Birth trauma of newborns is a pathological condition that develops during childbirth and is characterized by damage to the tissues and organs of the child, accompanied, as a rule, by a disorder of their functions. Factors predisposing to the development of birth trauma in newborns are the incorrect position of the fetus, the discrepancy between the size of the fetus and the main parameters of the bone small pelvis of the pregnant woman (large fetus or narrowed pelvis), features of intrauterine development of the fetus (chronic intrauterine hypoxia), prematurity, prematurity, duration of the act of labor (as rapid, or rapid, and protracted labor).

The immediate cause of birth trauma is often incorrectly performed obstetric aids when turning and retrieving the fetus, the application of forceps, a vacuum extractor, etc.

Distinguish between birth trauma of soft tissues (skin, subcutaneous tissue, muscles), skeletal system, internal organs, central and peripheral nervous system.

Birth injury to soft tissues:

Damage to the skin and subcutaneous tissue during childbirth (abrasions, scratches, hemorrhages, etc.), as a rule, are not dangerous and require only local treatment to prevent infection (treatment with a 0.5% alcohol solution of iodine, the imposition of an aseptic dressing); they usually disappear after 5-7 days.

More severe damage to the muscles.
One of the typical types of birth trauma is damage to the sternocleidomastoid muscle, which is characterized by either hemorrhage or rupture; the latter usually occurs in the lower third of the muscle. Such damage often develops during childbirth in a breech presentation, but also occurs when forceps and other manual aids are applied. In the area of ​​injury and hematoma, a small, moderately dense or doughy consistency, slightly painful on palpation, is determined.

Sometimes it is diagnosed only by the end of the 1st week of a child's life, when torticollis develops. In this case, the child's head is tilted towards the injured muscle, and the chin is turned in the opposite direction. Differentiate the hematoma of the sternocleidomastoid muscle should be with congenital muscle torticollis.
Treatment consists in creating a corrective position that helps to eliminate pathological tilt and turn of the head (using rollers), the use of dry heat, electrophoresis of potassium iodide; at a later date, massage is prescribed. As a rule, the hematoma resolves and after 2-3 weeks. muscle function is fully restored. In the absence of the effect of conservative therapy, surgical correction is indicated, which should be carried out in the first half of the child's life.

One of the manifestations of birth trauma in newborns, cephalhematoma, is hemorrhage under the periosteum of a bone of the cranial vault (more often one or both parietal, less often the occipital). It must be differentiated from a generic tumor, which is a local edema of the skin and subcutaneous tissue of a newborn, is located, as a rule, on the presenting part of the fetus and arises as a result of prolonged mechanical compression of the corresponding area.

A birth swelling usually occurs with prolonged labor, as well as with obstetric aids (forceps). Unlike cephalhematoma, a generic tumor extends beyond one bone, it has a soft elastic consistency, fluctuations and a roller along the periphery are not observed; the generic tumor disappears in 1-2 days and does not require special treatment.

Children who have suffered a birth trauma of soft tissues, as a rule, fully recover and do not require special dispensary observation in a polyclinic.

Birth injury to the skeletal system:

Birth trauma to the skeletal system includes cracks and fractures, of which damage to the clavicle, humerus, and femur is the most common. The reasons for these are incorrectly administered obstetric benefits. A clavicle fracture is usually subperiosteal and is characterized by a significant limitation of active movements, a painful reaction (crying) with passive hand movements on the affected side, and the absence of the Moro reflex.

With light palpation, swelling, soreness, and crepitus are noted over the fracture site. Fractures of the humerus and femur are diagnosed by the absence of active movements in the limb, pain response during passive movements, the presence of edema, deformation and shortening of the damaged bone. For all types of bone fractures, the diagnosis is confirmed by X-ray examination.

Treatment of a clavicle fracture consists in a short-term immobilization of the hand using a Dezo bandage with a roller in the axillary region or by tightly swaddling an outstretched arm to the body for a period of 7-10 days (while the child is placed on the opposite side). Fractures of the humerus and femur are treated by the method of limb immobilization (after reduction, if necessary) and its extension (more often with the help of an adhesive plaster). The prognosis for fractures of the clavicle, humerus and femur is favorable.

Rare cases of birth trauma of newborns include traumatic epiphysiolysis of the humerus, which is manifested by swelling, pain and crepitus on palpation in the shoulder or elbow joints, restriction of movement of the affected arm. With this injury, flexion contracture in the elbow and wrist joints often develops in the future due to paresis of the radial nerve. The diagnosis is confirmed by x-ray of the humerus. Treatment consists in fixing and immobilizing the limb in a functionally determined position for 10-14 days, followed by the appointment of physiotherapeutic procedures, the use of massage.

Children who have suffered a birth trauma to the bones, as a rule, fully recover and do not require special dispensary observation in the polyclinic.

Birth trauma to internal organs:

It is rare and, as a rule, is the result of mechanical influences on the fetus with improper management of childbirth, the provision of various obstetric benefits. However, a violation of the activity of internal organs is also often noted in case of birth trauma of the central and peripheral nervous system. It is manifested by a disorder of their function with anatomical integrity. The most commonly damaged liver, spleen and adrenal glands are caused by hemorrhage in these organs. During the first two days a clear clinical picture of hemorrhage in the internal organs is not noted ("light" interval).

A sharp deterioration in the child's condition occurs on the 3-5th day in connection with bleeding due to rupture of the hematoma, an increase in hemorrhage and depletion of the mechanisms of compensation for hemodynamics in response to blood loss. Clinically, this is manifested by symptoms of acute post-hemorrhagic anemia and dysfunction of the organ in which the hemorrhage occurred. When hematomas rupture, bloating and the presence of free fluid in the abdominal cavity are often noted. Hemorrhage in the adrenal glands, which is often found in breech presentation, has a pronounced clinical picture. It is manifested by severe muscular hypotension (up to atony), suppression of physiological reflexes, intestinal paresis, falling blood pressure, persistent regurgitation, and vomiting.

To confirm the diagnosis of birth trauma of internal organs, a survey x-ray and an ultrasound examination of the abdominal cavity are performed, as well as a study of the functional state of the damaged organs.

Treatment consists in carrying out hemostatic and post-syndromic therapy. With hemorrhage in the adrenal glands and the development of acute adrenal insufficiency, replacement therapy with glucocorticoid hormones is necessary. When a hematoma ruptures, intracavitary bleeding, surgery is performed.

The prognosis of birth trauma to internal organs depends on the volume and severity of organ damage. If the child does not die during the acute period of birth trauma, his subsequent development is largely determined by the preservation of the functions of the affected organ.Many newborns who have suffered adrenal hemorrhage subsequently develop chronic adrenal insufficiency.

In case of birth trauma of internal organs, the pediatrician monitors the child's condition 5-6 times during the first month of life, then once every 2-3 weeks. up to 6 months, then 1 time per month until the end of the first year of life (see. Newborn, Perinatal period). In case of hemorrhage in the adrenal glands, it is necessary to observe the pediatrician, endocrinologist and determine the functional state of the adrenal glands.

Birth trauma to the central nervous system:

It is the most difficult and life-threatening for the child. It combines pathological changes in the nervous system that are different in etiology, pathogenesis, localization and severity, resulting from the impact on the fetus of mechanical factors during childbirth.

These include intracranial hemorrhages, injuries of the spinal cord and peripheral nervous system due to various obstetric pathologies, as well as mechanical damage to the brain, which develops as a result of compression of the skull by the mother's pelvic bones during the passage of the fetus through the birth canal. In most cases, birth trauma to the nervous system occurs against the background of chronic fetal hypoxia caused by an unfavorable course of pregnancy (toxicosis, threat of miscarriage, infectious, endocrine and cardiovascular diseases, occupational hazards, etc.).

Intracranial hemorrhage:

There are 4 main types of intracranial hemorrhage in newborns: subdural, primary subarachnoid, intra- and periventricular, intracerebellar. In their pathogenesis, trauma and hypoxia play the main role. Various types of intracranial hemorrhages, as well as the main pathogenetic mechanisms of their development, can be combined in one child, but one of them always dominates in the clinical symptom complex and the clinical symptomatology depends, accordingly, not only on the disturbance of cerebral circulation, but also on its localization, as well as from the severity of mechanical damage to the brain.

Subdural hemorrhages:

Depending on the localization, there are: tentorial hemorrhages with damage to the direct and transverse sinuses of the Galen's vein or small infratentorial veins; occipital osteodiastasis - rupture of the occipital sinus; rupture of the sickle-shaped process of the dura mater with damage to the lower sagittal sinus; rupture of the connecting superficial cerebral veins. Subdural hematomas can be unilateral or bilateral, possibly their combination with parenchymal hemorrhages resulting from hypoxia.

Tentorial hemorrhages:

Tentorial rupture with massive hemorrhage, occipital osteodiastasis, damage to the lower sagittal sinus is characterized by an acute course with the rapid development of symptoms of compression of the upper parts of the brain stem, such as stupor, aversion of the eyes, anisocoria with a sluggish reaction to light, a symptom of "puppet eyes", muscle stiffness occiput, posture of opisthotonus; unconditioned reflexes are depressed, the child does not suck, does not swallow, there are attacks of asphyxia, convulsions.

If the hematoma grows, symptoms of compression of the lower parts of the brain stem appear: coma, dilated pupils, pendulum eye movements, arrhythmic breathing. With a subacute course of the pathological process (hematoma and rupture of smaller sizes), neurological disorders (stupor, excitability, arrhythmic breathing, bulging of the large fontanel, oculomotor disorders, tremors, convulsions) occur at the end of the first day of life or after several days and persist for several minutes or hours. Death, as a rule, occurs in the first days of a child's life from compression of the vital centers of the brain stem.

Convexital subdural hematomas caused by rupture of superficial cerebral veins are characterized by minimal clinical symptoms (anxiety, regurgitation, vomiting, tension in the large fontanelle, Gref's symptom, periodic increase in body temperature, signs of local brain disorders) or their absence and are detected only with an instrumental examination of the child.

The diagnosis of subdural hematoma is established on the basis of clinical observation and instrumental examination. Rapidly increasing stem symptoms suggest a hematoma of the posterior fossa, resulting from rupture of the tentorium of the cerebellum or other disorders. In the presence of neurological symptoms, convexital subdural hematoma can be assumed.

Lumbar puncture in these cases is not desirable, because it can provoke the wedging of the cerebellar tonsils into the foramen magnum with subdural hematoma of the posterior cranial fossa or temporal lobe into the notch of the tentorium of the cerebellum in the presence of a large unilateral convexital subdural hematoma. Computed tomography is the most adequate method for diagnosing subdural hematomas; they can also be detected using ultrasound. With transillumination of the skull, the subdural hematoma in the acute period is contoured with a dark spot against the background of a bright glow.

With severe ruptures of the tentorium of the cerebellum, the crescent of the dura mater and occipital osteodiastasis, therapy is not effective and children die as a result of compression of the brain stem. With the subacute course of the pathological process and the slow progression of stem symptoms, surgery is performed to evacuate the hematoma. In these cases, the outcome depends on the speed and accuracy of the diagnosis.

With convexital subdural hematomas, the tactics of managing patients may be different. With unilateral hematoma with signs of displacement of the cerebral hemispheres, massive hematomas with a chronic course, subdural puncture is necessary to evacuate the outflowing blood and reduce intracranial pressure. Surgical intervention is necessary if the subdural puncture is ineffective.

If neurological symptoms do not increase, conservative treatment should be carried out; dehydration and resorption therapy, as a result of which, after 2-3 months, the formation of so-called constricting subdural membranes occurs and the child's condition is compensated. Long-term complications of subdural hematoma include hydrocephalus, seizures, focal neurological symptoms, delayed psychomotor development.

Subarachnoid hemorrhage:

Primary subarachnoid hemorrhages are most common. They arise when vessels of various sizes are damaged inside the subarachnoid space, small venleptomeningeal plexuses or connective veins of the subarachnoid space. They are called primary, in contrast to secondary subarachnoid hemorrhages, in which blood enters the subarachnoid space as a result of intra- and periventricular hemorrhages, rupture of an aneurysm.

