Birth injury
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Here is a thorough overview of birth injury - its types, mechanisms, and key clinical points - drawn from authoritative textbook sources.
Birth Injury - Overview & Types
Birth injury (birth trauma) refers to physical damage to the neonate sustained during labor and delivery. The incidence is approximately 2 per 1,000 live births for significant injuries, though minor soft-tissue trauma is far more common. Risk factors include macrosomia, shoulder dystocia, instrumental delivery (forceps/vacuum), breech presentation, prolonged labor, and maternal diabetes.
1. Scalp & Cranial Injuries
These are the most common birth injuries and are distinguished by the anatomical layer involved:
| Feature | Caput Succedaneum | Cephalohematoma | Subgaleal Hemorrhage |
|---|---|---|---|
| Location | Connective tissue above epicranial aponeurosis | Subperiosteal (beneath periosteum) | Beneath epicranial aponeurosis |
| Suture lines | Crosses freely | Does NOT cross sutures | May extend to orbits or nape of neck |
| Onset | Maximal at birth | Increases over 12-24 hrs | Progressive after birth |
| Resolution | 48-72 hours | Weeks | Weeks |
| Severity | Minimal | Rarely severe | Can be severe (especially with coagulopathy) |
- Caput succedaneum: Diffuse pitting edema at the presenting scalp; shifts with gravity; self-resolving.
- Cephalohematoma: Firm, distinct swelling limited by periosteal attachments; does not cross suture lines; associated with underlying skull fracture in ~5% of cases; watch for hyperbilirubinemia as blood resorbs.
- Subgaleal (subaponeurotic) hemorrhage: Most dangerous - blood accumulates in a large potential space and can hold the entire neonatal blood volume. Presents as a fluctuant, ill-defined swelling that crosses sutures and may have a fluid wave. High risk of hemorrhagic shock, especially with coagulopathy.
(Source: Harriet Lane Handbook, 23rd ed., Table 18.3 & Fig. 18.3)
2. Hypoxic-Ischemic Encephalopathy (HIE)
HIE results from perinatal asphyxia - inadequate oxygen and blood flow to the neonatal brain. It is one of the most clinically significant birth injuries.
Criteria for diagnosis/treatment include:
- Cord gas or blood gas within the first hour: pH <7.0 or base deficit >16
- 10-minute APGAR ≤5
- Need for assisted ventilation at birth for ≥10 minutes
Management: Therapeutic hypothermia (33.5°C body cooling) is the standard of care and must be initiated within 6 hours of delivery in infants ≥35 weeks gestation with moderate-to-severe HIE. Head cooling and whole-body cooling are equally efficacious.
(Source: Harriet Lane Handbook, 23rd ed.; Creasy & Resnik's Maternal-Fetal Medicine)
3. Brachial Plexus Palsy (Obstetric Brachial Plexus Injury)
Occurs in approximately 2 per 1,000 births due to stretching or contusion of the brachial plexus - most often during shoulder dystocia, difficult vaginal delivery, or breech extraction.
Three classic types:
| Type | Nerve Roots | Clinical Presentation | Prognosis |
|---|---|---|---|
| Erb-Duchenne palsy | C5, C6 | "Waiter's tip" deformity - arm adducted, internally rotated; elbow extended, forearm pronated, wrist flexed | Best - most common; >90% resolve |
| Klumpke palsy | C8, T1 | Intrinsic hand weakness; claw hand; associated with Horner syndrome (ptosis, miosis, anhidrosis) | Poor |
| Total plexus palsy | C5-T1 | Flail arm | Worst |
Prognosis indicators:
- Lack of biceps function at 6 months = poor prognosis
- Presence of Horner syndrome = poor prognosis
- Progressive glenoid hypoplasia occurs in 70% with persistent internal rotation contracture
Management:
- Passive range of motion exercises (shoulder elevation, abduction, external rotation) by parents
- Await spontaneous recovery for up to 18 months
- Surgical options: microsurgical nerve grafting (early), tendon/muscle transfers (late), rotational osteotomy (>5 years)
(Source: Miller's Review of Orthopaedics, 9th ed.; Campbell's Operative Orthopaedics, 15th ed.)
4. Facial Nerve Palsy
- Incidence: ~1.8 per 1,000 deliveries
- ~80% are related to birth trauma (forceps delivery, cephalopelvic disproportion, sacral prominence pressure on the fetal face)
- Presents as asymmetric facial movement, inability to close the eye on the affected side
- Most cases are peripheral nerve injuries that resolve spontaneously within weeks; eye protection is important to prevent corneal damage
(Source: Shambaugh Surgery of the Ear; Scott-Brown's Otorhinolaryngology)
5. Skeletal (Birth) Fractures
The most common birth fractures are of the clavicle, humerus, and femur.
Risk factors: Macrosomia, breech presentation, instrumented delivery, small uterine incision (cesarean), prematurity, osteogenesis imperfecta.
Clinical features:
- Warmth, swelling, irritability with movement, pseudoparalysis of a limb
- 60-80% of patients have no positive findings on the initial newborn exam - diagnosis is often delayed 1-2 days
- Can mimic osteomyelitis, septic arthritis, or brachial plexus palsy
Management:
- Most heal without surgery and remodel fully
- Clavicular/humeral shaft fractures: pin the sleeve to the front of the shirt for 1-2 weeks
- Femoral fractures: Pavlik harness or splinting; spica cast rarely needed
- Physeal (Salter-Harris) separations at distal femur or humerus are rare but can occur with difficult delivery
(Source: Campbell's Operative Orthopaedics, 15th ed.)
6. Summary: Risk Factor Matrix
| Injury | Key Risk Factors |
|---|---|
| All birth injuries | Macrosomia, shoulder dystocia, forceps/vacuum, maternal diabetes |
| Brachial plexus palsy | Shoulder dystocia, LGA infant, forceps delivery, breech |
| Facial palsy | Forceps delivery, cephalopelvic disproportion |
| Fractures | Macrosomia, breech, instrumented delivery, prematurity, OI |
| HIE | Perinatal asphyxia, placental abruption, cord prolapse, prolonged labor |
| Subgaleal hemorrhage | Vacuum delivery (highest risk) |
In infants of diabetic mothers, birth injury risk is 2-5x higher at any given birth weight class, and the risk is further magnified by instrumental delivery. Tight glycemic control reduces shoulder dystocia by ~60% (Farrar et al. meta-analysis). (Creasy & Resnik's Maternal-Fetal Medicine)
Recent literature note: A 2024 review (PMID 38366382) and a 2026 narrative review (PMID 42080466) in J Hand Surgery (Eur) highlight ongoing advances and controversies in brachial plexus birth injury management, including anatomical predisposition and timing of surgical intervention.
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