The term "birth trauma" combines violations of the integrity (and hence the dysfunction) of the tissues and organs of the child that occurred during childbirth. Perinatal hypoxia and during childbirth often accompany birth injuries, but can also be one of the pathogenetic links in their occurrence.

The frequency of birth injuries has not been established, because it significantly depends on diagnostic approaches and examination capabilities, as well as on the art and skill of obstetricians, the frequency of caesarean sections, etc. However, birth trauma as a cause of death is currently extremely rare and, according to M.E. Wegmag (1994), is 3.7 per 100,000 live births.

Etiology

Birth injury- a much broader concept than obstetric trauma; obstetric benefits in childbirth - one of the causes of birth trauma. The traumatic nature of obstetric benefits is determined not only by the skills of the obstetrician, but also by how the fetus enters labor. Prolonged intrauterine hypoxia, severe intranatal increase the likelihood of birth trauma even in the normal course of childbirth.

Predisposing factors for the development of birth trauma are:

Breech and other abnormal presentations;

Macrosomia, large size of the fetal head;

Prolonged and excessively fast (rapid) childbirth;

Deep prematurity;

Oligohydroamnion;

Anomalies in the development of the fetus;

Size reduction (infantilism, consequences, etc.) and increased rigidity of the birth canal (elderly primiparous, excess vitamin D during pregnancy);

Obstetric aids - turns on the leg, the imposition of abdominal or output obstetric forceps, vacuum extractor, etc.

Examples of purely obstetric injuries are fractures of the skull, limbs, and clavicles.

Clinical picture

Soft tissue injuries. Petechiae and ecchymosis, abrasions in various parts of the body are the most common manifestation of birth injuries. They can be at the site of the presenting part of the fetus during childbirth, applying forceps or electrodes during intrauterine monitoring, taking blood from the fetal head. Birth trauma can occur as a result of resuscitation, gripping the obstetrician's hand during intrauterine benefits. Small abrasions and cuts require only local antiseptic measures - treatment with alcohol solutions of aniline dyes, dressing, etc. Petechiae and ecchymosis resolve on their own within a few days - 1 week of life.

Adiponecrosis is possible at the site of compression by the hand of an obstetrician or neonatologist.

Injuries and hemorrhages in the sternocleidomastoid muscle occur when forceps are applied, manual aids, especially during childbirth in the breech presentation. A muscle tear usually occurs in the lower third (sternal). In the area of ​​damage and hematoma, a small, moderately dense or doughy consistency tumor is palpable. Sometimes for the first time it is diagnosed by the middle - the end of the first week of life, when torticollis develops - the child's head is tilted towards the damaged muscle, and the chin is turned in the opposite direction. Often, hemorrhage into the muscle is combined with a spinal injury.

It is necessary to differentiate the hematoma of the sternocleidomastoid muscle with congenital muscular torticollis, the pathogenesis of which is not clear. In some cases, fibrous degeneration of the muscle before delivery is associated with an anomaly in the position of the fetus, a small amount amniotic fluid and pressure on the muscle of the bone part of the mother's pelvis, and sometimes is a manifestation of multiple lesions of the musculoskeletal system (spine, skull bones, etc.), probably of hereditary origin.

The diagnosis is made on the basis of the detection of the above position of the head, asymmetry of the face and a shortened dense sternocleidomastoid muscle, smaller auricles on the side of the lesion. With a bilateral process, the head is tilted forward, the cervical lordosis is increased, and the mobility of the spine in the cervical region is limited.

Treatment consists in creating a corrective position of the head (rollers that help eliminate the pathological tilt of the head and turning the face), the use of dry heat, physiotherapy (electrophoresis with potassium iodide), and a little later - massage. In case of inefficiency, surgical correction is required, which is carried out in the first half of life.

birth tumor

Swelling of the soft tissues of the head during cephalic presentation or at the site of the application of a vacuum extractor; it is often cyanotic, with many petechiae or ecchymosis, and may be the cause of hyperbilirubinemia. It does not require treatment, it passes on its own in 1-3 days; differentiate with cephalohematoma (see below), hemorrhage under the aponeurosis.