Subarachnoid hemorrhages are also possible with thrombocytopenia, hemorrhagic diathesis, congenital angiomatosis. In primary subarachnoid hemorrhages, blood accumulates between individual parts of the brain, mainly in the posterior cranial fossa, temporal regions. As a result of extensive hemorrhages, the entire surface of the brain is covered, as it were, with a red cap, the brain is swollen, the vessels are full of blood. Subarachnoid hemorrhages can be combined with small parenchymal hemorrhages.

Symptoms of subarachnoid hemorrhage:

Symptoms of neurological disorders depend on the severity of the hemorrhage, in combination with other disorders (hypoxia, hemorrhages of other localization). Mild hemorrhages with clinical manifestations such as regurgitation, hand tremors, restlessness, and increased tendon reflexes are more common. Sometimes neurological symptoms may appear only on the 2-3rd day of life after latching the baby to the breast.

With massive hemorrhages, children are born in asphyxia, they have anxiety, sleep disturbance, general hyperesthesia, stiff neck muscles, regurgitation, vomiting, nystagmus, strabismus, Graefe's symptom, tremor, convulsions. Muscle tone is increased, tendon reflexes are high with an expanded zone, all unconditioned reflexes are pronounced. On the 3-4th day of life, Harlequin's syndrome is sometimes noted, manifested by a change in the color of half of the newborn's body from pink to light red; the other half is paler than normal. This syndrome is clearly detected when the child is on his side. A change in body color can be observed for 30 seconds to 20 minutes, during this period the child's well-being is not disturbed. Harlequin's syndrome is considered as a pathognomonic sign of traumatic brain injury and newborn asphyxia.

Diagnosis is by clinical presentation, presence of blood, and increased protein in cerebrospinal fluid. With transillumination of the skull in the acute period, the glow halo is absent; it appears after blood resorption as a result of the progression of hydrocephalus.

To clarify the localization of the pathological process, computed tomography and ultrasound examination are performed. Computed tomography of the brain reveals the accumulation of blood in various parts of the subarachnoid space, and also excludes the presence of other hemorrhages (subdural, intraventricular) or atypical sources of bleeding (tumors, vascular anomalies). The neurosonography method is not very informative, with the exception of massive hemorrhages reaching the Sylvian sulcus (a thrombus in the Sylvian sulcus or its expansion).

Treatment of subarachnoid hemorrhage:

Treatment consists of correcting respiratory, cardiovascular and metabolic disorders. Repeated lumbar punctures to remove blood should be performed according to strict indications and very carefully, slowly removing cerebrospinal fluid. With the development of reactive meningitis, antibiotic therapy is prescribed. With an increase in intracranial pressure, dehydration therapy is necessary. The progression of hydrocephalus and the lack of effect of conservative therapy is an indication for surgery (bypass grafting).

The prognosis depends on the severity of neurological disorders. In the presence of mild neurological disorders or asymptomatic course, the prognosis is favorable. If the development of hemorrhage was combined with severe hypoxic and (or) traumatic injuries, children usually die, and the few survivors usually have such serious complications as hydrocephalus, seizures, cerebral palsy (see. Infantile paralysis), speech and mental delay. development.

Intraventricular and periventricular hemorrhages:

Intraventricular and periventricular hemorrhages are most typical for premature babies born with a body weight of less than 1500 g. The morphological basis of these hemorrhages is an immature vascular plexus located under the ependyma lining the ventricles (germinal matrix). Until the 35th week of pregnancy, this area is richly vascularized, the connective tissue framework of the vessels is underdeveloped, and the supporting stroma has a gelatinous structure. This makes the vessel very sensitive to mechanical stress, changes in intravascular and intracranial pressure.

Causes:

High risk factors for the development of hemorrhages are prolonged labor accompanied by deformation of the fetal head and compression of the venous sinuses, respiratory disorders, hyaline membrane disease, various manipulations performed by a midwife (mucus suction, replacement blood transfusion, etc.). In about 80% of children with this pathology, periventricular hemorrhages break through the ependyma into the ventricular system of the brain and blood spreads from the lateral ventricles through the holes of Magendie and Luschka into the cisterns of the posterior cranial fossa.

The most characteristic is the localization of the forming thrombus in the region of the large occipital cistern (with limited spread to the surface of the cerebellum). In these cases, abliterating arachnoiditis of the posterior cranial fossa may develop, causing obstruction by CSF circulation. Intraventricular hemorrhage can also capture the periventricular white matter of the brain, combined with cerebral venous infarctions, which are caused by compression of the venous outflow tract by the dilated ventricles of the brain.

Symptoms:

Hemorrhage usually develops in the first 12-72 hours of life, but may progress later. Depending on the extent and speed of spread, there are conventionally distinguished 3 variants of its clinical course - lightning-fast, intermittent and asymptomatic (low-symptom). With a fulminant course of hemorrhage, the clinical picture develops within a few minutes or hours and is characterized by a deep coma, arrhythmic breathing, tachycardia, and tonic convulsions. The child's eyes are open, the gaze is fixed, the reaction of the pupils to light is sluggish, nystagmus, muscle hypotension or hypertension, bulging of the large fontanelle are observed; reveal metabolic acidosis, decreased hematocrit, hypoxemia, hypo- and hyperglycemia.

The intermittent course is characterized by similar, but less pronounced clinical syndromes and “undulating course, when a sudden deterioration is followed by an improvement in the child's condition. These alternating periods are repeated several times within 2 days, until stabilization or death occurs. With this variant of the course of the pathological process, pronounced metabolic disorders are also noted.

Asymptomatic or oligosymptomatic course is observed in about half of children with intraventricular hemorrhage. Neurological disorders are transient and mild, metabolic changes are minimal.

The diagnosis is made on the basis of an analysis of the clinical picture, the results of ultrasound and computed tomography. It is believed that there are only 4 pathognomonic clinical symptoms: a decrease in hematocrit for no apparent reason, no increase in hematocrit against the background of infusion therapy, bulging of the large fontanelle, change in the child's motor activity. Ultrasound examination of the brain through the large fontanelle allows you to determine the severity of hemorrhage and its dynamics.

Intraventricular hemorrhage:

With intraventricular hemorrhage, echo-dense shadows are found in the lateral ventricles - intraventricular thrombi. Sometimes blood clots are detected in the I and IV ventricles. Ultrasound examination also makes it possible to trace the spread of hemorrhage to the brain substance, which can be observed up to the 21st day of a child's life. The resolution of the thrombus lasts 2-3 weeks, and a thin echogenic rim (cysts) is formed at the site of the echo-dense formation.

Hemorrhage into the germinal matrix:

Hemorrhage into the germinal matrix also leads to destructive changes with the subsequent formation of cysts, which form most often in the periventricular white matter of the brain - periventricular cystic leukomalacia. After an acute period, the ultrasound picture of intraventricular hemorrhage is manifested by ventriculomegaly, which reaches a maximum by 2-4 weeks. life. Ultrasound examinations of the brain are recommended to be carried out on the 1st and 4th days of a child's life (during these periods, about 90% of all hemorrhages are detected).

Computed tomography for diagnostic purposes is performed in cases where there is a suspicion of the simultaneous presence of subdural hematoma or parenchymal hemorrhage. With the penetration of blood into the subarachnoid space, valuable information about the presence of hemorrhage is provided by a lumbar puncture: an admixture of blood is found in the cerebrospinal fluid, an increase in the content of protein and erythrocytes (the degree of increase in the concentration of protein, as a rule, correlates with the severity of hemorrhage), the pressure is increased.

In the acute period, measures are taken to normalize cerebral blood flow, intracranial and blood pressure, metabolic disorders. It is necessary to limit unnecessary manipulations with the child, monitor the mode of pulmonary ventilation, especially in premature infants, constantly monitor pH, pO2 and pCO2 and maintain their adequate level in order to avoid hypoxia and hypercapnia. With the development of intraventricular hemorrhage, treatment of progressive hydrocephalus is carried out; repeated lumbar punctures are prescribed to remove blood, reduce intracranial pressure and control the normalization of cerebrospinal fluid.

Also used enterally are drugs that reduce the production of cerebrospinal fluid, such as diacarb (50-60 mg per 1 kg of body weight per day), glycerol (1-2 g per 1 kg of body weight per day). If ventriculomegaly does not increase, then diacarb is prescribed in courses of 2-4 weeks. at intervals of several days for another 3-4 months. and more. In cases of progression of hydrocephalus and ineffectiveness of conservative therapy, neurosurgical treatment (ventriculoperitoneal bypass grafting) is indicated.

Intra- and periventricular hemorrhage:

Mortality among newborns with intra- and periventricular hemorrhages is 22-55%. Surviving children form a group at high risk of developing complications such as hydrocephalus, delayed psychomotor development, and infantile cerebral palsy. A favorable prognosis is suggested for light hemorrhages in 80% of patients, with moderate hemorrhages - in 50%, and in severe ones - in 10-12% of children.

The highest, but not absolute criteria for an unfavorable prognosis for children with intra- and periventricular hemorrhages are the following features of the acute period: extensive hematomas that involve the brain parenchyma: a lightning-fast onset of clinical manifestations with bulging of the large fontanelle, convulsions, respiratory arrest; posthemorrhagic hydrocephalus, which does not stabilize spontaneously; simultaneous hypoxic brain damage.

Cerebellar hemorrhage:

Cerebellar hemorrhages result from massive supratentorial intraventricular hemorrhages in term infants and hemorrhages into the embryonic matrix in premature infants. Pathogenetic mechanisms include a combination of birth trauma and asphyxiation. Clinically characterized by a fast progressive course, as in subdural hemorrhages in the posterior cranial fossa: respiratory disorders increase, hematocrit decreases, and death occurs quickly. Perhaps a less acute course of pathology, manifested by atony, areflexia, drowsiness, apnea, pendulum eye movements, strabismus.

The diagnosis is based on the identification of stem disorders, signs of increased intracranial pressure, ultrasound and computed tomography of the brain.

Treatment consists of emergency neurosurgical intervention for early decompression. With progressive hydrocephalus, bypass surgery is performed, which is indicated for about half of children with intracerebellar hemorrhage.

The prognosis of massive cerebellar hemorrhages is usually poor, especially in premature infants. Survivors have disorders caused by destruction of the cerebellum: ataxia, motor awkwardness, intentional tremor, dysmetria, etc.; in cases of blockage of the cerebrospinal fluid, progressive hydrocephalus is detected.

Atypical intracranial hemorrhages in newborns can be caused by vascular anomalies, tumors, coagulopathies, hemorrhagic infarction. The most common type of hemorrhagic diathesis is vitamin K-deficiency hemorrhagic syndrome, hemophilia A, isoimmune thrombocytopenic purpura of newborns.

Hemorrhagic disorders in newborns can also be caused by congenital thrombocytopathy due to the appointment of the mother before childbirth acetylsalicylic acid, sulfa drugs, while hemorrhages are mainly subarachnoid, not severe. Neonatal intracranial hemorrhages can cause congenital arterial aneurysms, arteriovenous anomalies, coarctation of the aorta, and brain tumors (teratoma, glioma, medulloblastoma).

Spinal cord injury in newborns:

Spinal cord injury is the result of mechanical factors (excessive traction or rotation) in the pathological course of childbirth, leading to hemorrhage, stretching, compression and rupture of the spinal cord at various levels. The spine and its ligamentous apparatus in newborns are more extensible than the spinal cord, which is fixed from above by the medulla oblongata and the roots of the brachial plexus, and from below by the cauda equina. Therefore, damage is most often found in the lower cervical and upper thoracic regions, i.e. in the places of greatest mobility and attachment of the spinal cord. Excessive stretching of the spine can lead to the lowering of the brainstem and its wedging into the foramen magnum. It should be remembered that the spinal cord during birth trauma can be torn, and the spine is intact, and no pathology is found during X-ray examination.

Neuromorphological changes in the acute period are reduced mainly to epidural and intraspinal hemorrhages; spinal injuries are very rarely observed - these can be fractures, displacements or tears of the vertebral epiphyses. In the future, fibrous adhesions are formed between the membranes and the spinal cord, focal zones of necrosis with the formation of cystic cavities, a violation of the architectonics of the spinal cord.

Clinical manifestations depend on the severity of the injury and the level of injury. In severe cases, the picture of spinal shock is expressed: lethargy, weakness, muscle hypotonia, areflexia, diaphragmatic breathing, weak cry. The bladder is distended, the anus gapes. The child resembles a patient with respiratory distress syndrome. The withdrawal reflex is sharply expressed: in response to a single injection, the leg bends and unbends several times in all joints (oscillates), which is pathognomonic for damage to the spinal cord. Sensory and pelvic disorders can be present. In the future, there are 2 types of the course of the pathological process. Less commonly, spinal shock persists and children die from respiratory failure. More often, the phenomena of spinal shock gradually regress, but the child still has hypotension for weeks or months.

During this period, it is almost impossible to determine a clear level of damage and, accordingly, the difference in muscle tone above and below the site of injury, which is explained by the immaturity of the nervous system, stretching of the spinal cord and roots along the entire length of the length, the presence of multiple diapedetic hemorrhages. Then hypotension is replaced by spasticity, increased reflex activity. The legs take the position of "triple flexion", a pronounced Babinsky symptom appears. Neurological disorders in the upper extremities depend on the level of the lesion.

If the structures involved in the formation of the brachial plexus are damaged, hypotension and areflexia persist, if pathological changes are localized in the mid-cervical or upper cervical regions, then spasticity gradually increases in the upper limbs. Vegetative disorders are also noted: sweating and vasomotor phenomena; trophic changes in muscles and bones can be expressed. With mild spinal trauma, there is a transient neurological symptomatology caused by hemolikvorodynamic disorders, edema, as well as changes in muscle tone, motor and reflex reactions.

The diagnosis is made on the basis of obstetric history (breech delivery), clinical manifestations, results of examination using nuclear magnetic resonance, electromyography. A spinal cord injury can be combined with damage to the spine, therefore, an X-ray of the suspected lesion area, examination of the cerebrospinal fluid is necessary.

Treatment consists of immobilizing the suspected area of ​​injury (cervical or lumbar); in the acute period, dehydration therapy is carried out (diacarb, triamterene, furosemide), antihemorrhagic agents are prescribed (vikasol, rutin, ascorbic acid, etc.). In the recovery period, an orthopedic regimen, exercise therapy, massage, physiotherapy, electrical stimulation are indicated. Aloe, ATP, dibazol, pyrogenal, B vitamins, galantamine, proserin, xanthinol nicotinate are used.

If the child does not die in the acute period of spinal cord injury, then the outcome depends on the severity of the anatomical changes. With persistent neurological disorders, children need long-term rehabilitation therapy. Prevention involves the correct management of labor in the breech presentation (see. Breech presentation of the fetus) and with discoordination of labor, prevention of fetal hypoxia, the use of cesarean section in order to exclude hyperextension of its head, identification of surgically corrected lesions.

Peripheral Nervous System Injury:

Peripheral nervous system injury includes trauma to the roots, plexuses, peripheral nerves, and cranial nerves. The most common trauma is the brachial plexus, phrenic, facial and median nerves. Other types of traumatic injuries of the peripheral nervous system are less common.

Brachial plexus injury in children:

Paresis of the brachial plexus occurs as a result of trauma to the CV-ThI roots, its frequency is from 0.5 to 2 per 1000 live newborns. Brachial plexus trauma (obstetric paresis) is observed mainly in children with a large body weight, born in a breech or foot presentation. The main cause of the injury is obstetric benefits provided when the upper limbs of the fetus are thrown back, when the shoulders and head are difficult to remove. Traction and rotation of the head with fixed shoulders and, conversely, traction and rotation of the shoulders with a fixed head lead to tension of the roots of the lower cervical and upper thoracic segments of the spinal cord over the transverse processes of the vertebrae. In the vast majority of cases, obstetric paresis occurs against the background of fetal asphyxia

Pathomorphological examination reveals perineural hemorrhages, punctate hemorrhages in the nerve trunks, roots; in severe cases - rupture of the nerves that form the brachial plexus, separation of the roots from the spinal cord, damage to the substance of the spinal cord.

Depending on the localization of damage, paresis of the brachial plexus is divided into upper (proximal), lower (distal) and total types. The upper type of obstetric paresis (Duchenne - Erb) occurs as a result of damage to the upper brachial bundle of the brachial plexus or cervical roots, originating from the CV-CVI segments of the spinal cord. As a result of paresis of the muscles abducting the shoulder, rotating it outward, raising the arm above the horizontal level, flexors and instep supports of the forearm, the function of the proximal upper limb is disrupted.

The child's hand is brought to the body, unbent, rotated inward in the shoulder, pronated in the forearm, the hand is in a state of palmar flexion, the head is tilted to the sore shoulder. Spontaneous movements are limited or absent in the shoulder and elbow joints, dorsiflexion of the hand and movement in the fingers are limited; there is muscle hypotonia, there is no reflex of the biceps brachii. This type of paresis can be combined with trauma to the phrenic and accessory nerves.

Obstetric paresis:

The lower type of obstetric paresis (Dejerine-Klumpke) occurs as a result of a decrease in the middle and lower primary bundles of the brachial plexus or roots, originating from the CVII-ThI segments of the spinal cord. As a result of paresis of the flexors of the forearm, hand and fingers, the function of the distal arm is impaired. Muscle hypotension is noted; movements in the elbow, wrist joints and fingers are sharply limited; the hand hangs down or is in the position of the so-called clawed paw. In the shoulder joint, the movements are preserved. On the side of paresis, the Bernard-Horner syndrome is expressed, trophic disorders can be observed, Moro and grasping reflexes are absent, sensory disturbances in the form of hypesthesia are observed.

The total type of obstetric paresis is caused by damage to nerve fibers originating from the CV-ThI segments of the spinal cord. Muscle hypotension is pronounced in all muscle groups. The child's arm hangs passively along the torso, it can easily be wrapped around the neck - a symptom of a scarf. Spontaneous movements are absent or insignificant. Tendon reflexes are not triggered. The skin is pale, the hand is cold to the touch. Bernard-Horner syndrome is sometimes expressed. By the end of the neonatal period, muscle atrophy usually develops.

Obstetric paresis is often unilateral, but can also be bilateral. In severe paresis, along with trauma to the nerves of the brachial plexus and the roots forming them, the corresponding segments of the spinal cord are also involved in the pathological process.

The diagnosis can be established already at the first examination of the newborn on the basis of the characteristic clinical manifestations. Electromyography helps to clarify the localization of damage.

Treatment should be started from the first days of life and carried out continuously in order to prevent the development of muscle contractures and train active movements. The hand is given a physiological position with the help of splints, a splint, massage, exercise therapy, thermal (applications of ozokerite, paraffin, hot wraps) and physiotherapeutic (electrical stimulation) procedures are prescribed; drug electrophoresis (potassium iodide, proserin, lidase, aminophylline, nicotinic acid). Drug therapy includes B vitamins, ATP, dibazol, prop-mil, aloe, proserin, galantamine.

With timely started and correct treatment, the functions of the limbs are restored within 3-6 months; the recovery period for moderate paresis lasts up to 3 years, but often compensation is incomplete, severe obstetric paralysis leads to a persistent hand defect. Prevention is based on rational, technically competent management of childbirth.

Diaphragm paresis (Kofferat's syndrome):

Diaphragm paresis (Kofferat's syndrome) is a limitation of the function of the diaphragm as a result of damage to the roots of the CIII-CV phrenic nerve with excessive lateral traction during labor. Diaphragm paresis can be one of the symptoms of congenital myotonic dystrophy. Clinically manifested by shortness of breath, rapid, irregular or paradoxical breathing, repeated attacks of cyanosis, swelling of the chest on the side of paresis. In 80% of patients, the right side is affected, bilateral involvement is less than 10%. Paresis of the diaphragm is not always clinically pronounced and is often found only on chest fluoroscopy. The dome of the diaphragm on the side of the paresis is high and has little mobility, which in newborns can contribute to the development of pneumonia. Diaphragm paresis is often associated with trauma to the brachial plexus.

Diagnosis is based on a combination of characteristic clinical and radiographic findings.

Treatment is to provide adequate ventilation until spontaneous breathing is restored. The child is placed in a so-called rocking bed. If necessary, carry out artificial ventilation of the lungs, percutaneous stimulation of the phrenic nerve.

The prognosis depends on the severity of the lesion. Most children recover within 10-12 months. Clinical recovery may occur before radiological changes disappear. With a bilateral lesion, the mortality rate reaches 50%.

Facial nerve paresis:

Facial nerve paresis is a traumatic injury during labor of the trunk and (or) branches of the facial nerve. It occurs as a result of compression of the facial nerve by the promontorium of the sacrum, obstetric forceps, with fractures of the temporal bone. In the acute period, edema and hemorrhage in the sheaths of the facial nerve are found.

The clinical picture is characterized by facial asymmetry, especially when screaming, widening of the palpebral fissure (lagophthalmos, or "hare's eye"). When screaming, the eyeballs can move upward, and in the loosely closed palpebral fissure, a protein membrane is visible - Belle's phenomenon. The corner of the mouth is lowered in relation to the other, the mouth is shifted to the healthy side. Severe peripheral paresis of the facial nerve can impede the sucking process.

Diagnosis is based on characteristic clinical symptoms. Differential diagnosis is carried out with congenital aplasia of the trunk nuclei (Moebius syndrome), subdural and intracerebellar hemorrhages in the posterior cranial fossa, central paresis of the facial nerve, brain contusion, in which there are other signs of damage to the nervous system.

The course is favorable, recovery often proceeds quickly and without specific cookies. With a deeper lesion, ozokerite, paraffin and other thermal procedures are applied. The consequences (synkinesis and contractures) are rare.

Pharyngeal Nerve Injury:

Injury of the pharyngeal nerve is observed with an incorrect intrauterine position of the fetus, when the head is slightly rotated and tilted to the side. Such movements of the head can also occur during childbirth, which leads to paralysis of the vocal cords. Lateral flexion of the head with solid thyroid cartilage causes compression of the upper branch of the pharyngeal nerve and its lower recurrent branch. As a result, if the upper branch of the pharyngeal nerve is damaged, swallowing is impaired, and if the lower recurrent branch is damaged, the vocal cords are closed, which leads to dyspnea. Rotation of the head causes the face to be pressed against the walls of the mother's pelvis, therefore, the facial nerve can be injured on the opposite side. If lateral flexion of the neck is expressed, then a lesion of the phrenic nerve can be observed and, accordingly, paresis of the diaphragm occurs.

The diagnosis is based on direct laryngoscopy.

Treatment is symptomatic, in severe cases, tube feeding, tracheostomy is necessary. Noisy breathing and threat of aspiration may persist for the first year of life or longer. The prognosis is often favorable. Recovery usually occurs by 12 months. life.

Median nerve injury:

Trauma to the median nerve in newborns can be in 2 places - in the antecubital fossa and in the wrist. Both types are associated with percutaneous arterial puncture (brachial and radial, respectively).

The clinical picture in both cases is similar: the digital grasp of the object is impaired, which depends on the flexion of the index finger and the abduction and opposition of the thumb of the hand. The position of the hand is characteristic, due to the weakness of flexion of the proximal phalanges of the first three fingers, the distal phalanx of the thumb, and also associated with the weakness of abduction and opposition of the thumb. There is atrophy of the eminence of the thumb.

Diagnosis is based on characteristic clinical symptoms. Treatment includes the imposition of splints on the hand, exercise therapy, massage. The prognosis is favorable.

Radial nerve injury:

Radial nerve injury occurs when the shoulder is fractured with compression of the nerve. This can be caused by an incorrect intrauterine position of the fetus, as well as a difficult course of labor. Clinically manifested by fatty necrosis of the skin above the epicondyle of the ray, which corresponds to the compression zone, weakness of extension of the hand, fingers and thumb (hand hanging). Differential diagnosis is carried out with trauma to the lower sections of the brachial plexus, however, with damage to the radial nerve, the grasping reflex and the function of other small muscles of the hand are preserved. The prognosis is favorable, in most cases, the function of the hand is quickly restored.

Lumbosacral plexus injury:

Injury to the lumbosacral plexus occurs as a result of damage to the roots LII-LIV and LIV-SIII during traction in a pure breech presentation; is rare. Characterized by total paresis of the lower limb; extension in the knee is especially impaired, there is no knee reflex. Differentiate with sciatic nerve injury and dysraphic status. With the latter, skin and bone abnormalities are observed and the lesion is rarely limited to only one limb. The prognosis is often favorable; only mild movement disorders may persist after 3 years.

Sciatic nerve injury in newborns:

Injury of the sciatic nerve in newborns occurs as a result of improper intramuscular injections into the gluteal region, as well as with the introduction of hypertonic solutions of glucose, analeptics, calcium chloride into the umbilical artery, as a result of which spasm or thrombosis of the lower gluteal artery, which supplies blood to the sciatic nerve, is possible. It manifests itself as a violation of the abduction of the hip and restriction of movement in the knee joint, sometimes there is necrosis of the muscles of the buttocks. In contrast to the injury to the lumbosacral plexus, flexion, adduction, and external rotation of the hip are preserved.

The diagnosis is based on anamnesis data, characteristic clinical symptoms, determination of the speed of the impulse along the nerve. Differentiation should be with peroneal nerve injury. Treatment includes the imposition of splints on the foot, massage, exercise therapy, thermal procedures, drug electrophoresis, electrical stimulation. The prognosis may be unfavorable in cases of improper intramuscular administration of drugs (long recovery period). With paresis of the sciatic nerve resulting from thrombosis of the gluteal artery, the prognosis is favorable.

Peroneal Nerve Injury:

Peroneal nerve injury occurs as a result of intrauterine or postnatal compression (with intravenous fluids). The site of injury is the superficial part of the nerve located around the head of the fibula.

Characterized by a drooping foot caused by weak dorsiflexion of the lower leg as a result of damage to the peroneal nerve. The diagnosis is based on typical clinical manifestations and the determination of the speed of the impulse along the nerve. Treatment is the same as for sciatic nerve injury. The prognosis is favorable, recovery in most cases is observed within 6-8 months.

Management tactics for children who have suffered a birth trauma of the central and peripheral nervous system. These children are at risk of developing neurological and mental disorders of varying severity in the future. Therefore, they should be put on dispensary registration and in the first year of life every 2-3 months. undergo examinations by a pediatrician and a neurologist. This will make it possible to timely and adequately carry out treatment and correction measures in the early stages of development.

Cerebral palsy treatment in children:

Treatment of children with cerebral palsy and severe movement disorders after brachial plexus injury should be carried out continuously for many years until the maximum compensation of the defect and social adaptation is achieved. Parents take an active part in the treatment of the child from the first days of life. They should be explained that the treatment of a child with a lesion of the nervous system is a long process, not limited only to certain courses of therapy, it requires constant training with the child, during which motor, speech and mental development is stimulated. Parents should be taught the skills of specialized care for a sick child, the basic techniques of therapeutic exercises, massage, orthopedic regime, which should be performed at home.

Mental disorders in children who have suffered a birth trauma of the nervous system are expressed by various manifestations of the psychoorganic syndrome, which in the long-term period of birth traumatic brain injury in children corresponds to an organic defect of the psyche. The severity of this defect, like neurological symptoms, is associated with the severity and localization of brain damage (mainly hemorrhages). It consists in intellectual disability, convulsive manifestations and psychopathic behavioral features. In all cases, cerebrasthenic syndrome is necessarily detected. Various neurosis-like disorders can also be observed, psychotic phenomena occasionally occur.

Intellectual disability during birth trauma of newborns associated with damage to the nervous system manifests itself primarily in the form of oligophrenia. A distinctive feature of such oligophrenia is a combination of mental underdevelopment with signs of organic decline in personality (more gross violations of memory and attention, exhaustion, complacency and uncriticality), convulsive seizures and psychopathic behavior are not uncommon. In milder cases, intellectual disability is limited to secondary mental retardation with a picture of organic infantilism.

With encephalopathy with a predominance of convulsive manifestations, various epileptiform syndromes, asthenic disorders and a decrease in intelligence are observed.

Psychopathic behavioral disorders with increased excitability, motor disinhibition and the detection of coarse drives are significant among the long-term consequences of traumatic brain injury in children. Cerebrastenic syndrome is the most constant and characteristic, it manifests itself in the form of prolonged asthenic states with neurosis-like disorders (tics, fears, anuresis, etc.) and signs of organic mental decline. Psychotic disorders are rare, in the form of episodic or periodic organic psychosis.

A common distinguishing feature of mental disorders in birth traumatic brain injury (except for oligophrenia) is the lability of symptoms and the relative reversibility of painful disorders, which is associated with a generally favorable prognosis, especially with adequate treatment, which is mainly symptomatic and includes dehydration, resorption, sedative and stimulant (nootropics) therapy. Psychocorrectional and treatment-pedagogical measures are essential.

Prevention is associated with preventing complications, improving care for pregnant women and childbirth.

The birth process of newborns is always associated with a certain risk. Any mistakes made by a doctor or features of the female body cause consequences that significantly worsen the quality of a person's adult life. A birth trauma to the head causes many brain injuries.

Causes of damage

Traumatization occurs with mechanical stress during birth, as a result of which the structure of tissues is disrupted. In other words, they talk about such a phenomenon when newborns have injuries that have arisen during their birth. The doctor's mistakes do not always affect the likelihood of a birth injury. Often, injuries are formed due to an improper lifestyle of a pregnant woman, the structural features of the woman's pelvis, the position of the fetus, and for a number of other reasons.

Features of the structure of the head of a newborn

The structure of the head in newborns has several significant differences. This part of the body is the largest before birth. In most cases, the fetus moves with its head in front. As a result, she experiences maximum loads. She manages to maintain her previous shape due to two qualities:

• elasticity;
• elasticity.

The fontanelles influence the development of the first quality. These structures are cavities between the bones of the skull filled with a dense membrane. The latter is formed from the hard shell of the brain and periosteum. Newborns have four fontanelles.

The increased elasticity of the child's skull is also due to the structural features of the seams made of connective tissue. This structure provides a relatively free passage of the head through the birth canal. When the child's skull is under stress, it deforms slightly, while eliminating the likelihood of injury to tissues and the brain.

Birth trauma in newborns appears with strong squeezing. This effect leads to damage to the structural elements and tissues of the skull. After birth, the head remains deformed.

Risk factors

Such damage occurs under the influence of three specific factors. Let's consider them in more detail:

Extension of the head also leads to brain damage in newborns. More often the skull is injured under the influence of a group of factors. The development of congenital pathologies is facilitated by a cesarean section performed before the onset of labor. When the fetus is forcibly removed, negative pressure is formed inside the uterus. To reach the child, the doctor has to make an effort. And if the position of the hands is unsuccessful, the likelihood of injury is high.

Clinical picture

There is a general classification of birth injuries. The latter are subdivided into:

In addition, birth injuries are usually classified into the following types:

1. Spontaneous. It occurs for reasons not attributable to the actions of the doctor.
2. Obstetric. The injury was caused by the mistaken actions of the doctor who delivered the baby.

The clinical picture depends on the location of the pathological disorders and their severity. Postpartum symptoms appear either immediately or after a certain time (sometimes even after several years).

The short-term effects of head trauma to a child are of the following types:

Congenital brain injuries include hemorrhages of various types. Head injury during labor often leads to the formation of intracranial hemorrhages. Because of this, brain functions are impaired, as indicated by:

As the condition worsens and the size of the intracranial hematoma increases, the child's mood changes: he constantly screams, is in an agitated state. In extreme cases, death is possible.

Recovering a newborn

It is possible to detect a skull injury in a newborn only after a comprehensive examination using ultrasound, MRI and other devices. The recovery of a child after such injuries is carried out mainly in a hospital setting, where children are provided with the most sparing regimen.

In the presence of small abrasions, the affected area is treated with a solution of brilliant green, and the child is prescribed antibiotics to prevent infection of the body (Amoxicillin). The same drugs are used for various edema.

Most often, cephalohematoma gradually resolves without medical intervention. The process takes about two months. In rare cases, ossification of the formation occurs, which leads to deformation of the child's skull. To prevent this, in severe cases, cephalohematomas are removed within the first 10 days of life. The procedure is carried out using two special needles. Subgaleneurotic hematomas are also removed through a small incision made in the scalp.

Surgical intervention is indicated if multiple fractures have been identified during head examination. During the operation, the doctor restores the shape of the skull by means of an elevator, which is inserted into the skull. Removal of blood clots is performed using a craniotomy. The procedure is indicated for multiple lesions. Craniotomy involves the phased removal of blood through punctures.

In order to avoid negative consequences in case of birth trauma to the head, the child is prescribed:

1. Compensatory therapy with the use of mechanical ventilation in the mode of moderate hyperventilation.
2. Decongestant therapy. The drugs are Dexamethasone, Furosemide, Euphyllin.
3. Hemostatic therapy. Dicinon is introduced.
4. Anticonvulsant therapy. Sibazon, Phenobarbital are prescribed.
5. Metabolic therapy. Piracetam, Curantil are used.

Possible consequences

Complications of birth trauma to the skull are of a varied nature. In the event of brain damage, the parents of the newborn may eventually face:

• lag in the intellectual development of the child;
• neuroses;
• epilepsy.

With hydrocephalus, there is a gradual accumulation of cerebrospinal fluid in the ventricles of the brain. With such a pathology, the child's head circumference is actively increasing. Symptoms suggestive of hydrocephalus include:

In the future, there are frequent headaches and epileptic seizures. Hydrocephalus leads to a lag in intellectual development, which becomes noticeable after several years. This problem can be identified by the following criteria:

• aggressive or indecisive behavior;
• difficulties with adaptation in society;
• isolation;
• unsteady attention;
• problems remembering information;
• the child is late to start holding his head.

Birth trauma to the skull can lead to the development of oligophrenia, characterized by an inability to acquire new skills and a lack of critical thinking. The defeat of the central nervous system is complicated by such pathologies.

Care

Diapers

Swaddling

The process of childbirth is quite unpredictable and can end in complications for both the mother and the baby. Birth trauma is one of these complications.

What is it?

Birth trauma of newborns is called the pathological conditions arising during the course of childbirth, in which the tissues or organs of the newborn are damaged, as a result of which their functions are impaired.

With prenatal trauma in a newborn, the work of the main body systems is disrupted

Types of injury

All birth injuries are divided into:

1. Mechanical... These are bone fractures, head injuries, birth tumors, various hemorrhages, injuries of the spinal cord and central nervous system, cephalohematomas, injuries of the cervical spine, nerve damage, traumatic brain injury and other pathologies.
2. Hypoxic... They are represented by damage to internal organs and brain tissues, which are caused by hypoxia and asphyxia during the birth process.

Cardiotocography is one of the methods for early diagnosis of intrauterine fetal hypoxia

Depending on the localization of the lesion, injuries are distinguished:

• Bones.
• Soft tissue.
• Nervous system.
• Internal organs.

Common causes

To the appearance of mechanical birth injuries give various obstacles in the advancement of the fetus along the female birth canal.

The cause of the appearance of hypoxic injuries is a complete or partial cessation of oxygen access to the child.

Damage to the central nervous system or traumatic brain injury of the baby is one of the most common problems during childbirth.

To predisposing factors in which the risk of injury during childbirth increases, include:

• Large fetal weight.
• Prematurity of the child.
• A narrow pelvis of a pregnant woman.
• Mother's pelvic injury.
• Incorrect presentation.
• Mom's advanced age.
• The swiftness of the birth process.
• Delaying the process of childbirth.
• Stimulation of labor.
• Cesarean section.
• Use of obstetric aids and devices.
• Postmaturity.
• Chronic fetal hypoxia.
• Umbilical cord problems (entanglement, short length).

For a detailed explanation of how prenatal injuries occur in a baby, see the video:

Symptoms

• The most common birth injuries are presented swelling of the soft tissues of the baby's head, called a birth tumor... It looks like a slight swelling on the head of a newborn. With this edema, babies may also experience hemorrhages in the skin in the form of small dots.
• Cephalohematoma is manifested by hemorrhage in the baby's head. It occurs due to displacement of the skin and rupture of blood vessels, as a result of which blood collects under the periosteum of the cranial bones. The tumor appears immediately after childbirth and increases in size in the first two to three days.
• Muscle hemorrhage often occurs in the neck(in the sternocleidomastoid muscles) and looks like a moderately dense mass of small size (for example, the size of a nut or the size of a plum).
• Among the fractures of bones, the clavicle (often the right) is most often damaged without displacement. With such an injury, when feeling the body of the newborn in the place of the broken collarbone, swelling, crunching and soreness are revealed. Fractures of the femur or humerus are much less common. With them, movements in the limbs are impossible, their lethargy and soreness is noted.

Hematoma on the head of a newborn

• Nerves can be damaged due to hypoxia and mechanical injury. The most common nerve problem is damage to the facial nerve. Brachial plexus injuries are also common.
• Traumatic brain injury can have different severity. In severe cases, the baby may die in the first days or even hours after birth. Also, with severe trauma, organic changes in the tissues of the nervous system are possible, manifested by paralysis, paresis, and the development of mental retardation. Immediately after childbirth, the baby may develop convulsions, inhibition of the sucking reflex, breathing problems, crying heavily, tremors of the arms and legs, insomnia and other symptoms of CNS arousal. Further, the baby becomes lethargic, his cry and muscle tone weakens, the skin turns pale, the child sleeps a lot, sucks poorly, spits up a lot.
• Internal injuries are less common than other types of injuries and usually do not appear in the first time after childbirth. Your baby may have damage to the adrenal glands, spleen, or liver. The baby's condition worsens from the third to fifth day of life, when the hematoma in the damaged organ ruptures, which leads to internal bleeding and anemia.

Effects

The prognosis for birth injuries is influenced by the severity of the injury, the timeliness of treatment, and the correctness of the selected therapy. If the child was diagnosed correctly on time and started to heal immediately, in 70-80% of cases he will fully recover.

The least dangerous is damage to soft tissues and bones. The birth swelling usually disappears in one to two days without any consequences for the child's body. A small cephalohematoma resolves by 3-7 weeks of life without treatment. Due to hemorrhage in the muscles of the neck, the child develops torticollis, in which the head of the crumbs tilts towards the formation, and the chin is directed in the opposite direction. This condition is corrected with a special massage.

The size of the hematoma affects the consequences of damage to internal organs. It is equally important how much the function of the affected organ is preserved. For example, a large hemorrhage in the adrenal glands in many children leads to the development of chronic insufficiency of these glands.

The consequences of hypoxic injuries depend on the length of the period when the child was experiencing a lack of oxygen. If such a period was long, a severe degree of delay in intellectual and physical development is possible, caused by the death of nerve cells in the brain. Children may develop cerebral palsy, hydrocephalus, seizures, nerve damage, encephalopathy and other pathologies. With an average degree of hypoxia in older children, increased fatigue, headaches, dizziness, and problems with posture may appear.

For what hypoxia is and how to avoid it, see the following story:

Therapy

In most cases birth injuries are diagnosed at the hospital, where the child is immediately prescribed the necessary treatment. In case of fractures, the damaged area is immobilized. In a serious condition, the baby is fed through a tube with colostrum, which is expressed by the mother.

With a severe degree of hypoxia, the treatment of the baby is carried out in the resuscitation of newborns

In the treatment of injuries, depending on the type of damage, drugs are used for blood vessels and the heart, drugs that affect the central nervous system, hemostatic agents, oxygen therapy, the introduction of vitamins and glucose.

Update: October 2018

Childbirth is rightfully considered a complex and unpredictable process, since this period can end unfavorably for both the woman and the fetus, and often for both. Birth trauma of newborns, according to different authors, occurs in 8 - 18% of cases, and, nevertheless, these figures are considered underestimated.

It is characteristic that half of the cases of birth trauma of a newborn are combined with birth traumatism of the mother. The further physical and mental development of the child, and in some cases his life, depends on how early this pathology is diagnosed and treatment started.

Definition of birth trauma of newborns

Birth trauma of newborns is said to be when the fetus, as a result of the action of mechanical forces in the process of the birth act, damage the tissues, internal organs or the skeleton, which is accompanied by a violation of compensatory and adaptive processes. Roughly speaking, birth trauma of a newborn is any injury that has arisen during childbirth.

It is completely unfair to blame the obstetric service for causing all birth traumas in children (the method of delivering childbirth, the provision of benefits, etc.). It is necessary to take into account not only the course and management of childbirth, but also the course of pregnancy, the impact of environmental factors, and so on. For example, in cities with developed industry, there is a large number of children with neurological disorders, up to mental retardation.

Causes of pathology

When analyzing the causes of birth injuries, it was revealed that all factors are divided into 3 groups:

Factors that relate to the mother

Factors that relate to the fetus

• presentation by the pelvic end;
• large fruit;
• lack of amniotic fluid;
• prematurity;
• wrong position of the fetus (transverse, oblique);
• in childbirth;
• fetal malformations;
• asynclitism in childbirth (incorrect insertion of the head);
• extensor insertion of the head (facial and others);
• intrauterine hypoxia;
• short umbilical cord or its entanglement;

Factors due to the course and management of labor

• protracted course of childbirth;
• rapid or rapid labor;
• discoordination of the birth forces;
• tetanic contractions (violent labor activity);
• dystocia of the cervix;
• obstetric turns;
• imbalance between the baby's head and the mother's pelvis;
• the imposition of obstetric forceps (the most common cause of pathology);
• the use of vacuum extraction of the fetus;
• cesarean section.

As a rule, a combination of several factors at once causes a birth trauma in children. It was also noted that during a cesarean section, this pathology occurs three times more often than during spontaneous childbirth. This is facilitated by the so-called canning effect: when, during abdominal delivery, the fetus is removed from the uterus (and this is a violent event, since there are no contractions), then negative intrauterine pressure is formed behind it. Due to the resulting vacuum behind the child's body, its normal extraction is disrupted and the doctor makes significant efforts to reach the baby. This leads to injuries to the cervical spine.

Classification

Conventionally, there are 2 types of birth injuries:

• mechanical - arise as a result of external influences;
• hypoxic - caused by mechanical damage, due to which oxygen starvation of the child develops, which leads to damage to the central nervous system and / or internal organs.

Depending on the location of the damage:

• damage to soft tissues (this can be skin and subcutaneous tissue, muscles, birth swelling and cephalohematoma);
• damage to bones and joints (these are cracks and fractures of tubular bones: femur, shoulder, clavicle, trauma to the bones of the skull, dislocations and subluxations, etc.);
• damage to internal organs (hemorrhage in organs: liver and spleen, adrenal glands and pancreas);
• damage to the nervous system (brain and spinal cord, nerve trunks).

In turn, damage to the nervous system is subdivided into:

• intracranial birth injury;
• injury to the peripheral nervous system (damage to the brachial plexus and damage to the facial nerve, total paralysis and paresis of the diaphragm, and others);
• spinal cord injury.

Birth trauma to the brain includes various hemorrhages (subdural and subarachnoid, intracerebellar, intraventricular and epidural, mixed).

Also, birth trauma is differentiated according to the degree of influence of the obstetric service:

• spontaneous, which occurs either during normal or complicated childbirth, but regardless of the doctor's reasons;
• obstetric - as a result of the actions of the medical staff, including the correct ones.

Clinical picture

Symptoms of injury in newborns immediately after childbirth can differ significantly (be more pronounced) after a certain period of time and depends on the severity and location of the injury.

Soft tissue injury

When soft tissues (skin and mucous membranes) are damaged, various scratches and abrasions are observed (possibly during an amniotomy), cuts (during a cesarean section), hemorrhages in the form of ecchymosis (bruises) and petechiae (red dots). Such injuries are not dangerous and quickly disappear after local treatment.

More serious soft tissue injury is damage (rupture with hemorrhage) of the sternocleidomastoid muscle. As a rule, such a birth trauma occurs during childbirth with breech presentation, but it may also occur if obstetric forceps or other aids are applied during childbirth. Clinically, in the area of ​​muscle damage, a small, moderately dense or doughy to the touch swelling is determined, its slight soreness is noted. In some cases, muscle damage is detected by the end of the first week of a newborn's life, which is manifested by torticollis. Therapy includes the creation of a corrective head position (elimination of pathological tilt using rollers), dry heat, potassium iodide electrophoresis. Later, a massage is prescribed. After a couple of weeks, the hematoma resolves and the muscle function is restored. If there is no effect of treatment, surgical correction is performed (at 6 months).

Birth injuries to the head include:

• Birth tumor

This swelling appears as a result of soft tissue edema due to increased pressure on the head or buttocks. If the birth was in the occipital presentation, the tumor is located in the region of the parietal bones, in the breech presentation - on the buttocks and genitals, and in the case of the facial presentation - on the face. The birth tumor looks like a cyanotic edema with many petechiae on the skin and develops in the case of prolonged labor, a large fetus or the application of a vacuum extractor. A birth tumor does not require treatment and disappears on its own in a couple of days.

• Subaponeurotic hemorrhage

It is a hemorrhage under the scalp aponeurosis and can "descend" into the subcutaneous spaces of the neck. Dough swelling, edema of the parietal and occipital parts are clinically determined. This hemorrhage can also increase after birth, is often infected, and is the cause of post-hemorrhagic anemia and intensifying jaundice (bilirubin builds up). Disappears on its own after 2 - 3 weeks.

• Cephalohematoma

When blood vessels rupture, blood flows out and accumulates under the periosteum of the skull, usually in the region of the parietal bones (rarely in the region of the occipital bone). At first, the tumor has an elastic consistency and is determined 2 - 3 days after delivery, when the birth tumor subsides. Cephalohematoma is located within one bone, never extends to neighboring ones, there is no pulsation, painless. With careful palpation, fluctuation is determined. The skin over the cephalohematoma is unchanged, but petechiae are possible. In the first days after childbirth, cephalohematoma tends to increase, then it becomes tense (considered a complication). The size of the injury decreases by 2 - 3 weeks, and complete resorption occurs in 1.5 - 2 months. In the case of tense cephalohematoma, x-rays of the skull are indicated to exclude bone fractures. In rare cases, cephalohematoma calcifies and stiffens. Then the bone at the site of injury is deformed and thickened (the shape of the skull changes as the child grows). Treatment is carried out only with significant and increasing cephalohematomas (puncturing, applying a pressure bandage and prescribing antibiotics).

Practical example

An obstetrician involved in childbirth is not without the risk of inflicting this or that damage on the baby. Birth injuries in this case are considered iatrogenic complications, and not a doctor's mistake. During the emergency caesarean section, I cut the skin on the baby's buttocks and head a couple of times. Since the cesarean section was emergency, that is, already with active labor, when the lower segment of the uterus is overstretched, the soft tissues of the baby were affected during its incision. Such cuts are absolutely safe for the child, do not require stitches, there is no heavy bleeding and heal on their own (provided they are regularly treated with antiseptics).

Skeletal injury

Birth injuries of the osteoarticular system include cracks, dislocations and fractures. They arise as a result of incorrectly or correctly provided obstetric benefits:

• Clavicle fracture

As a rule, it has the character of the subperiosteum (the periosteum remains intact, and the bone breaks). Clinically, there is limited active movements, a painful reaction (crying) to an attempt to make passive movements of the hand on the side of the broken collarbone, there is no Moreau reflex. On palpation, swelling, soreness and crepitus (snow creak) over the site of injury are determined. Treatment is conservative: the imposition of a tight bandage that fixes the shoulder girdle and the handle. Healing occurs after 2 weeks.

• Humerus fracture

This fracture is often located in the middle or upper third of the bone, possibly a detachment of the pineal gland or partial rupture of the ligaments of the shoulder joint. Sometimes there is a displacement of bone fragments and outflow of blood into the joint. A shoulder fracture often occurs when the arms are pulled out in the case of a breech presentation or when the child is pulled out by the pelvic end. Clinically: the baby's handle is brought to the body and "looks" inward. Active flexion in the injured arm is weakened, violent movements are painful. Severe deformity of the limb is visible. Treatment: immobilizing plaster cast. Healing takes place within three weeks.

• Femur fracture

This fracture is characteristic of the internal rotation of the fetus on the pedicle (the fetus is removed by the pelvic end). It is characterized by a significant displacement of fragments due to pronounced muscle tension, edema of the thigh, spontaneous movements are sharply limited. Often, the thigh turns blue as a result of hemorrhage in muscle tissue and subcutaneous tissue. Treatment: limb extension or reduction (matching of fragments) with further immobilization. Healing occurs after 4 weeks.

• Cranial bone fracture

In born children, there are 3 types of skull fractures: linear (the bone loses its integrity along the line), depressed (the bone sags inward, but the integrity is usually not lost) and occipital osteodiastasis (the scales of the occipital bone are separated from its lateral parts). Impressed and linear fractures occur after the application of obstetric forceps. Occipital osteodiastasis is caused either by subdural hemorrhage or by compression of the skull at this site. Clinically asymptomatic. Only a depressed fracture appears - a clear deformation of the skull, if there is a strong deflection of the bone inward, then as a result of its pressure on the brain, convulsions occur. No treatment required. The depressed fracture heals on its own.

• Cervical birth injury

The cervical spine is characterized by mobility, fragility and special sensitivity to various influences. Injury to the cervical spine is caused by severe flexion, accidental stretching, or violent twisting. The following types of disorders occur in the neck:

• distraction;
• rotation;
• compression-flexion.

Rotational disorder occurs either during manual manipulations or when applying obstetric forceps, when the head rotates, which leads to subluxation of the first cervical vertebra or to damage to the joint between the first and second vertebrae.

Compression-flexion disorders are characteristic of rapid labor and large fetuses.

The most common neck injuries include over-stretching, hammer-in subluxations, and twisting of the head and / or neck.

Internal trauma

A rather rare pathology and is observed with improper management or pathological course of childbirth or with the provision of obstetric benefits. The functions of internal organs can also be impaired during birth trauma of the nervous system. As a rule, the liver and spleen and adrenal glands are damaged. Due to the outpouring of blood into these organs. The first two days there is no symptomatology, the so-called "light interval". But then, on the 3rd - 5th day, there is a sharp deterioration in the baby's condition due to bleeding caused by a ruptured hematoma, an increase in hemorrhage and hemodynamic disturbances. With such a birth injury, the following symptoms are noted:

• posthemorrhagic anemia;
• disruption of the damaged organ;
• the stomach is swollen;
• ultrasound detects fluid in the abdominal cavity;
• severe muscle hypotension;
• suppression of reflexes;
• intestinal paresis (no peristalsis);
• drop in blood pressure;
• vomit.

Treatment includes the appointment of hemostatics and post-syndromic therapy. With significant hemorrhage in the abdomen, an emergency operation is indicated. If the adrenal glands are damaged, glucocorticoids are prescribed.

Injury to the nervous system

Birth injuries of the nervous system include damage to the central system (brain and spinal cord) and peripheral nerves (plexus, roots, damage to peripheral or cranial nerves):

Intracranial injury

This group of birth injuries includes various types of hemorrhages in the brain caused by rupture of intracranial tissues. These include hemorrhages under various membranes of the brain: subdural, epidural, and subarachnoid; hemorrhage in the brain tissue is called intracerebral, and in the ventricles of the brain - intraventricular. Brain damage is considered the most severe birth injury. Symptoms depend on the location of the hematoma in the brain. Common signs of all intracranial injuries are:

• sudden and sharp deterioration in the baby's condition;
• the nature of the cry changes (moaning or meowing type);
• the large fontanelle begins to bulge;
• abnormal movements (twitching, etc.) of the eyes;
• thermoregulation is disturbed (temperature rise, the child is constantly freezing, trembling);
• suppression of reflexes;
• swallowing and sucking is impaired;
• there are attacks of suffocation;
• movement disorders;
• tremors (tremors);
• vomiting not associated with food intake;
• the child constantly spits up;
• convulsions;
• tension of the occipital muscles;
• anemia is growing (an increase in intracerebral hematoma).

If cerebral edema and hematoma increase, death is possible. With the stabilization of the process, the general condition gradually returns to normal, with deterioration, depression (stupor) is replaced by irritation and excitement (the child screams incessantly, "twitches").

Spinal cord injury

Birth trauma to the spine and spinal cord is also considered one of the most severe types of damage to the nervous system. The spine of the fetus and newborn is well stretched, which cannot be said about the spinal cord, which is fixed in the spinal canal from below and from above. Spinal cord injury occurs when excessive longitudinal or lateral traction is performed or when the spine is twisted, which is characteristic of difficult breech delivery. The spinal cord is usually affected in the lower cervical spine or in the upper thoracic region. A rupture of the spinal cord is also possible with visible integrity of the spine, which is very difficult to diagnose even with X-ray. The common symptoms of this type of injury are signs of spinal shock:

• weak cry;
• weakness;
• lethargy;
• muscle tone is weak;
• reflexes are impaired;
• diaphragmatic breathing, asthma attacks;
• distended bladder;
• gaping anus.

In the event of a severe spinal cord injury, the child dies from respiratory failure. But often there is a slow healing of the spinal cord and an improvement in the condition of the newborn.

Treatment includes immobilization of the alleged site of injury; in the acute period, diuretics and hemostatic drugs are prescribed.

Peripheral Nervous System Injuries

In such injuries, individual nerves or plexuses and nerve roots are damaged. With the defeat of the facial nerve, there is a unilateral paresis of the face, an open palpebral fissure on the damaged side, the absence of a nasolabial fold and displacement of the corner of the mouth in the opposite direction, omission of the corner of the mouth. It passes on its own in 10 - 15 days. With Erbo's paralysis ("upper" paralysis) - damage to the brachial plexus or roots of the spinal cord at the C5 - C6 level, there are no movements in the shoulder joint, while in the elbow joint and cyst remain. With paralysis of Klumpka or "lower" paralysis (damage to the roots of the spinal cord C7 - T1 or middle / lower bundles of the brachial plexus) there are movements in the shoulder, but not in the elbow and hand. In the case of total paralysis (all cervical and thoracic roots and brachial plexus are injured). There is no movement in the affected limb at all. The phrenic and median nerves or the corresponding roots of the spinal cord can also be affected. The clinical picture contains:

• incorrect head position;
• torticollis;
• abnormal location of the limbs;
• limitation of movement in the limbs;
• muscle hypotension;
• many reflexes are missing;
• dyspnea;
• cyanosis;
• swelling of the chest.

In the case of bilateral paresis of the phrenic nerve, the death of the child occurs in 50% of situations.

Diagnostics

In newborns (no more than 7 days after birth), the following methods are used to diagnose a birth injury:

• inspection;
• palpation (head and neck, limbs and abdomen, chest);
• ultrasound procedure;
• X-ray examination;
• MRI and CT;
• neurosonography;
• functional tests;
• spinal tap;
• electroencephalography;
• laboratory tests (total blood count, coagulability, group and Rh factor);
• indicators of CBS blood;
• specialist consultations (neurologist, neurosurgeon, ophthalmologist, traumatologist)

Recovery and care

After being discharged from the hospital, children after birth injuries must be provided with appropriate care, if necessary, treatment continues, and measures are prescribed aimed at the early rehabilitation of babies. Treatment and care depends on the type of injury that occurred during labor:

• Damage to soft tissues

With minor skin lesions (abrasions, cuts), local treatment of wounds with antiseptic solutions (brilliant green, fukortsin, potassium permanganate) is prescribed. In case of damage to the sternocleidomastoid muscle, an immobilizing bandage (Shants collar) is applied for 7-10 days, then a soft passive change in the position of the head and active movements of the head in the direction opposite to the lesion are performed. If there is no effect, surgical treatment is performed.

• Limb fractures

The injured limb is immobilized with a plaster cast, the child is swaddled tightly, and if necessary, the limbs are stretched. After the fracture has healed, physiotherapy and massage are prescribed.

• Spine and spinal cord injury

First of all, the child's head and neck are immobilized (ring-shaped bandage or cotton-gauze collar). The baby is swaddled in a bandage (already in the delivery room). The dressing lasts 10-14 days. If hemorrhages that compress the spinal cord are significant, surgical treatment is performed. For anesthesia, seduxen is prescribed, in the acute period of hemostatics. Swaddling is done with care while supporting the neck. Child care should be gentle. In the recovery period, physiotherapy exercises and massage are prescribed.

• Internal trauma

The mother and baby are transferred from the maternity hospital to a specialized surgical department, where syndrome-based treatment is prescribed. If necessary, an emergency laparotomy is performed to remove blood from the abdominal region and stop intra-abdominal bleeding.

• Intracranial injury

A protective regime is assigned, which includes: restriction of sound and light stimuli, examinations, swaddling and the production of various manipulations are carried out as sparingly as possible, maintaining the temperature regime (being in the incubator). Feeding the child is carried out depending on his condition: from a bottle, tube or parenteral. All manipulations (feeding, swaddling, etc.) are performed in a crib (jug). If necessary, surgery (removal of intracranial hematomas, lumbar puncture). Of the drugs, antihemorrhagic, dehydration, antihypoxants and anticonvulsants are prescribed.

Effects

Birth injuries of the nervous system (brain and spinal cord) are considered to be prognostically unfavorable. After such a birth trauma, there are almost always residual effects and / or consequences.

The consequences of spinal (cervical) injuries include:

• the occurrence of osteochondrosis and scoliosis;
• decreased muscle tone against a background of increased flexibility;
• weakening of the muscles of the shoulder girdle;
• persistent headaches;
• impaired fine motor skills (fingers);
• clubfoot;
• vegetative-vascular dystonia;
• arterial hypertension.

The consequences of the transferred intracranial birth trauma (in 20 - 40%):

Hydrocephalus

Hydrocephalus or dropsy of the brain is a disease when cerebrospinal fluid accumulates in the ventricles of the brain and under its membranes, and its accumulation progresses. Hydrocephalus is congenital, that is, the result of infections suffered by a woman during pregnancy or an intrauterine disorder of the development of the brain and acquired, in most cases caused by birth trauma. A clear sign of the disease is a rapid increase in the circumference of the child's head (by 3 or more cm per month). Also, the symptoms of pathology are:

• intracranial hypertension (constant regurgitation, poor appetite, moodiness and anxiety of the baby);
• bulging and long non-closing large fontanelle;
• convulsions;
• persistent drowsiness or hyperexcitability;
• irregularity of eye movements, problems with the development of vision, strabismus;
• hearing problems (worsening);
• tilting the head.

The consequences of this disease are quite severe: delayed intellectual development, cerebral palsy, speech, hearing and vision impairments, significant headaches due to increased intracranial pressure, epileptic seizures.

Intellectual development gap

Delayed mental development can be caused not only by birth trauma, but also by other reasons (prematurity, infections in early childhood, pathological course of pregnancy, etc.). Symptoms of delayed intellectual development can be expressed insignificantly and appear only before entering school (indecision and isolation, aggressiveness and difficulties in communication in a team) or be expressed, up to oligophrenia (lack of criticism, complacency, gross memory impairments, unstable attention, difficulties in acquired skills: dressing and shoes, tying shoelaces). The first signs of mental retardation are: the child starts to hold his head late, walk and talk, later he has difficulties with speech.

