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Injury at birth


Birth Injuries in Newborns - Children's Health Issues

By

Arcangela Lattari Balest

, MD, University of Pittsburgh, School of Medicine

Full review/revision Oct 2022

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Birth injury is damage that occurs as a result of physical pressure during the birthing process, usually during transit through the birth canal.

  • Many newborns have minor injuries during birth.

  • Infrequently, nerves are damaged or bones are broken.

  • Most injuries resolve without treatment.

A difficult delivery, with the risk of injury to the baby, may occur with extremely large fetuses. Doctors recommend cesarean delivery Cesarean Delivery Cesarean delivery is surgical delivery of a baby by incision through a woman’s abdomen and uterus. In the United States, up to 30% of deliveries are cesarean. Doctors use a cesarean delivery... read more (C-section) when they estimate the baby weighs more than 11 pounds (more than 10 pounds when the mother has diabetes). Injury is also more likely when the fetus is lying in an abnormal position in the uterus before birth ( see Figure: Position and Presentation of the Fetus Position and Presentation of the Fetus ).

Birth injuries are most commonly due to the natural forces of labor and delivery. In the past, when risks of cesarean delivery were high, doctors did difficult deliveries by pulling the fetus out using forceps Operative Vaginal Delivery Operative vaginal delivery is delivery using a vacuum extractor or forceps. A vacuum extractor consists of a small cup made of a rubberlike material that is connected to a vacuum. It is inserted... read more (a surgical instrument with rounded edges that fit around the fetus's head). However, bringing the fetus down from high in the birth canal with forceps had a high risk of causing birth injury. Today, forceps are used only in the final stages of delivery and rarely cause injury. Overall, the rate of birth injuries is much lower now than in previous decades because of improved prenatal assessment with ultrasonography Overview of General Problems in Newborns Problems in newborns may develop Before birth while the fetus is growing During labor and delivery After birth About 9% of newborns need special care after birth due to prematurity, problems... read more , the limited use of forceps, and because doctors often do cesarean delivery if they foresee an increased risk of birth injury.

(See also Overview of General Problems in Newborns Overview of General Problems in Newborns Problems in newborns may develop Before birth while the fetus is growing During labor and delivery After birth About 9% of newborns need special care after birth due to prematurity, problems... read more .)

Position and Presentation of the Fetus

Toward the end of pregnancy, the fetus moves into position for delivery. Normally, the position of a fetus is facing rearward (toward the woman’s back) with the face and body angled to one side and the neck flexed, and presentation is head first.

An abnormal position is facing forward, and abnormal presentations include face, brow, breech, and shoulder.

Did You Know...

Head injury is the most common birth-related injury.

Head molding is not an injury. Molding refers to the normal change in shape of the baby's head that results from pressure on the head during delivery. In most births, the head is the first part to enter the birth canal. Because a fetus's skull bones are not rigidly fixed in position, the head elongates as it is pushed through the birth canal, which allows the fetus to pass through more easily. Molding does not affect the brain and does not cause problems or require treatment. The head shape gradually becomes more rounded over several days.

Swelling and bruising of the scalp is common but not serious and generally resolves within a few days.

Scalp scratches can occur when instruments (such as monitor leads attached to the scalp, forceps, or vacuum extractors Operative Vaginal Delivery Operative vaginal delivery is delivery using a vacuum extractor or forceps. A vacuum extractor consists of a small cup made of a rubberlike material that is connected to a vacuum. It is inserted... read more ) are used during a vaginal delivery.

Bleeding outside of the skull bones can lead to an accumulation of blood either above or below the thick fibrous covering (periosteum) of one of the skull bones.

A cephalhematoma is blood accumulation below the periosteum. Cephalohematomas feel soft and can increase in size after birth. Cephalohematomas disappear on their own over weeks to months and almost never require any treatment. However, they should be evaluated by the pediatrician if they become red or start to drain liquid. Sometimes some of the blood calcifies and leaves a hard lump in the scalp. The lump is not dangerous, is usually hidden by hair, and requires no treatment.

A subgaleal hemorrhage is bleeding directly under the scalp above the periosteum covering the skull bones. Blood in this area can spread and is not confined to one area like a cephalohematoma. It can cause significant blood loss and shock Shock Shock is a life-threatening condition in which blood flow to the organs is low, decreasing delivery of oxygen and thus causing organ damage and sometimes death. Blood pressure is usually low... read more , which may even require a blood transfusion Overview of Blood Transfusion A blood transfusion is the transfer of blood or a blood component from one healthy person (a donor) to a sick person (a recipient). Transfusions are given to increase the blood's ability to... read more . A subgaleal hemorrhage may result from the use of forceps or a vacuum extractor, or may result from a blood clotting problem Overview of Blood Clotting Disorders Blood clotting (coagulation) disorders are dysfunctions in the body's ability to control the formation of blood clots. These dysfunctions may result in Too little clotting, leading to abnormal... read more .

Fracture of one of the bones of the skull may occur before or during the birth process. Unless the skull fracture forms an indentation (depressed fracture), it generally heals rapidly without treatment.

Did You Know...

Bleeding in and around the brain (intracranial hemorrhage) is caused by the rupture of blood vessels and may be caused by

Prematurity Preterm (Premature) Newborns A preterm newborn is a baby delivered before 37 weeks of gestation. Depending on when they are born, preterm newborns have underdeveloped organs, which may not be ready to function outside of... read more increases the risk of intracranial hemorrhage.

Sometimes, intracranial hemorrhage occurs after a normal delivery in an otherwise well newborn. The cause of bleeding in these cases is unknown.

Bleeding in the brain is much more common among very preterm infants. Newborns who have bleeding disorders (such as hemophilia Hemophilia Hemophilia is a hereditary bleeding disorder caused by a deficiency in one of two blood clotting factors: factor VIII or factor IX. Several different gene abnormalities can cause the disorder... read more ) are also at increased risk of bleeding in the brain.

Most infants with bleeding do not have symptoms, whereas others can be sluggish (lethargic), feed poorly, and/or have seizures.

Bleeding can occur in several places in and around the brain:

  • Subarachnoid hemorrhage is bleeding below the innermost of the two membranes that cover the brain. This is the most common type of intracranial hemorrhage in newborns, usually occurring in full-term newborns. Newborns with a subarachnoid hemorrhage may occasionally have apnea (periods when they stop breathing), seizures Seizures in Children Seizures are a periodic disturbance of the brain’s electrical activity, resulting in some degree of temporary brain dysfunction. When older infants or young children have seizures, they often... read more , or lethargy during the first 2 to 3 days of life but usually ultimately do well.

  • Subdural hemorrhage is bleeding between the outer and the inner layers of the brain covering. It is now much less common because of improved childbirth techniques. A subdural hemorrhage can put increased pressure on the surface of the brain. Newborns with a subdural hemorrhage may develop problems such as seizures.

  • Epidural hematoma is bleeding between the outer layer (dura mater) of tissue covering the brain (meninges) and the skull. An epidural hematoma may be caused by a skull fracture. If the hematoma increases the pressure in the brain, the soft spots between skull bones (fontanelles) may bulge. Newborns with an epidural hematoma may have apnea or seizures.

  • Intraventricular hemorrhage is bleeding into the normal fluid-filled spaces (ventricles) in the brain.

  • Intraparenchymal hemorrhage occurs into the brain tissue itself. Intraventricular hemorrhages and intraparenchymal hemorrhages usually occur in very preterm newborns Preterm (Premature) Newborns A preterm newborn is a baby delivered before 37 weeks of gestation. Depending on when they are born, preterm newborns have underdeveloped organs, which may not be ready to function outside of... read more and occur more typically as a result of an underdeveloped brain rather than a birth injury. Most of these hemorrhages do not cause symptoms, but large ones may cause apnea or a bluish gray discoloration to the skin, or the newborn's entire body may suddenly stop functioning normally. Newborns who have large hemorrhages have a poor prognosis, but those with small hemorrhages usually survive and do well.

Newborns who have a hemorrhage may be admitted to a neonatal intensive care unit Neonatal intensive care unit (NICU) Problems in newborns may develop Before birth while the fetus is growing During labor and delivery After birth About 9% of newborns need special care after birth due to prematurity, problems. .. read more (NICU) for imaging tests (such as a CT scan or MRI) and monitoring, supportive care (such as warmth), fluids given by vein (intravenously), and other treatments to maintain body function.

Bleeding Around the Brain

Bleeding may occur in several areas in and around the brain.

Nerve injuries may occur before or during delivery. These injuries usually cause weakness of the muscles controlled by the affected nerve. Nerve injuries may involve the

  • Facial nerve: Lopsided facial expression

  • Brachial plexus: Arm and/or hand weakness

  • Phrenic nerve (rare): Difficulty breathing

  • Spinal cord (rare): Paralysis

Facial nerve injury is evident when the newborn cries and the face appears lopsided (asymmetric). The facial nerve is the nerve injured most often. This injury is caused by pressure against the nerve due to

  • The way the fetus was positioned in the uterus before birth

  • The nerve being pressed against the mother's pelvis during delivery

  • Forceps used to assist the delivery

No treatment of facial nerve injury is needed, and the muscle weakness usually resolves by 2 to 3 months of age. However, sometimes facial nerve weakness is caused by a congenital disorder rather than an injury and does not resolve.

The brachial plexus is a group of large nerves located between the neck and shoulder, leading to each arm. During a difficult delivery, one or both of the baby's arms can be stretched and injure the nerves of the brachial plexus ( see Plexus Disorders Plexus Disorders Plexuses (networks of interwoven nerve fibers from different spinal nerves) may be damaged by injury, tumors, pockets of blood (hematomas), or autoimmune reactions. Pain, weakness, and loss... read more ) and cause weakness or paralysis of part or all of the baby's arm and hand. Weakness of the shoulder and elbow is called Erb palsy, and weakness of the hand and wrist is called Klumpke palsy. About half of the cases of brachial plexus injuries are related to difficult deliveries, typically involving large babies, and about half occur in babies with normal deliveries. Brachial plexus injury is less frequent in babies delivered by cesarean delivery. Extreme movements at the shoulder should be avoided to allow the nerves to heal. Many milder injuries resolve over a few days. If the abnormality is more severe or lasts for more than 1 or 2 weeks, physical therapy or occupational therapy for proper positioning and gentle movement of the arm are recommended. If there is no improvement over 1 or 2 months, doctors typically recommend the baby be evaluated by a pediatric neurologist and/or orthopedist at a pediatric specialty hospital to see whether surgery may be beneficial.

The phrenic nerve, which is the nerve going to the diaphragm (the muscular wall that separates the organs of the chest from those of the abdomen and assists in breathing), is occasionally damaged, resulting in paralysis of the diaphragm on the same side. In this case, the newborn may have difficulty breathing and sometimes requires assistance with breathing. Injury of the phrenic nerve usually resolves completely within a few weeks.

Spinal cord injuries due to overstretching during delivery are extremely rare. These injuries can result in paralysis below the site of the injury. Damage to the spinal cord is often permanent. Some spinal cord injuries that occur high up in the neck are fatal because they prevent the newborn from breathing properly.

Other nerves, such as the radial nerve in the arm, the sciatic nerve in the lower back, or the obturator nerve in the leg, also may be injured during delivery.

Bones may be broken (fractured) before or during delivery even when the delivery is normal.

  • A fracture of the collarbone (clavicle) is relatively common, occurring in 1 to 2% of newborns. Sometimes these fractures are not recognized until several days after birth when a lump of tissue forms around the fracture. Clavicle fractures do not seem to bother newborns and need no treatment. Healing is complete over a few weeks.

  • Fractures of the upper arm bone (humerus) or upper leg bone (femur) sometimes occur. Doctors usually apply a loose splint to limit movement. These fractures may cause pain with movement in the first few days. These fractures usually heal well unless the head of the bone (where growth occurs) is involved.

  • Fractures of multiple bones can occur in newborns with certain genetic conditions in which the bones are very fragile.

The newborn’s skin may have minor injuries after delivery, especially areas that receive pressure during contractions or that first emerge from the birth canal during delivery. Instruments needed for delivery, such as forceps Operative Vaginal Delivery Operative vaginal delivery is delivery using a vacuum extractor or forceps. A vacuum extractor consists of a small cup made of a rubberlike material that is connected to a vacuum. It is inserted... read more , can injure the skin. Swelling and bruising may occur around the eyes and on the face during face-first deliveries and on the genitals after breech deliveries (see Abnormal Presentations Abnormal Presentations Position refers to whether the fetus is facing rearward (toward the woman’s back—that is, face down when the woman lies on her back) or forward (face up). It’s important to check the baby’s... read more ). No treatment for these bruises is needed.