Hemorrhage under the aponeurosis

It is manifested by test-like swelling, swelling of the parietal and occipital parts of the head. Unlike cephalohematoma, swelling is not limited to one bone, but from a birth tumor, it can increase in intensity after birth. Risk factors are: vacuum extractor and other obstetric aids in childbirth. It is often the cause of posthemorrhagic anemia in the first days of life, because it can contain up to 260 ml of blood (Plauche W.C., 1980), and then hyperbilirubinemia. Possible infection. With large hemorrhages, it is necessary to exclude hereditary hemorrhagic diseases. An x-ray of the skull is needed to rule out fractures. Often combined with signs of intracranial birth trauma. According to W.C. Plauche (1980), mortality reaches 25%. The hemorrhage is resorbed in 2-3 weeks.

cephalohematoma

External cephalohematoma- hemorrhage under the periosteum of any bone of the cranial vault; may appear clearly only a few hours after childbirth (more often in the region of one or both parietal and less often in the region of the occipital bone); observed in 0.4-2.5% of newborns (Mangurten N. N., 2002).

The tumor initially has an elastic consistency, never passes to the adjacent bone, does not pulsate, is painless, with careful palpation, fluctuation is detected and, as it were, a roller along the periphery. The surface of the skin over the cephalohematoma is not changed, although sometimes there are petechiae. In the first days of life, cephalohematoma may increase, often due to increased extravascular production of bilirubin. At the 2-3rd week of life, the size of the cephalohematoma decreases, and complete resorption occurs by the 6-8th week. In some cases, calcification is possible, rarely - suppuration.

Cause of subperiosteal hemorrhage- detachment of the periosteum during movements of the head at the time of its eruption, less often - cracks in the skull (5-25%).

As a result, all children with large cephalohematomas (diameter greater than 6 cm) should have a skull x-ray to rule out a crack.

Very rarely, cephalohematoma is the first manifestation of hereditary coagulopathy. In preterm infants, cephalohematoma may be associated with generalized intrauterine mycoplasma.

Differential diagnosis is carried out with a birth tumor (passes through the sutures, disappears after 2-3 days), hemorrhage under the aponeurosis (flat, doughy consistency, passes over the sutures, fluctuates), cerebral hernias (protrusion of the meninges and brain substance through the fontanel and bone defects; pulsate, reflecting respiratory movements, located more often in the forehead; a bone defect is visible on the x-ray of the skull).

Treatment

For the first 3-4 days of life, feed expressed breast milk from a bottle, and then, if the condition is stable, attach the baby to the breast. Vitamin K (if not introduced at birth) once intramuscularly. Despite the fact that sometimes cephalohematomas become infected, calcified, and after resorption of large (more than 8 cm in diameter) hemorrhages, the underlying bone plate may sharply become thinner or bone cystic outgrowths form, neonatologists for many years refused any surgical intervention. Currently, tactics are changing somewhat: it is customary to puncture cephalohematomas larger than 6-8 cm in diameter at the end of the first week of life. Linear cracks in the skull do not require any specific treatment.

Paralysis of the facial nerve

Occurs when the peripheral part of the nerve and its branches are damaged by the imposed output obstetric forceps. It is characterized by the drooping and immobility of the corner of the mouth, its swelling, the absence of the nasolabial fold, the superciliary reflex, the loose closure of the eyelids on the side of the lesion, the asymmetry of the mouth when crying, and lacrimation. Differentiate with Mobius syndrome (absence of the nerve nucleus), intracranial hemorrhages. Treatment is carried out in consultation with a neurologist.

Birth injury of the spinal cord and brachial plexus.

There are two approaches to the interpretation of "obstetric paralysis of the shoulder" and "congenital paralysis of the shoulder", described for the first time in the 19th century. Erb and Duchenne and named after the original writers: a consequence of a brachial plexus injury and a consequence of a spinal cord injury. In Russia, among neonatologists, the point of view of Alexander Yuryevich Ratner and his school is more popular: in most cases, Duchenne-Erb palsy is caused by lesions of the spine and spinal cord. Foreign experts and a number of Russian neurologists consider this pathology to be the result of a lesion of the brachial plexus.