Neurosis-like states

Another consequence of the CNS trauma suffered during childbirth is neurosis-like conditions. Symptoms of this pathology include:

• emotional lability (crying, aggression in response to comments, depression and anxiety, anxiety), although such children are active and inquisitive, they study well;
• hyperactivity up to motor disinhibition, unstable attention;
• fears and nightmares;
• enuresis and;
• stool disorder (constipation and / or diarrhea);
• increased sweating or dry skin;
• rapid fatigue, which replaces excitability and anxiety;
• anorexia nervosa (while eating, nausea and vomiting appear).

Epilepsy

Epilepsy is considered a serious consequence of birth trauma to the brain. Due to trauma during childbirth, the baby's brain experiences oxygen deprivation, which leads to disruption of the gray matter cells. Convulsive seizures can be the main manifestation of both epilepsy itself and complement other pathological conditions (hydrocephalus, mental retardation, cerebral palsy). Of course, other factors can cause epilepsy: head trauma after birth or in adults, infections and brain tumors, and others.

Cerebral palsy

It includes a large group of neurological conditions that appear as a result of brain damage in a baby either during pregnancy or during childbirth (birth trauma). In the clinical picture, in addition to movement disorders, there are speech disorders, intellectual retardation, epileptic seizures and emotional-volitional disorders. Symptoms of pathology include:

• delay in motor development;
• late disappearance of unconditioned reflexes (for example, grasping);
• gait disturbances;
• limitation of mobility;
• speech disorders;
• hearing and vision problems;
• convulsive syndrome;
• mental retardation and others.

Other pathologies

• Development of allergic diseases (bronchial asthma, neurodermatitis and others)
• Development of cardiovascular pathology

• muscle atrophy;
• various paralysis;
• delayed physical development;
• emotional lability;
• headaches (due to intracranial hypertension);
• bed-wetting;
• hand / leg spasms;
• speech disorders.

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Birth trauma to the head

What is Birth Injury to the Head -

Birth trauma to the head are one of the main causes of disability and death in childhood. This type of injury requires a special approach to their management, which usually differs significantly from that adopted in neurotraumatology. This is due to the fact that the body of a newborn in its anatomical and physiological characteristics is significantly different from the body of older children and especially adults. In addition, the mechanisms of birth head injury are significantly different from the mechanisms of postnatal traumatic brain injury. This difference lies in the fact that birth trauma is a consequence of the effect of static mechanical energy on the head in the form of a rather prolonged compression of the head, while in postnatal traumatic brain injury, mainly dynamic energy acts on the head. In addition, a number of factors that are characteristic exclusively for this type of injury are of great importance in the pathogenesis of birth trauma, namely fetal hypoxia during placental abruption, aspiration of amniotic fluid, etc.

Despite the long history of attempts at surgical treatment of birth trauma to the head, this type of injury was considered until recently as unpromising in terms of its successful therapy. This was due to the lack of sufficiently effective diagnostic methods, which led to the fact that surgical interventions for birth trauma to the head were performed in the stage of decompensation. In addition, in the treatment of birth trauma to the head, traumatic techniques of craniotomy, adopted in "adult" neurotraumatology, were used.

Progress in this direction was outlined in the second half of the 20th century and was associated with the emergence of new diagnostic methods, in particular neuroimaging, as well as the introduction of minimally invasive surgical techniques into neurosurgical practice.

What provokes / Causes Birth trauma to the head:

Compression of the head occurs in any childbirth. Compression is physiological if the force and duration of exposure to the head does not lead to disruption of the adaptation mechanisms of the skull and its contents. With pathological compression, there is a breakdown of adaptation mechanisms with damage to the integument, bones and contents of the skull and the development of the birth trauma itself. It is customary to distinguish three groups of factors that predispose to pathological compression of the head during childbirth, namely: the state of the fetus (prematurity, postmaturity, large head sizes), features of the birth canal (narrow pelvis, rigidity of the birth canal, pelvic deformity) and labor dynamics (rapid labor , obstetric benefits, etc.).

Pathogenesis (what happens?) During birth trauma to the head:

The head of the fetus and the newborn has a number of fundamental anatomical and physiological differences from the head of an adult. At the time of delivery, the head is the largest circumference of the newborn's body. In addition, in the overwhelming majority of cases, the head forms the birth canal and takes on the maximum load. The ability of a newborn's head to deform during childbirth is due to the presence of two properties that are absolutely not characteristic of the adult's head, namely elasticity and elasticity. The elasticity of the skull is due to the presence of fontanelles, which are interosseous spaces filled with a dense membrane formed by the dura mater and periosteum fused together. In total, there are four fontanelles on the head of a newborn: large, small and two lateral. In addition, the elasticity of the skull is due to the structure of its seams, which are also made of a connective tissue membrane.

These formations provide the mutual mobility of the bones of the skull during the labor act and a decrease in the volume of the head when passing through the birth canal. The formations that provide the elasticity of the newborn's skull prevent excessive deformation of the head during childbirth, protecting the intracranial formations from trauma.

These formations include the large sickle-shaped process of the dura mater and the outline of the cerebellum located perpendicular to it. The large crescent bone, fixed to the parietal bones, limits their significant movement. In addition, the triangular scales of the occipital bone, located between the parietal bones, also limit their mobility. The marking of the cerebellum, in turn, limits the excessive displacement of the occipital scales into the cranial cavity.
The processes of the dura mater after stretching are capable of contracting, causing the restoration of normal anatomical relationships between the bones of the skull after childbirth.

When the head is compressed, there is a movement of the cerebrospinal fluid from the rather extensive cerebrospinal fluid spaces of the skull to the spinal cerebrospinal fluid spaces. The wide pachyon opening allows dislocation of the brain during compression of the head without functional impairment.

Symptoms of Birth Injury to the Head:

There is no generally accepted classification of birth trauma to the head. To formulate the diagnosis, the classification principles adopted in neurotraumatology are used, taking into account the features characteristic of neonatal traumatic brain injury. The classification includes general characteristics of head injury (severity, prevalence, origin of mechanical energy - compression in the birth canal or obstetric trauma), types of structural head injuries and features of functional disorders.

Among the traumatic brain lesions in a newborn are distinguished:
- hemorrhages in the brain, which can occur in the form of hematomas or hemorrhagic impregnation of the medulla;
- hemorrhages under the lining of the brain, among which there are subarachnoid, subdural, epidural hemorrhages;
- intraventricular hemorrhage;
- contusion lesions of the brain substance.

Features of the clinical picture of birth trauma to the head are largely determined by the functional immaturity of the brain structures, neuro-reflex and behavioral reactions of newborns.

The most important indicator of the severity of intracranial injuries is the state of consciousness. It is not entirely correct to use in newborns the gradation of impairments of consciousness adopted in adults. More acceptable is the assessment of the so-called behavioral states.

Pathological behavioral conditions include the following:
- lethargy - the newborn is in a state of sleep, wakes up in response to intense painful irritations;
- stunnedness is characterized by the absence of periods of awakening with the preservation of reactions to external stimuli in the form of a change in facial expression;
- stupor is characterized by a minimal reaction of the newborn to external stimuli;
- coma in a newborn - lack of reactions to intense painful stimuli.

Diagnostics of the birth trauma of the head:

Topical diagnosis of lesions of the nervous system in newborns is difficult due to the functional immaturity of the nuclei and pathways of the brain. Physiological neurological status extremely variable. Healthy newborns are characterized by a sluggish reaction to light, anisocoria, transient squint, floating eye movements.

Sucking and swallowing disorders as signs of bulbar and pseudobulbar syndromes are of great diagnostic value. A symptom of spastic paresis is often a decrease in tone and tendon reflexes.

When assessing the local status, attention should be paid to the damage to the soft tissues of the head and the condition of the large fontanelle. Normally, the brain does not protrude above the bony edge of the fontanelle, and on palpation, cerebral pulsation is determined. In newborns, a number of clinical syndromes are described that are characteristic of birth trauma to the head.

The hyperexcitability syndrome is characterized by sleep disturbance and general anxiety in the newborn. Convulsive syndrome is characterized by the presence of seizures or various convulsive equivalents (apnea attacks). Meningeal syndrome is characterized by general hyperesthesia, pain with head percussion. Hydrocephalic syndrome is manifested by an increase in head size, bulging fontanelle, vomiting, anxiety, increased venous pattern.

Thus, the clinical diagnosis of organic brain pathology in young children presents significant difficulties. This is due to the fact that in early childhood the central nervous system functions mainly at the level of the brainstem and diencephalic parts of the brain, the work of hemispheres begins as the nervous system matures and develops in a later period. Clinical methods for topical diagnostics of brain lesions, which make it possible to suspect organic pathology in young children, are not informative. In this regard, neuroimaging methods are of great importance in clarifying the diagnosis of birth trauma.

Currently, the leading role in the diagnosis of birth trauma is assigned to ultrasonography... The possibilities of this diagnostic method in newborns are significantly expanded due to the presence of a large fontanelle. Transrodial ultrasonography is effective in diagnosing the most commonly observed types of intracranial lesions, namely epi- and subdural hematomas. However, with ultrasonography, it is impossible to assess the condition of the bones of the skull, as well as the convexital surface of the brain. Radiography remains an effective method for diagnosing damage to the bones of the skull.

X-ray computed tomography and magnetic resonance imaging of the head allow you to get the most comprehensive information about the state of the brain.

So, sub- and epidural hematomas on tomographic sections are visualized as a pathological volumetric fluid process in the intershell spaces (normally, the membranes are closely adjacent to each other and the intershell spaces are not determined). It is quite clearly possible to determine the presence of blood as a substrate of the described volumetric process. The presence of hemoglobin in the hematoma leads to an increase in the MR signal, therefore, hematomas of all types will be characterized by an increased signal in the T1-weighted mode, which is due to the presence of blood or its elements in the fluid. In cases where the blood filling the intershell cavity is in a liquid homogeneous phase, a uniform increase in the MR signal is observed from the hematoma and in the T2-weighted mode. When the blood filling the hematoma is organized into a clot, during the T2-weighted mode, the signal from the blood clot will be reduced, which reflects the structure of the clot, the blood in the liquid phase around the clot will be characterized by a uniform increase in the MR signal. Differentiating the hard and soft membranes of the brain when conducting a tomographic study, especially in early childhood, in most cases is not possible. However, the shape and position of the intershell fluid volumetric process make it possible to differentiate the epi- and subdural position of the cavity. So, epidural processes look more delimited, mainly in the area of ​​the bone suture junction, more local and thickened in comparison with subdural processes, they are found both in the convexital and in the basal parts of the brain. In the literature, their shape is often described as a "lens". Subdural processes, on the contrary, are more widespread in length, sometimes with extension to most or all of the hemisphere. They are found in most cases in the convexital regions of the brain, although their spread from the convexital to the basal regions of the brain is observed quite often. There is also a spread of subdural hematomas in the area of ​​the interhemispheric fissure.

The presence of cavity intershell processes located above the sinuses, crossing them, makes it possible to clearly define the described hematoma as an epidural. An exception is the nature of the tomographic signal from the blood in young children with subdural chronic hematomas. The features of the metabolism of blood breakdown products in the subdural cavities in early childhood are such that the signal from the blood in a chronic process in the T1-weighted mode can be reduced, in contrast to subdural hemorrhages at an older age, when the blood gives a clearly pronounced increase in the T1-weighted signal in any period of hemorrhage.

Intracerebral hemorrhages are in the form of hematomas or hemorrhagic impregnation of the brain. The nature of the hematoma is determined by the mechanism of vascular damage in cases of rupture, rupture, which often occurs when large and medium-sized vessels are affected, bleeding is observed, which forms a hematoma. When there is a lesion of mainly small vessels associated with their compression, concussion, violation of the hemodynamic regime, a diapedetic hemorrhage is formed with diffuse hemorrhagic impregnation of the substance of the affected area of ​​the brain. In cases of hematoma during tomographic examination, it will be characterized by T1-weighted programs in the first hours by a slight decrease in the MR signal, in the subsequent period - by a persistent increase in the MR signal, which indicates the presence of blood. According to T2-weighted programs in the liquid state, the blood of the hematoma will be characterized by an increase in the MR signal, in the case of blood retraction and the formation of a clot, the latter will reflect a decrease in the MR signal, the blood in the liquid phase around the clot will be characterized by an increase in the MR signal. This allows you to assess the functional state of the hematoma. When hemorrhagic impregnation of the brain substance according to T1-weighted programs, the affected area of ​​the brain will be characterized by an increase in the MR signal, which makes it possible to differentiate hemorrhagic impregnation from contusion and ischemic brain damage. Therefore, T1-weighted sequences for the diagnosis of hemorrhagic brain saturation are decisive.

