Birth Trauma, Newborn Brain Injuries and Perinatal Asphyxia
Birth Trauma refers to the physical damage or injury caused to the baby during the different stages of the birth process.
- Minor injuries are common in newly delivered babies.
- Occasionally, nerve damage and fractures may have occurred.
- Birth injuries often require no treatment.
When the baby is larger than usual, or when the mother’s birth canal is too narrow, it may cause complications during the delivery, and may result in injuries to the baby. Mothers who are diabetic tend to have larger babies, and the risk of birth injury is increased in such cases. The wrong position of the baby inside the uterus prior to birth, such as a breech position, may increase the chances of injury during birth. Advancements in prenatal screening have significantly lowered the number of birth trauma in recent years. If abnormalities which may lead to a difficult delivery are detected through ultrasound tests, the doctor can opt to deliver the baby by a caesarean section.
Perinatal Asphyxia: It may occur during delivery when blood flow to the fetus gets cut off so that the fetal tissues do not get enough blood supply. When the oxygen content in the blood gets lowered due to some reason, it may result in perinatal asphyxia. This condition may occur because of different reasons; but in some cases, it may not be possible to determine the reason. A few of the factors responsible for perinatal asphyxia are:
- Abnormal genetic conditions resulting in abnormally developed fetus
- Getting exposed to harmful drugs when the fetus is inside the womb
- Certain infections affecting the fetus within the uterus
- Umbilical cord getting compressed or a blood clot forming in the cord which obstructs the flow of blood to the fetus
- Severe blood loss occurring suddenly
- placental insufficiency towards the end of pregnancy
- Placental separation from the uterine wall at the time of labor, compromising blood and oxygen supply to the baby.
Newborns affected by perinatal asphyxia are born pale, with abnormally low heart rate and weak breathing. Some may appear almost lifeless, with apparently no breathing, and barely perceptible pulse. If the cause of asphyxia has been severe blood loss, the baby may be in shock. However, immediate intervention may save the newborn’s life. Fluids are administered into the vein and a blood transfusion is initiated. Ventilator support may be necessary to assist with breathing. Circulation support also is given, if necessary. Blood glucose levels should be checked and maintained, while the baby is kept in the incubator for maintaining warmth.
Multiple organ systems may be affected by asphyxia, and some irreversible damage may have occurred, but often, babies recover from the adverse effects with timely intervention and adequate medical care. If brain is affected, the newborn may be lethargic, and may have seizures. They may go into coma too. If kidneys are affected due to oxygen insufficiency, urine output may be low, but it is often a temporary problem. The lungs may be affected too, resulting in troubled breathing.
Asphyxiated infants may recover completely in many cases, but some may survive with certain permanent disabilities arising from irreversible injury to the brain that may have occurred due to poor blood and oxygen supply for prolonged periods. The resultant effects of neurological damage may manifest as development delays, or mild learning difficulties. In severe cases, cerebral palsy may result. In some cases, perinatal asphyxia may have a fatal outcome.
If the causes of asphyxia are identified, appropriate treatments may be initiated for better outcome. If an infection in the blood is causing this condition, it may be treated with antibiotics. If blood loss is the cause, transfusions can remedy it. To prevent brain injury, and reduce neurological damage, due to asphyxia, a new procedure has been helpful in the case of babies born at full-term. The baby’s head is rapidly cooled and kept at low temperature for many hours immediately after birth because it has been found that the oxygen needs of the brain is significantly reduced at low temperatures.
Head and Brain Injury: Most babies are born head first, and consequently, head experiences the most compression as it enters the narrow birth canal. During delivery also, the head gets bruised, especially if vacuum or forceps is used to assist the process. Swellings, bruises and a misshapen head may result, but they are not usually serious, and rapidly resolve without any treatment.
There may be soft swellings called cephalohematomas, which may grow further after birth. They are accumulations of blood under the thick covering of the skull plates called periosteum. When the bony plates shift and overlap as the head gets squeezed in the birth canal, it may result in bleeding, and this blood gets collected under the periosteum. It may take a few weeks or even a month or two for these bulges to resolve, but they eventually do disappear without any treatment.
It is rare for skull fractures to occur, but occasionally one or two bony plates may be fractured, but they heal fast, except in the case of a depressed fracture which is otherwise called an indentation.
