The surgeon fractured the child's thigh, how to identify neonatal birth trauma?

Recently, Ms. Zhang of Tianjin posted on social media that during her cesarean section at Tianjin Wuqing District Traditional Chinese Medicine Hospital on April 9, the surgeon fractured the child's thigh without informing the family. After the birth of the child, he cried frequently, and the next day he found that the child's right leg was thick and swollen, and he went to Tianjin Children's Hospital for examination and was diagnosed with a fracture of the right femur.

Causes of femoral fractures during cesarean section of the newborn:

(1) The surgical incision is too small, or the anesthesia effect is not good, so that the abdominal wall muscles and uterine smooth muscles are not relaxed enough, making it difficult to rotate the fetus's hips and lower limbs during delivery;

(2) Improper traction methods, especially when the fetal hip and tie joints are stuck on the anteroposterior diameter of the pelvis, and do not rotate properly, just blindly hook or violently pull;

(3) The operation is too fast and too violent in order to save the fetus during emergency surgery.

Neonatal femoral fractures are one of the more common neonatal birth traumas, and other common birth traumas include scalp injuries, soft tissue injuries, intracranial hemorrhage, skull fractures, clavicle and long bone fractures, spinal injuries, brachial plexus injuries, and other common peripheral nerve injuries.

Common associated factors in neonatal birth trauma

1. Mode of delivery

(1) Assisted delivery by artificial auxiliary equipment: the risk of export forceps and low-level forceps is significantly lower than that of medium and high forceps

(2) Cesarean section: Among them, fetal injury during breech cesarean section, especially neonatal fractures, are mostly related to deep fixation of the hip presentation, poor formation or poor elasticity of the lower uterus, difficulty in expansion, and the operator's unfamiliarity with the mechanism of breech delivery.

(3) Others: inappropriate episiotomy during vaginal delivery; Abnormal progression of labour is a red flag for neonatal birth trauma.

2. Fetal factors

(1) Birth weight: macrosomia is one of the important causes of dystocia, such as shoulder dystocia at the same time, it is more likely to have birth injuries.

(2) Fetal presentation abnormalities: All kinds of fetal presentation abnormalities can lead to dystocia. Dystocia can lead to birth trauma if it is not managed properly.

(3) Others: genetics, premature birth, etc. are related to the occurrence of neonatal birth trauma. The brain and blood vessels of premature infants are immature, and the incidence of intracranial hemorrhage, cerebral palsy and spastic paralysis is much higher than that of full-term infants.

3. Maternal factors

(1) Pre-pregnancy weight and weight gain during pregnancy: Regardless of whether the pregnant woman is overweight before pregnancy, excessive weight gain during pregnancy is a risk factor for birth trauma in macrosomia and newborns. The incidence of neonatal birth trauma is still higher than normal in those who gain excess weight during pregnancy but do not deliver a large baby.

(2) Complications during pregnancy: the mother has gestational diabetes, post-term pregnancy, etc., and the incidence of neonatal birth injuries is increased. Hypertensive diseases during pregnancy, etc., predispose to fetal growth restriction, resulting in decreased fetal tolerance during delivery, resulting in birth trauma.

Several common birth injuries

1. Scalp injury

Includes tumorigenesis, scalp hematoma, subaponeurotic hemorrhage.

Scalp hematoma is formed when the skull and maternal pelvis are rubbed against or squeezed on each other during the delivery of the fetus, causing damage to the periosteum of the skull and rupture of subperiosteal blood vessels, and blood accumulates between the skull and periosteum. Scalp hematoma can occur in any part of the skull, but only limited to a single bone suture, will not exceed the midline of the skull, generally appear in 2~3 days after delivery, most of the hematoma disappears naturally within a few weeks, a small number will calcification.

Subaponeurotic hemorrhage is due to bleeding caused by external force compression and traction of the fetal head as it passes through the pelvic cavity, and there is a fluctuating sensation on palpation.

Scalp haematomas and subaponeurotic haemorrhages occur more commonly in neonates undergoing forceps delivery.

2. Soft tissue injury

These include skin abrasions, bruising, subcutaneous fat necrosis, and sternocleidomastoid muscle injury.

Bruising bruises: common in patients with prolonged labor, dystocia, or abnormal fetal position, and resolves spontaneously within 1 week.

Subcutaneous fat necrosis: often caused by birth injury, lack of oxygen, excessive cold, 3~4 days after birth, newborn's back, buttocks, cheeks and thighs appear local hardening, skin color red or normal, touch with heat and tenderness, clear edges, 6~8 weeks gradually disappeared. Generally, no specific treatment is required. However, patients with secondary infection need to control the infection promptly.

Sternocleidomastoid muscle injury: caused by excessive traction or excessive rotation of the fetal head, local palpable 1~2 cm size mass, may lead to torticollis. Some require surgical correction.

