Birth trauma or birth injury refers to physical injury sustained by a newborn during labor and birth. Some birth injuries are avoidable. Small percentage of significant birth injuries are unavoidable despite skilled and competent obstetric care. 

Birth trauma includes any physical injury sustained by a newborn during labor and birth.

• Retinal and subconjunctival hemorrhages result from rupture of capillaries caused by increased pressure during birth. Hemorrhages usually clear within 7 to 10 days and present no further problems.

• Erythema, ecchymoses, petechiae, abrasions, lacerations, or edema of the buttocks and extremities can be present.

• Localized discoloration can appear over the presenting part as a result of forceps- or vacuum-assisted birth.

• Ecchymoses and edema can appear anywhere on the body.

• Petechiae (pinpoint hemorrhagic areas) acquired during birth can extend over the upper trunk and face. They are benign if they disappear within two or three days of birth and no new lesions appear. If this does not occur, petechiae can be indicative of a more serious disorder, such as thrombocytopenic purpura. To differentiate hemorrhagic areas from a skin rash or discolorations, the nurse attempts to blanch the skin by pressing with two fingers, lifting the fingers off the skin, and waiting for the return of blood. Petechiae and ecchymoses will not blanch because extravasated blood remains within the tissues, whereas skin rashes and discolorations will blanch.

• Trauma to the presenting fetal part can occur during labor and birth.

• Accidental lacerations can be inflicted with a scalpel during a cesarean birth. If skin closure is needed, an adhesive substance or strips may be applied. Sutures are rarely needed.

• Caput succedaneum: common edema that crosses cranial suture lines and the midline. It appears on infant scalps shortly after birth. Cephalhematoma: small blood vessels crossing the periosteum of the newborn skull rupture and serosanguinous/bloody fluid collects between the scalp and the periosteum.

• Forceps injury and bruising from the vacuum cup occur at the site of application of the instruments. A forceps injury commonly produces a linear mark across both sides of the face in the shape of the forceps blades. If the skin is broken, then the affected areas should be kept clean to minimize the risk for infection.

• Bruises over the face can be the result of face presentation.

• In a breech presentation, bruising and swelling may be seen over the buttocks or genitalia.

• Skin over the entire head can be ecchymotic and covered with petechiae caused by a tight nuchal cord. If the hemorrhagic areas do not disappear spontaneously in two days or if the infant’s condition changes, the primary health care provider should be notified.

Pathophysiology

Fluctuations in blood glucose levels and episodes of ketoacidosis are believed to cause congenital anomalies. The combination of the increased supply of maternal glucose and other nutrients and increased fetal insulin results in excessive fetal growth. Macrosomia or LGA refers to birthweight greater than 4000 g (8 lbs, 13 oz). LGA is a relative term defined as a birth weight greater than the 90th percentile for gestational age. Hyperinsulinemia accounts for many of the problems experienced by the fetus or newborn.

Congenital Anomalies

Most frequently occurring anomalies occur in the cardiac, renal, musculoskeletal, gastrointestinal (GI), and central nervous systems (CNS). Coarctation of the aorta, transposition of the great vessels, and atrial or ventricular septal defects are the most common cardiac anomalies. Genitourinary system, renal agenesis (failure of the kidney to develop) and obstruction of the urinary tract have been associated with maternal diabetes. Central nervous system (CNS) anomalies include anencephaly, encephalocele, myelomeningocele, and hydrocephalus. The musculoskeletal system can be affected by caudal regression syndrome (sacral agenesis, with weakness or deformities of the lower extremities; malformation and fixation of the hip joints; and shortening or deformity of the femurs). Neonatal small left colon syndrome is a functional intestinal disorder often noted in these infants.

Macrosomia

At birth the typical LGA infant has a round face, a chubby body, and a plethoric or flushed complexion. The infant has enlarged internal organs (hepatosplenomegaly, splanchnomegaly, cardiomegaly) and increased body fat. The placenta and umbilical cord are larger than average. Insulin is considered the primary growth hormone for intrauterine development.

Respiratory Distress Syndrome

Maternal hyperglycemia can affect fetal lung maturity.If the fetus exposed to high levels of maternal glucose, synthesis of surfactant can be delayed because of the high fetal serum levels of insulin and/or glucose.

Hypoglycemia

Hypoglycemia is defined as a blood glucose concentration inadequate to support neurologic, organ, and tissue function. Hypoglycemia most frequently occurs within the first 1 to 6 hours after birth. Signs of hypoglycemia include:

• Jitteriness

• Apnea

• Tachypnea

• Hypotonia

• Decreased activity

• Cyanosis

Hypocalcemia and Hypomagnesemia

Hypocalcemia and hypomagnesemia can occur in infants of mothers with insulin-dependent diabetes, although they are not usually present until 48 to 72 hours after birth.

Cardiomyopathy

All infants of mothers with diabetes need careful observation for cardiomyopathy (disease affecting the structure and function of the heart) because an increased heart size is often found in these infants. Hypertrophic cardiomyopathy is characterized by:

• • Hypercontractile

  • Thickened myocardium

  • Mitral valve is poorly functioning

Hyperbilirubinemia and Polycythemia

Infants of diabetic mothers are at increased risk of developing polycythemia and hyperbilirubinemia.

Nursing Interventions

Nursing care depends on the neonate’s particular problems. Most common problems experienced by infants of diabetic mothers that require intervention:

• Birth trauma

• Perinatal asphyxia

• RDS

• Difficult metabolic transition