatic relief
- communication with parents
Brachial plexus palsy
Risk factors: shoulder dystocia, prolonged or sustained pulling of the shoulder
Physiology: damage to the brachial nerve innervating the arm and hand
- floppy arm, atonic, poor movement
- weakness on the effected side
Midwifery management
Erbs palsy
Risk factors: shoulder dystocia, prolonged or sustained pulling of the shoulder, macrosomia, breech
Physiology: damage to the brachial nerve innervating the arm and hand
- waiters tip hand
Midwifery management
- regular physiotherapy to maintain ROM
- encourage movement and exercise to prevent atrophy
- referral to paedeatric neurologist
- may require surgical intervention if severe
Klumpke’s palsy
Risk factors: shoulder dystocia, prolonged or sustained pulling of the shoulder
Physiology: damage to the brachial nerve innervating the arm and hand
- claw hand
- less common
Midwifery management
Phrenic nerve palsy
Risk factors: birth trauma like significant hyperextension of neck or stretching during delivery
Physiology: damage to the phrenic nerve innervating the diaphragm, causing paralysis of diaphragm
- limited to no respiratory effort depending on severity
- requires mechanical ventilation
Midwifery management
Facial nerve palsy
Risk factors: poorly applied forceps
Physiology: damage to cranial nerve innervating the face
- facial drooping of effected side, difficulty closing eyes
Midwifery management:
Hpyoxic Ischaemic Encephalopathy (HIE)
Risk factors: impaired placental function, birth trauma, placental abruption, cord prolapse, PET
Physiology: Hypoxia - reduced oxygen supply and ischaemia - decreased blood supply, to the brain due to a hypoxic event in labour and birth causing neural tissue damage
Grade 1: Mild
- baby will be agitated (they have a headache essentially), poor feeding
- lasts approx 24 hours and self resolving with management
Grade 2: Mod
- Symptoms last for 12-14 days depending on area
- higher risk of long term disability
- Lack of tone, floppy, limited gag reflex, may seizure
Grade 3: Severe
- Often fatal
- Seizures difficult to control
- cerebral palsy, epilepsy, learning difficulty, death
- hypotonia, may be in coma, absent reflexes, seizure visible on EEG but not visible due to poor tone
secondary apnoea - must be mechanically ventilated
- Diagnosed via MRI
Midwifery management:
- therapeutic cooling and admission to NICU
- this prevents further damage to neurons caused by secondary reperfusion of the brain
- >35 weeks and within 6hrs of birth
- must have severe acidosis, APGAR <5 at 10 mins, ventilation extends >10 mins post birth, and there is evidence of an acute hypoxic perinatal event
- to avoid cold stress - higher glucose conc infusion, ventilate to meet O2 requirements
Intraventricular Haemorrhage
Risk factors: <32 weeks prem
Physiology: fluctuations in blood volume and pressure causes bleeiding from the germinal matrix, ino the ventricles, or brain matter
- germinal matrix germinates neurons, therefore is very vascular
- matures around 32-24 weeks
therefore prem babies <32 weeks are at risk of IVH due to
- fragile germinal matrix
- underdeveloped cerebral autoregulation leading to changes in blood pressure
Grade 1: bleed within germinal matrix
Grade 2: bleed from germinal matrix extending into ventricles but not dialting
Grade 3: bleed from germinal matrix extending into and dilating ventricles
Grade 4: Insult severe enough to cause bleeding in cerebral cortex
- diagnosed with cranial ultrasound
- outcome dependent on grade and location
- cerebral palsy is a major implication
Midwifery management:
