Anemia of Prematurity - Portal Neonatal

Birth Trauma
Last Updated: August 4, 2004
Synonyms and related keywords: birth injury, compression, traction, cephalhematoma, subgaleal
hematoma, caput succedaneum, abrasions, lacerations, subcutaneous fat necrosis, brachial plexus
injury, cranial nerve injuries, laryngeal nerve injury appears, spinal cord injury, clavicular fracture,
long bone fracture, epiphysial displacement, intraperitoneal bleed, hepatic rupture
AUTHOR INFORMATION Section 1 of 10
Author: Nirupama Laroia, MD, Director of Special Care Nursery, Associate Professor, Department
of Pediatrics, Division of Neonatology, Children's Hospital at Strong and University of Rochester
Nirupama Laroia, MD, is a member of the following medical societies: American Academy of
Pediatrics
Editor(s): Oussama Itani, MD, Medical Director of Neonatology, Borgess Medical Center, Clinical
Assistant Professor, Department of Pediatrics and Human Development, Michigan State University;
Robert Konop, PharmD, Director, Clinical Account Management, Ancillary Care Management;
David A Clark, MD, Chairman, Professor, Department of Pediatrics, Albany Medical College; Carol
L Wagner, MD, Associate Professor, Department of Pediatrics, Division of Neonatology, Medical
University of South Carolina; and Neil N Finer, MD, Director, Division of Neonatology, Professor,
Department of Pediatrics, University of California at San Diego
INTRODUCTION Section 2 of 10
Injuries to the infant resulting from mechanical forces (ie, compression, traction) during the process of
birth are categorized as birth trauma. Factors responsible for mechanical injury may coexist with
hypoxic-ischemic insult. One may predispose the infant to the other. Lesions that are predominantly
hypoxic in origin are not discussed in this article. Significant birth injury accounts for fewer than 2% of
neonatal deaths and stillbirths in this country. It still occurs occasionally and unavoidably with an
average of 6-8 injuries per 1000 live births. In general, larger infants are more susceptible to birth
trauma. Higher rates are reported for infants weighing more than 4500 g
Most birth traumas are self-limiting and have a favorable outcome. Nearly half are potentially
avoidable with recognition and anticipation of obstetric risk factors. Infant outcome is the product of
multiple factors. Separating the effects of a hypoxic-ischemic insult from those of traumatic birth injury
is difficult.
Risk factors include large-for-date infants, especially larger than 4500 g; instrumental deliveries,
especially forceps (midcavity) or vacuum; vaginal breech delivery; and abnormal or excessive traction
during delivery.
Mortality/morbidity: Birth injuries account for fewer than 2% of neonatal deaths. From 1970-1985,
rates of infant mortality resulting from birth trauma fell from 64.2 to 7.5 deaths per 100,000 live births,
a remarkable decline of 88%. This decrease reflects, in part, the technologic advancements for
today's obstetrician to recognize birth trauma risk factors by ultrasonography and fetal monitoring
prior to attempting vaginal delivery. Use of potentially injurious instrumentation such as midforceps
rotation and vacuum delivery has also declined. The accepted alternative is a cesarean delivery.
Causes: The process of birth is a blend of compression, contractions, torques, and traction. When
fetal size, presentation, or neurologic immaturity complicates this event, such intrapartum forces may
lead to tissue damage, edema, hemorrhage, or fracture in the neonate. The use of obstetric
instrumentation may further amplify the effects of such forces or may induce injury alone. Under
certain conditions, delivery by cesarean delivery can be an acceptable alternative, but it does not
guarantee an injury-free birth. Factors predisposing to injury include the following: