Birth Injuries in the Newborn
Birth Injuries in the Newborn
Birth injury is structural or functional damage sustained by a baby during labour, delivery or immediate resuscitation. Injury may be minor and self-limiting, or life-threatening. A nurse must recognise the pattern early, stabilise the newborn, prevent secondary harm, document objectively and arrange timely referral.
Predisposing Factors
- Macrosomia, cephalopelvic disproportion, malpresentation, shoulder dystocia and prolonged or obstructed labour.
- Precipitous delivery, difficult assisted vaginal delivery, breech extraction or emergency caesarean birth.
- Prematurity, fragile vessels, congenital bleeding disorder, fetal distress or abnormal fetal lie.
- Inappropriate traction, compression or instrument placement; however, many injuries occur despite correct care and should never be assumed to prove negligence.
Classification
| Group | Examples | Key concern |
|---|---|---|
| Soft tissue/scalp | Bruising, petechiae, caput succedaneum, cephalohaematoma, subgaleal haemorrhage | Occult blood loss and jaundice |
| Skeletal | Clavicle, humerus, femur or skull fracture | Pain, impaired movement, associated nerve injury |
| Peripheral nerve | Brachial plexus palsy, facial nerve palsy, phrenic nerve injury | Weakness, respiratory compromise |
| Central nervous system | Intracranial haemorrhage, spinal cord injury | Seizures, apnoea, shock and disability |
| Visceral | Liver, spleen or adrenal injury | Internal bleeding and shock |
Scalp Injuries: Essential Differences
| Feature | Caput succedaneum | Cephalohaematoma | Subgaleal haemorrhage |
|---|---|---|---|
| Site | Subcutaneous oedema | Blood beneath periosteum | Blood beneath scalp aponeurosis |
| Sutures | Crosses sutures | Does not cross sutures | Diffuse and crosses sutures |
| Feel/onset | Soft, present at birth | Firm/fluctuant, often appears hours later | Boggy, fluctuant, spreading; ears may displace and eyelids swell |
| Course | Resolves in days | Resolves over weeks; jaundice risk | Emergency: massive concealed blood loss and shock |
| Action | Observe; no aspiration | Observe bilirubin and anaemia; never aspirate routinely | Resuscitate, serial head circumference/haematocrit, blood products and urgent neonatal care |
Clinical Assessment
- Airway and breathing: note cry, airway patency, respiratory rate, grunting, recession, asymmetrical chest movement and oxygen saturation.
- Circulation: heart rate, capillary refill, colour, pulses, blood pressure, temperature and signs of blood loss.
- Neurological status: alertness, tone, pupils, fontanelle, seizures, symmetry of facial and limb movement, Moro and grasp reflexes.
- Head-to-toe examination: scalp swelling, bruises, clavicles, ribs, long bones, abdomen and spine. Compare both sides gently.
- History: gestation, birth weight, duration and complications of labour, presentation, instruments, resuscitation, vitamin K and onset/progression of signs.
Specific Injuries and Management
Subgaleal haemorrhage
Torn emissary veins bleed into a large potential space. A newborn can lose a substantial proportion of circulating volume before the swelling appears dramatic.
- Call for urgent neonatal/paediatric help; maintain airway, breathing, warmth and vascular access.
- Measure head circumference frequently, mark the swelling edge, monitor vital signs, perfusion, urine output and consciousness.
- Send full blood count/haematocrit, blood group and cross-match, coagulation profile, glucose and blood gas as available.
- Give isotonic fluid and compatible blood components according to shock severity and local neonatal protocol; treat coagulopathy and hypoglycaemia.
- Do not compress, aspirate or massage the swelling.
Clavicle and long-bone fractures
Clavicle fracture may cause tenderness, swelling, crepitus, reduced arm movement and an asymmetric Moro reflex. Most uncomplicated clavicle fractures heal with gentle handling and analgesia. Support the arm against the chest for comfort; avoid tight binding. Humeral or femoral fracture requires imaging, analgesia and orthopaedic review; assess distal pulses, colour, warmth and movement before and after splinting.
Brachial plexus injury
Erb palsy (C5–C6) produces an adducted, internally rotated arm with extended elbow (“waiter’s tip”), while grasp is usually preserved. Klumpke palsy (C8–T1) primarily affects the hand and may accompany Horner syndrome. Exclude fracture, protect the limb, teach gentle positioning, commence physiotherapy when advised and arrange follow-up. Never pull the affected arm.
Facial and phrenic nerve injury
Facial palsy causes asymmetry during crying and incomplete eye closure. Protect the cornea with prescribed lubrication and assess feeding. Phrenic nerve injury may cause diaphragmatic paralysis, respiratory distress and asymmetric chest/diaphragm movement; provide respiratory support and urgent specialist assessment.
Intracranial and spinal injury
Warning signs include altered consciousness, bulging fontanelle, abnormal tone, apnoea, seizures, unequal pupils, poor feeding, shock or rapid deterioration. Stabilise ABC, correct glucose/electrolyte disturbance, treat seizures per neonatal protocol, avoid hypoxia and hypotension, and obtain neuroimaging/specialist referral. Suspected spinal injury requires neutral alignment and minimal handling.
Visceral injury
Pallor, abdominal distension, a mass, discolouration, falling haematocrit or unexplained shock suggests liver, splenic or adrenal injury. Keep nil by mouth if unstable, obtain urgent imaging and surgical/paediatric review, and prepare blood products.
Investigations
- Full blood count/serial haematocrit, blood group and cross-match, coagulation studies, glucose, electrolytes and blood gas as indicated.
- Bilirubin monitoring after significant bruising or cephalohaematoma.
- Radiograph for suspected fracture; cranial ultrasound, CT or MRI according to stability and specialist advice.
- Ultrasound of abdomen/diaphragm where visceral or phrenic injury is suspected.
Detailed Nursing Care
| Nursing intervention | Rationale |
|---|---|
| Perform structured ABCDE assessment and escalate deterioration immediately. | Prioritises reversible threats and shortens time to resuscitation. |
| Maintain neutral thermal environment; use skin-to-skin only when clinically safe or a warmer/incubator when unstable. | Cold stress increases oxygen and glucose consumption. |
| Record heart rate, respiration, saturation, temperature, perfusion, blood pressure and pain at a frequency matched to severity. | Trends reveal concealed bleeding and neurological decline earlier than isolated readings. |
| Measure and chart head circumference and swelling characteristics in suspected subgaleal bleeding. | Expansion reflects continuing blood loss. |
| Handle gently; support injured limb; avoid pressure, massage or aspiration of scalp collections. | Reduces pain, displacement, infection and further bleeding. |
| Assess feeding safety, suck–swallow coordination and intake; use prescribed alternative feeding if unsafe. | Nerve or neurological injury increases aspiration and hypoglycaemia risk. |
| Administer prescribed analgesia and reassess response using a neonatal pain tool. | Untreated pain destabilises physiology and interferes with feeding and bonding. |
| Observe for jaundice, pallor, seizures, apnoea, reduced movement and abdominal distension. | Detects common complications promptly. |
| Explain findings honestly, involve parents in safe care and avoid blame. | Supports bonding, trust and adherence to follow-up. |
| Document time, site, size, progression, observations, interventions, response and persons informed. | Ensures continuity, clinical accountability and accurate review. |
Complications
- Hypovolaemic shock, anaemia, disseminated intravascular coagulation and death.
- Hyperbilirubinaemia and kernicterus.
- Seizures, cerebral palsy, developmental delay, hearing/visual impairment.
- Contractures or persistent weakness after nerve injury; malunion is uncommon with correct care.
- Feeding problems, parental anxiety and impaired bonding.
Prevention
- Quality antenatal risk assessment and timely referral for macrosomia, malpresentation and pelvic disproportion.
- Skilled monitoring of labour, correct instrument use, appropriate response to obstructed labour and shoulder dystocia.
- Gentle newborn handling, competent resuscitation, vitamin K prophylaxis and systematic post-birth examination.
- Early review of all infants after difficult or assisted delivery, even when initially well.
Discharge Teaching and Follow-up
Teach caregivers to return urgently for poor feeding, repeated vomiting, increasing sleepiness, fever or coldness, jaundice spreading to palms/soles, seizures, breathing difficulty, worsening swelling, pallor or reduced limb movement. Arrange bilirubin, neurological, orthopaedic, physiotherapy, eye or developmental follow-up as indicated.
Revision Questions
- Differentiate caput succedaneum, cephalohaematoma and subgaleal haemorrhage.
- Describe the emergency management of a newborn with suspected subgaleal haemorrhage.
- Outline assessment and nursing care for brachial plexus injury.
- State five complications and five preventive measures for birth injury.
References
- WHO: Managing Newborn Problems
- WHO: Early Essential Newborn Care
- Use Uganda Ministry of Health neonatal and referral protocols and the current facility formulary.
Educational note: doses, investigations and referral pathways must follow the infant’s weight, clinical condition and current local neonatal protocol.