Obstetrics Simplified - Diaa
Foetal Birth Trauma
Usually occurs due to difficult forceps delivery. It may be:
- Vault fracture:
- usually affecting the frontal or parietal bone.
- It may be linear or depressed fracture.
- It needs no treatment unless there is intracranial haemorrhage.
- Fracture base:
- usually associated with intracranial haemorrhage.
- It is a subperiosteal haematoma most commonly lies over one parietal
- It may result from difficult vacuum or forceps extraction.
Diagnosis and Differential Diagnosis
|Develops hours or days after
||Present at birth.
|Localised haematoma to one
bone limited by sutures at its edges.
||Diffuse tissue oedema overlying
more than one bone.
|Elastic, does not pit on
||Soft , pits on pressure.
|Disappears within few weeks.
||Disappears within 1-2 days.
- It usually resolves spontaneously.
- Vitamin K 1 mg IM is given.
- Sudden compression and decompression of the head as in breech and
- Marked compression by forceps or in cephalopelvic disproportion.
- Fracture skull.
- Prematurity due to physiological hypoprothrombinaemia, fragile blood
vessels and liability to trauma.
- Asphyxia due to anoxia of the vascular wall .
- Blood diseases.
- Subdural: results from damage to the superficial veins where the
vein of Galen and inferior sagittal sinus combine to form the straight
- Subarachnoid: The vein of Galen is damaged due to tear in the dura
at the junction of the falx cerebri and tentorium cerebelli.
- Intraventricular: into the brain ventricles.
- Intracerebral: into the brain tissues .
Subdural and subarachnoid haemorrhage is usually due to birth trauma,
in Intraventricular and Intracerebral haemorrhage the foetus is usually
a premature exposed to hypoxia.
- Altered consciousness.
- Breathing is absent, irregular and periodic or gasping.
- Eyes: no movement, pupils may be fixed and dilated.
- Opisthotonus, rigidity, twitches and convulsions.
- High pitched cry.
- Anterior fontanelle is tense and bulging.
- Lumbar puncture reveals bloody C.S.F.
- Ultrasound is of value.
- CT scan is the most reliable.
- Vitamin K: 10 mg IM to the mother in late pregnancy or early in
- Episiotomy: especially in prematures and breech delivery.
- Forceps delivery: carried out by an experienced obstetrician respecting
the instructions for its use.
- Minimal handling, warmth and oxygen to the baby.
- No oral feeding for 72 hours.
- IV fluids.
- Vitamin K 1mg IM.
- Lumbar puncture: is diagnostic and therapeutic to relieve the intracranial
tension if the anterior fontanelle is bulging.
- Sedatives for convulsions.
- 60 cc. of 10% sodium chloride per rectum to relieve brain oedema.
- 1 cc of 50% magnesium sulphate IM to relieve brain oedema and convulsions.
- Antibiotics: to guard against infections particularly pulmonary.
These usually occur during difficult breech delivery.
Vertebral Column Injuries
These are fatal if associated with spinal cord transection above C4 due
to diaphragmatic paralysis.
Femur, Humerus and Clavicle
Managed by splint to the long bone and a sling for clavicular fracture.
Facial Palsy (Bell’s palsy)
- It is usually due to pressure by the forceps blade on the
facial nerve at its exit from the stylomastoid foramen or in its course
over the mandibular ramus.
- It appears within 1-2 days after delivery due to resultant
oedema and haemorrhage around the nerve.
- Manifestations: There is paresis of the facial muscles on
the affected side with partially opened eye and flattening of the nasolabial
fold. The mouth angle is deviated towards the healthy side.
Brachial Plexus Palsy
It is due to over traction on the neck as in:
- Shoulder dystocia.
- After-coming head in breech delivery.
- It is the common, due to injury to C5 and C6 roots.
- The upper limb drops beside the trunk, internally rotated with flexed
wrist (policeman’s or waiter’s tip hand).
- It is less common, due to injury to C7 and C8 and 1st thoracic roots.
- It leads to paralysis of the muscles of the hand and weakness of
the wrist and fingers' flexors.
- Support to prevent stretching of the paralysed muscles.
- Physiotherapy: massage, exercise and faradic stimulation.
Sternomastoid injury due to exaggerated lateral flexion of the neck leading
to torticollis and swelling in the muscle. It is usually improved within
2 weeks but permanent torticollis may continue.
Liver, spleen and kidney may be injured in breech delivery which should
be avoided by holding the foetus from its hips.
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Edited by Aldo Campana,