Bleeding in the Brain: Bleeding in the brain, also called intracranial hemorrhage, is often caused when blood vessels inside the skull get ruptured. The bleeding may have resulted from deformed bones of the skull, or due to lack of adequate oxygen content. Premature babies are more prone to intracranial hemorrhage, and the usual reason is either ischemia, or reduced supply of blood to the brain, or hypoxia, characterized by abnormally low blood oxygen levels.
Intracranial bleeding may not precipitate any external symptoms, but poor feeding and sluggishness of newborns may be due to this condition. It may cause seizures in the newborn too.
Bleedings occurring in different areas of the brain are classified as:
Subarachnoid hemorrhages:
These are the most frequently occurring type of hemorrhages, especially in babies born at full-term. The bleeding takes place under the inner layer of the double membrane enclosing the brain. When subarachnoid hemorrhage occurs, the newborns may have seizures in the initial period after birth, but long term prospects are usually good.
Subdural hemorrhages:
In this type of hemorrhage, the blood enters the space between the outer and inner layers of the membranes covering the brain. Subdural hemorrhages can exert pressure on the the brain and compress it. Babies who suffer from this type of hemorrhage may have several problems including seizures. The bilirubin levels in their blood are usually elevated, resulting in jaundice. Improvements in the delivery techniques have reduced the frequency of subdural hemorrhages in recent years.
Intraventricular hemorrhages:
In an intraventricular hemorrhage, the bleeding is occurring into the ventricles or the chambers of the brain which are normally filled with fluid. In intraparenchymal hemorrhage, the blood seeps into the cellular tissue of the brain. These two types of hemorrhages are more common in premature babies whose brains are severely under-developed. Hence, intraparenchymal and intraventricular hemorrhages are not considered birth injuries, but as the effects of prematurity.
Babies who suffer from hemorrhages should get special care, including intravenous administration of fluids, and support for other functions of the body such as breathing and circulation, depending on the requirement. Surgical intervention may be necessary in case of a subdural hemorrhage.
Nerve Injury: Nerve injuries occurring during delivery may be due to compression of nerves, or tearing of nerve fibers as a result of extreme stretching. When the nerve on one side of the face gets compressed during a forceps assisted surgery, it can cause muscle weakness only on that side. If a side of the baby’s head is pressed against the pelvis of the mother, then also, this may happen. The face of the newborn looks asymmetrical, especially when the baby is crying. This condition gets resolved eventually, without any specific treatment, but it may take two to three months.
When the delivery is difficult, especially in the case of larger babies, a large vein running into the baby’s arm can get stretched too much, resulting in damage to that nerve. It may cause the arm or hand to be paralyzed. In such cases, the baby should be handled in such a way that the shoulder is prevented from moving too much, to help the nerves heal faster. If the hand does not improve even after a period of many weeks, surgical repair of the nerve fibers which had got torn may be necessary.
When one of the nerves supplying the diaphragm is damaged during delivery, one side of the diaphragm gets paralyzed. The diaphragm is the large muscular membrane separating the chest cavity from the abdomen, and its contraction and relaxation helps in breathing. Paralysis of this membrane results in breathing difficulty, which may gradually improve, and completely resolve in a few weeks’ time. If the spinal cord is overstretched at the time of delivery, it may get damaged. The usual outcome of spinal cord injury is paralysis of the body below the location of the injury. Spinal cord injury is rare, but, when it has occurred, the effects are usually permanent.
Injury to the Bones: A complicated delivery may occasionally cause bone fractures in the newborn. One of the common fractures encountered is that of the collarbone, which is called clavicle. The bone of the upper arm known as humerus, and that of the upper leg, namely femur, also suffer fractures occasionally, but it is not very common. A cast or sling may be needed to keep the fractured bones from moving, so that it can heal faster. Usually, within a short period, complete healing is achieved in case of fractures sustained during delivery.
Skin and Soft Tissue Injury: The skin of the newborn may suffer bruises in several places where compression has occurred at the time of contractions. The passage through the birth canal may precipitate damage to the skin and the fat tissue which may show up as swellings or bruises afterwards. When the baby is delivered face-first, injuries are observed commonly on the face and around the eyes. A breech-delivery may result in injuries to the external genital parts and the buttocks of the baby.
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Yasser Elnahas
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