Use of instruments during delivery and stress on the newborn (such as caused by asphyxia) can injure the fat under the skin (called subcutaneous fat necrosis of the newborn). This skin injury can look like red, firm, raised areas on the trunk, arms, thighs, or buttocks. This type of injury usually resolves on its own over weeks to months.

Perinatal asphyxia is a decrease in blood flow to the baby's tissues or a decrease in oxygen in the baby's blood before, during, or just after delivery. Some common causes include the following:

  • Separation of the placenta from the uterus before delivery (placental abruption Placental Abruption Placental abruption is the premature detachment of the placenta from the wall of the uterus, usually after 20 weeks of pregnancy. Women may have abdominal pain and tenderness and vaginal bleeding... read more )

  • Obstruction of umbilical cord blood flow

  • Abnormal development of the fetus (for example, when there is a genetic abnormality)

  • Severe infection in the fetus

  • Exposure to certain drugs or medications before birth

  • Severe maternal hemorrhage

  • Severe maternal illness

Sometimes the exact cause of perinatal asphyxia cannot be identified.

Regardless of the cause, affected newborns appear pale and lifeless at birth. They breathe weakly or not at all and have a very slow heart rate. They need to be revived (resuscitated) after delivery. Resuscitation may include use of a resuscitation bag and mask to push air into the lungs or insertion of a breathing tube in the newborn's throat (endotracheal intubation). If asphyxia resulted from rapid blood loss, the newborn may be in shock Shock Shock is a life-threatening condition in which blood flow to the organs is low, decreasing delivery of oxygen and thus causing organ damage and sometimes death. Blood pressure is usually low... read more . They are immediately given fluids by vein, and sometimes a blood transfusion Overview of Blood Transfusion A blood transfusion is the transfer of blood or a blood component from one healthy person (a donor) to a sick person (a recipient). Transfusions are given to increase the blood's ability to... read more .

Newborns with asphyxia may show signs of injury to one or more organ systems, including the following:

  • Heart: Poor color, low blood pressure

  • Lungs: Difficulty breathing and low oxygen levels

  • Brain: Lethargy, seizures, or even coma

  • Kidneys: Reduced output of urine

  • Liver: Difficulty making proteins that are needed for blood to clot normally

  • Intestines: Difficulty digesting milk

  • Blood forming system: Low platelet count and bleeding

Newborns may need medications to help their heart function and a mechanical ventilator Mechanical Ventilation Mechanical ventilation is use of a machine to aid the movement of air into and out of the lungs. Some people with respiratory failure need a mechanical ventilator (a machine that helps air get... read more to support their breathing. Some newborns who have been revived may benefit from having their body temperature lowered below the normal temperature of 98.6° F (37° C) for 72 hours. Blood cell transfusions and plasma may be necessary to manage problems with the blood forming system. Most of the organs damaged by perinatal asphyxia recover over a week, but brain damage may persist.

Survivors who have minimal injury to the brain may be completely normal. Survivors who have moderate to severe injury to the brain may have permanent signs of damage, ranging from mild learning disorders Learning Disorders Learning disorders involve an inability to acquire, retain, or broadly use specific skills or information, resulting from deficiencies in attention, memory, or reasoning and affecting academic... read more to delayed development to cerebral palsy Cerebral Palsy (CP) Cerebral palsy refers to a group of conditions that involve difficulty moving and muscle stiffness (spasticity). It results from brain malformations that occur before birth as the brain is developing... read more . Some severely asphyxiated infants do not survive.

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Birth injury (to the mother)

Birth injury (to the mother) | Pregnancy Birth and Baby beginning of content

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What is birth injury?

Birth injuries are physical injuries experienced during childbirth, and can affect either the mother or the baby. In newborn babies, a birth injury (often called 'neonatal birth trauma') can include many things, from bruising to a broken bone.

In mothers, birth injuries range from tearing in the vaginal area to damage to the pelvic floor.