3. Intracranial hemorrhage

There may be supradural hemorrhage, subdural hemorrhage, and subarachnoid haemorrhage.

Etiology: excessive pressure on the fetal head during delivery, uneven local compression and excessive head deformation can be caused, in addition, hypoxia is also an important cause of subarachnoid hemorrhage.

Clinical manifestations:

Supradural hemorrhage increases intracranial pressure, anterior fontanelle bulges, neonatal convulsions, and the eyeball is tilted to one side.

Subdural hemorrhage can be seen clinically with symptoms of brainstem compression, such as one side of the eyeball, coma, unequal pupil, and opisthotonus.

Subarachnoid hemorrhage is the most common intracranial hemorrhage in newborns, with clinical manifestations such as convulsions, confusion, restlessness, and apnea. Requires surgery.

4. Spinal injury

Usually occurs in the cervicothoracic spine and is common in complex breech delivery. High-level spinal injuries may cause neonatal respiratory failure, spinal shock syndrome, and even death, while low-level spinal injuries may cause symptoms such as weakness of the limbs or lower extremities, weakness of the sphincters, and loss of sensation.

5. Brachial plexus injury

Caused by excessive pulling of the head or arm during delivery of the fetus, usually in macrosomia. According to the injured part, it can be divided into upper arm type (Erb's palsy), lower arm type (Klumpke's palsy) and full arm type.

Upper arm type: injury to the 5th and 6th cervical nerve roots, mainly affecting the shoulder and arm so that the child's upper arm can not abduct and external rotation, the affected limb droops, adduction, shoulder internal rotation, elbow pronation, wrist and knuckle flexion, embrace reflexion asymmetry.

Lower arm type: mainly damages the 8th cervical nerve root and the 1st thoracic vertebrae, resulting in weakness of the wrist flexors and hand muscles, and weak grip reflex. The full-arm type mainly affects the 5th cervical nerve root to the 1st thoracic vertebrae, and the upper arm and forearm of the hand are affected, and Horner syndrome can occur in patients with cervical sympathetic nerve involvement. Most patients recover, and a small number of children who do not recover may be considered for surgery.

6. Other common peripheral nerve injuries

Median nerve injury: manifested by poor grip of the thumb and index finger.

Sciatic nerve injury: manifests as poor hip abduction and immobility of joints below the knee.

Radial nerve injury: often associated with humeral fracture manifested by wrist weakness.

Facial nerve paralysis and injury: may be related to the use of forceps, the affected side has shallow nasolabial folds, the corners of the mouth are tilted to the healthy side, the eye fissures are large, the injured eye cannot be closed, and the face on the affected side has no expression changes.

Pharyngeal nerve injury: may occur in conjunction with facial nerve injury, and clinical manifestations are dysphagia, breathing, and vocalization.

Diaphragmatic nerve injury: often combined with brachial plexus injury, clinical manifestations are dyspnea, cyanosis, abdominal respiratory restriction, loss of diaphragm activity on the affected side, decreased breath sounds, need to assist breathing to improve symptoms, severe cases require surgical treatment.

7. Skull fracture

Includes linear fractures, depressed fractures, occipital separation.

Linear fractures are most common clinically and generally do not require treatment unless there is concomitant intracranial haemorrhage.

Skull depressed fracture, also known as table tennis fracture, may occur in the birth canal squeeze, improper use of forceps and postnatal head trauma, etc., severe cases can lead to intracranial hemorrhage, often require neurosurgery correction.

Occipital separation is rare, but is often associated with posterior subdural haematoma and intracranial injury.

8. Clavicle and long bone fractures

Etiology: mostly due to fetal excess weight, breech delivery, cesarean section, and other dystocia.

Common sites: separation of the clavicle, humeral shaft, femoral shaft, humerus, or epiphysis of the femur or femur.

Clavicle fractures are the most common, accounting for about 90% of birth trauma fractures, and the voluntary movements of the affected limb are reduced, and the hug reflex is absent due to non-nerve injury. In some cases, the symptoms of a clavicle fracture are not obvious, and accidental radiographs may not be detected until the fracture has healed and an olive-sized mass appears at the collarbone.

If multiple fractures occur, pay attention to whether it is a pathological fracture caused by congenital osteogenesis imperfecta.

Bibliography:

[1] Zhang Liwen, Gu Hang Prevention of neonatal birth trauma[J]. Chinese Journal of Practical Gynecology and Obstetrics, DOI:10.7504/fk2016070112

JIANG Zhixia,CUI Junming,WANG Yaoqi,FU Haiyang Identification of medical disputes for femur fracture by cesarean section of neonatesis: 1 case[J]. Legal Expo 2095 - 4379 - ( 2018) 12 - 0127 - 01

Liang Cheng, He Jing Breech cesarean section: prevention of neonatal fractures[J]. Chinese Journal of Practical Gynecology and Obstetrics, DOI:10.19538/j.fk2019020106

Written by | Metz Medicine

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