With hemorrhage into the ventricles, blood can also be detected in the liquid phase or in clots. In cases of clot formation, the blood can tampon the ventricle and cause a violation of the outflow of cerebrospinal fluid from the overlying parts of the ventricular system of the brain with the formation of hydrocephalus, or it can cause compression of the brain structures surrounding the ventricle, which is most important for tamponade of the 4th ventricle, when the structures of the brain stem are compressed, which can lead to vital stem disorders due to compression. T1-weighted sequences are the main ones in the diagnosis of intraventricular hemorrhage. Due to a pronounced increase in the T1 signal from the blood, with a sharp decrease in it from the cerebrospinal fluid, topic, the size of hematomas inside the ventricles is determined quite clearly. Assessment of the state of the ventricular system, impaired CSF dynamics are also better defined by T1-weighted sequences due to the high contrast of CSF in the ventricles and brain matter.

The possibility of a clear topical definition of the observed areas of brain damage, the extent of the lesion and the degree of reaction to it of the brain and its cerebrospinal fluid systems, differentiation of the nature of the pathomorphological process allow choosing the optimal approach to the treatment of neurosurgical brain pathology, observing and effectively correcting the course of the process.

The disadvantage of these methods is the need for sedation of the examined newborn, as well as removing it from the incubator and transportation. In this regard, these techniques should be used in newborns strictly according to indications.
Invasive diagnostic methods used in newborns include lumbar and ventricular punctures, as well as puncture of the subdural space.
Lumbar puncture retained its significance only in the diagnosis of subarachnoid hemorrhages and neuroinfection. When performing a puncture, it should be borne in mind that the spinal cord of newborns ends lower than in adults, therefore, the puncture should be performed at the L3 level and below. Contraindications to performing manipulation are suspicion of the presence of space-occupying lesions in the temporal or occipital region and the threat of dislocation.

Ventricular puncture is performed for the diagnosis and treatment of intraventricular hemorrhage. Puncture of the subdural spaces through the fontanelles or sutures is currently performed mainly for therapeutic purposes to evacuate subdural hematomas and hydromas.

Treatment for Birth Injuries to the Head:

Treatment of newborns with birth traumatic brain injury and caring for them, of course, have a number of essential features. The primary task is to ensure the most sparing regimen, and in a serious condition - to find the child in a jail in a specialized department. In the presence of attacks of respiratory failure, secondary asphyxia, seizures, you should avoid moving the child. Skin toilet, swaddling and feeding should be done in a crib.

The newborn should be fed with a spoon or pipette in the early days to avoid unnecessary energy consumption. In the absence of a swallowing reflex, it is advisable to establish tube feeding. The newborn should receive 100-150 ml of fluid per day, taking into account the introduced solutions.

Scalp injury are the most common signs of head injury. The presence of local traumatic scalp injuries requires in-depth diagnostics to exclude concomitant intracranial lesions. The optimal technique in this regard is transorbital ultrasonography.

Abrasions usually require treatment with a brilliant green solution. Scalp wounds, which may be the result of obstetric manipulations, require primary surgical treatment with the mandatory prescription of antibiotics. In the primary surgical treatment of wounds in the scalp free of hair, it is preferable to use white suture material for suturing the aponeurosis, since dark threads can be seen through the skin for a long time.

Birth edema is edema of soft tissues and is localized on the part of the head presenting in labor. Usually goes away on its own. In rare cases, it can become necrotic. In this situation, the use of antibiotics is indicated.

In origin subgaleal and subperiosteal hematomas the structural features of the scalp of newborns are of great importance. So, the periosteum of the skull is tightly fused with the bones only in the area of ​​the seams. Outside the sutures, newborns have a subperiosteal space filled with loose tissue, rich in vessels that carry out trophism of bones. In this regard, subperiosteal hematomas (cephalohematomas) are limited to the perimeter of one bone. This type of hematoma usually does not resolve spontaneously and requires removal within the first 10 days of life. Removal is carried out under local anesthesia using two Dufo needles (the second needle is used to prevent negative pressure in the hematoma cavity) inserted into the base of the hematoma. After emptying the hematoma, a pressure bandage is applied to the head. In rare cases, the procedure for removing the cephalohematoma must be repeated. Unremoved cephalohematomas can lead to lysis of the underlying bone with the formation of a bone defect.
Subgoneurotic hematomas are not limited to the perimeter of a single bone and can be quite common. In some cases, in the presence of massive subgaleal hematomas, blood loss may develop, requiring appropriate correction. The source of bleeding in this case is the veins coming from the periosteum into the subcutaneous tissue of the head. Subgoneurotic hematomas usually require removal, since there is a high risk of infection, especially in the presence of damage to the scalp. Hematomas are removed through a small incision. In this case, the liquid part of the hematoma flows out on its own, the clots are removed with a curette. The wound is not closed. A rubber graduate is left in the hematoma cavity.

Injuries to the bones of the skull are more often the result of obstetric benefits. Sometimes they can occur with significant deformities of the mother's pelvis. In newborns, linear and depressed fractures can be observed. The latter are usually not accompanied by bone destruction with the formation of fragments. The term ping-pong ball fractures is used to refer to this type of fracture. This is due to the high elasticity of the skull bones of newborns with an almost complete absence of diploe. Impressed fractures in some cases tend to spontaneous reduction. Surgical treatment is indicated for extensive fractures with significant depression, neurological symptoms, and no tendency towards spontaneous reduction. The operation consists in restoring the natural configuration of the bone using an elevator inserted under the bone through a milling hole.

Intracranial hemorrhage are the most dangerous type of birth trauma of the head and are accompanied by the highest mortality in newborns.

Epidural hematomas are collections of blood between the bones of the skull and the dura mater. The source of bleeding are the vessels of the dura mater, diploe (which in newborns is present only in the region of the parietal bones), as well as the vessels of the epidural tissue. These hematomas are more often the result of obstetric manipulations. Accompanied by progressive depression of consciousness, the appearance of seizures, hemiparesis. The diagnosis is clarified with neuroimaging. With computed tomography, the hematoma looks like a biconvex lens. Hematoma is usually treated with surgery. The hematoma is removed by craniotomy with suturing of the dura mater to the aponeurosis. When removing a hematoma, it is important to control the volume of blood loss with adequate replenishment of the BCC. Special attention should be paid to the fact that intracranial hemorrhage in newborns can be accompanied by significant blood loss.

In the presence of skull fractures bleeding is possible not only epidurally, but also under the periosteum. In such cases, subperiosteal-epidural clusters form. In the case of a stable condition of the newborn, they are limited to puncture removal of the subperiosteal component of the cluster. If the condition worsens, the epidural component of the hematoma is removed by craniotomy.

Subdural hematomas represent an accumulation of blood under the dura mater. Bridge veins are usually the source of bleeding. In childbirth, the separation of arachnoid villi with the outflow of cerebrospinal fluid into the subdural space is also possible. In such cases, subdural hydromas are formed, or the so-called subdural accumulations, containing blood and cerebrospinal fluid in various proportions. With neuroimaging, the subdural hematoma has a crescent shape. Clinically, subdural hematomas are manifested by depression of consciousness, convulsions, and motor prolapse. Only small hematomas that are asymptomatic are treated conservatively. If the condition of the newborn worsens, surgical treatment is indicated. Currently, three methods of evacuation of subdural hematomas have been proposed: puncture method, craniotomy, and a step-by-step method of removal.

The choice of the method is carried out individually, depending on the nature of the hematoma and the condition of the newborn. The puncture method is effective in the presence of liquid hematoma. If the blood obtained during the diagnostic puncture does not clot, then it is necessary to allow the blood to flow freely (without aspiration) from the subdural space. To improve evacuation, it is advisable to flush the subdural space with isotonic sodium chloride solution. Do not remove more than 10-15 ml of blood at a time. The criterion for the effectiveness of puncture is the improvement of the condition of the newborn, compensation of the neurological deficit, and decrease in the tension of the large fontanelle.

Craniotomy indicated if the hematoma is predominantly represented by clots.

Staged puncture removal of subdural hematomas is indicated in cases of severe condition of the newborn. At the initial stage, no more than 30-40 ml of blood is removed. After stabilization of the condition, repeated puncture is performed to remove the remnants of the hematoma.

Currently puncture removal complemented by the creation of an anastomosis between the subdural and subgaleal space.

Therapy for intraventricular hemorrhage is usually conservative. Surgical treatment, consisting in the implantation of a long-term drainage system, is performed with the development of the so-called post-hemorrhagic hydrocephalus.

Conservative therapy of birth traumatic brain injury provides for compensation of vital disorders (mechanical ventilation in the mode of moderate hyperventilation), decongestant (restriction of the administration of solutions, diacarb, aminophylline, lasix, corticosteroids), hemostatic (g-aminocaproic acid, dicinone), anticonvulsant (sibazon, phenobarbital) and metabolic therapy (trental, curantil , piracetam). In the presence of damage to the scalp, antibiotic therapy is indicated.

Despite the sufficient development of diagnostic and surgical methods in the treatment of birth traumatic brain injury, narrow specialists in this field are often recruited to provide assistance in the phase of gross decompensation, which, of course, reduces survival. In this regard, it is of great importance to provide quality care to this category of patients in maternity hospitals, neonatological centers, as well as at the outpatient and pre-hospital stages. In addition, timely transportation of patients to the hospital is of great importance, where they can be provided with specialized neurosurgical assistance.

Which doctors should you contact if you have head injuries:

Neonatalogue

Are you worried about something? Do you want to know more detailed information about Birth trauma to the head, its causes, symptoms, methods of treatment and prevention, the course of the disease and diet after it? Or do you need an inspection? You can make an appointment with the doctor- clinic Eurolab always at your service! The best doctors will examine you, study the external signs and help identify the disease by symptoms, advise you and provide the necessary assistance and diagnose. you also can call a doctor at home... Clinic Eurolab open for you around the clock.

How to contact the clinic:
The phone number of our clinic in Kiev is (+38 044) 206-20-00 (multichannel). The secretary of the clinic will select a convenient day and hour for you to visit the doctor. Our coordinates and directions are indicated. Look in more detail about all the services of the clinic on her.

(+38 044) 206-20-00

If you have previously performed any research, be sure to take their results for a consultation with your doctor. If the research has not been performed, we will do everything necessary in our clinic or with our colleagues in other clinics.

You? You need to be very careful about your overall health. People don't pay enough attention symptoms of diseases and do not realize that these diseases can be life-threatening. There are many diseases that at first do not manifest themselves in our body, but in the end it turns out that, unfortunately, it is too late to treat them. Each disease has its own specific signs, characteristic external manifestations - the so-called disease symptoms... Identifying symptoms is the first step in diagnosing diseases in general. To do this, you just need to several times a year. be examined by a doctor, in order not only to prevent a terrible disease, but also to maintain a healthy mind in the body and the body as a whole.

If you want to ask a question to the doctor - use the section of the online consultation, perhaps you will find answers to your questions there and read self-care tips... If you are interested in reviews of clinics and doctors, try to find the information you need in the section. Also register on the medical portal Eurolab to keep abreast of the latest news and information updates on the site, which will be automatically sent to your mail.

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Anemia of pregnancy

Autoimmune thyroiditis during pregnancy

Fast and impetuous labor

Management of pregnancy and childbirth in the presence of a scar on the uterus

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Hepatitis D in pregnant women

Hepatitis G in pregnant women

Hepatitis A in pregnant women

Hepatitis B in pregnant women

Hepatitis E in pregnant women

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Group A Streptococcus Infections in Pregnant Women

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