Birth injuries in mothers typically fall into 2 main categories:

Injuries to the perineal area

  • Perineal tears and episiotomy — around 3 in 4 women who give birth vaginally experience 'perineal trauma' (a tear or surgical cut to the area between the vagina and anus).
  • Nerve damage — occasionally, nerves in the perineal area can get damaged during childbirth, which can lead to a painful condition called pudendal neuralgia.
  • Haemorrhoids (piles) — these are swollen veins around the anus that you might feel as lumps. While they can be painful or itchy, they are usually not serious.

Injuries to the pelvic floor

  • Muscle damage — the 'pelvic floor' is a group of muscles inside the pelvis that helps hold the uterus, bladder and bowel in place. In up to half of all women who give birth vaginally, there are permanent changes to the pelvic floor due to over-stretching or tearing (avulsion).
  • Pelvic organ prolapse — if the pelvic muscles are damaged or weakened, the organs inside the pelvis can drop down towards the vagina, causing bladder and bowel problems.

While these birth injuries are physical, many mothers can experience emotional or psychological distress — before, during or after the birth. This is known as birth trauma. There are ways to decrease your risk of birth trauma, and both treatment and support are available.

What causes birth injury?

If you suffer a birth injury, the cause was most likely something out of your control.

Some of the main risk factors for birth injury include:

  • the position of the baby, such as in a breech birth
  • having a large baby (over 4kg)
  • having a very quick or very long labour
  • labour complications
  • assisted delivery using forceps or ventouse (vacuum)
  • having a small or unusually shaped pelvis

Can birth injury be prevented?

Although it's often not possible to prevent birth injury, there are some things you can do during pregnancy to reduce your risk:

  • Exercise regularly (make sure you do pregnancy safe exercise).
  • Strengthen your pelvic muscles with daily pelvic floor exercises.
  • Avoid getting constipated or straining on the toilet, as this can weaken your pelvic muscles.
  • Giving birth by caesarean could prevent some birth injuries, but this is major surgery so carries health risks of its own.

How is birth injury treated?

Some birth injuries are minor and may heal on their own — for example, a minor perineal tear or graze. Other injuries need treatment at the time, such as a deeper tear that needs stitches. You may also need some pain relief.

If you had a more serious birth injury, such as a significant tear or damage to the muscles of the pelvic floor, treatment may include physiotherapy and exercises to strengthen your pelvic floor muscles. Some women may need to use pessaries in their vagina or surgery to repair a prolapse.

Sometimes, signs of pelvic floor damage or prolapse are not detected and treated until much later.

If you have had a birth injury, you may be at more risk of it happening again with your next baby. Your doctor will talk to you about whether you should consider a planned caesarean section next time.

If you experience any ongoing symptoms, such as pelvic pain or bladder and bowel problems, you should see your doctor.

Resources and support

  • Talk to your doctor, midwife or obstetrician.
  • You can call Pregnancy, Birth and Baby on 1800 882 436 to speak with a maternal child health nurse (7 days a week, 7am to midnight AET).
  • The Continence Foundation of Australia offers information and support to people with bowel and bladder problems. You can call the helpline on 1800 33 00 66 between 8am and 8pm (AEST), Monday to Friday.
  • Visit the Australasian Birth Trauma Association website for information and support, including peer-to-peer support.
  • Visit the PANDA (Perinatal Anxiety & Depression Australia) website for information and support after a traumatic birth. You can call the PANDA national helpline on 1300 726 306 ((Mon to Fri, 9am to 7. 30pm AEST).

Sources:
Mater Mothers Hospital (Labour and birth - assisted vaginal birth), Medical Hypotheses (The significance of incomplete skull fracture in the birth injury), Stanford Children's Health (Birth injury), Australian Commission on Safety and Quality in Health Care (Neonatal birth trauma), Medscape (Birth trauma), Merck Manual (Birth injuries in newborns), Australian Institute of Health and Welfare (Australia's mothers and babies data visualisations perineal status), PANDA (Childbirth trauma), Cerebral Palsy Alliance Research Foundation (What causes cerebral palsy)

Learn more here about the development and quality assurance of healthdirect content.

Last reviewed: May 2021


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Related pages

  • Birth trauma (emotional)
  • Birth injury (to the baby)
  • When birth doesn't go to plan

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Psychological Trauma - Birth Trauma