According to A.Yu.Ratner and his school, spinal injury develops 2-3 times more often than intracranial. In 40-85% of dead newborns, special studies reveal spinal cord injury, but only in 20% of cases it is regarded as the cause of death. With a thorough neurological examination, A.Yu. Ratner and his staff diagnose the so-called obstetric paralysis of the hands in 2-2.5% of newborns. At the same time, congenital paralysis of the hands is diagnosed much less frequently abroad: for example, in England and Ireland - 0.42 per 1000 live births (Evans-Jones G. et al., 2003), and in no country in the world, according to these authors , does not exceed 2.0 per 1000. Whether this is due to more advanced obstetric tactics and a higher frequency of caesarean sections abroad or with overdiagnosis is not clear in our country. It seems to us that the point of view of A.Yu.

Etiology

The cause of spinal cord lesions is a forced increase in the distance between the shoulders and the base of the skull, which is observed when pulling the head with fixed shoulders and pulling the shoulders with a fixed head (with breech presentation), excessive rotation (with face presentation in 25%). At the time of delivery, these children often used forceps, a vacuum extractor, and various manual aids.

Pathogenesis

Various factors may be relevant:

1. Defects of the spine: subluxation in the joints of the I and II cervical vertebrae, blocking of the atlanto-axial and intervertebral joints by a capsule strangulated in them, displacement of the vertebral bodies (dislocation of the I-II vertebrae), fracture of the cervical vertebrae and their transverse process, anomalies in the development of the vertebrae (nonfusion arches, underdevelopment of the arch of the I cervical vertebra, its absence in the back).

2. Hemorrhages in the spinal cord and its membranes, epidural tissue due to vascular tears or increased permeability.

3. Ischemia in the basin of the vertebral arteries due to stenosis, spasm or occlusion, compression of the Adamkevich artery, spinal cord edema.

4. Damage to the intervertebral discs.

In the mechanism of traumatic injury of the spinal cord, according to A.Yu. Vascular disorders occur with a sharp flexion, traction or torsion of the cervical spine of the fetus during childbirth. At birth in breech presentation the greatest load falls not only on the cervical, but also on the thoracic and lumbar sections of the spinal cord. Traction behind the body of a newborn with a fixed head can lead to spinal stretch up to 4-5 cm, and the spinal cord - up to 0.5-0.6 cm, so spinal injury is less common than spinal cord injury.

N.G. Palenova and A. Yu. Ratner note that in severe intrauterine hypoxia, there is a lesion of the motor neurons of the anterior internal group of cells of the anterior horn, i.e. spinal cord injuries can develop antenatal, resulting in childbirth.

The pathogenesis of damage to the cervical roots and brachial plexus is still actively discussed. Along with mechanical factors (tension of the nerve trunks, pressure from the clavicle or rotated shoulder) during obstetric manipulations, prolapse of the handles, they indicate the possible role of intrauterine changes in the brachial plexus, disorders of the segmental circulation of the spinal cord, including spinal injuries.

The clinical picture depends on the location and type of damage. In the presence of an injury to the cervical spine, as a rule, there is a pain symptom (changes in the position of the child, taking him in his arms, and especially the study of Robinson's symptom cause sharp crying). In addition, there may be fixed torticollis, a shortened or elongated neck, tension in the cervico-occipital muscles, bruising and hardening of the soft tissues of the neck, lack of sweat, and dry skin over the lesion.

If the upper cervical segments (Q-Cy) are damaged, a picture of spinal shock is observed: lethargy, adynamia, diffuse muscle hypotension, a tendency to hypothermia, arterial hypotension, hypo- or areflexia; tendon and pain reflexes are sharply reduced or absent; complete paralysis of voluntary movements distal to the site of injury or spastic tetraparesis. From the moment of birth, a syndrome of respiratory disorders has been noted (breathing is difficult, tachypnea or respiratory arrhythmia, intercostal spaces are smoothed or sunken, the stomach is swollen). Typical is the increase in respiratory disorders with a change in the position of the patient, up to (Kucherov A.P., 1993).

Urinary retention (neurogenic bladder) or intermittent urinary incontinence is characteristic. When examining a child, you can find a “frog pose”. Often the head is turned to one side (often spastic torticollis is found on the same side). Focal symptoms of damage to the III, VI, VII, IX, X pairs of cranial nerves and the vestibular portion of the VIII pair can also be detected. The combination of symptoms of damage to the brain stem, dysfunction of the pelvic organs and movement disorders of the myotonic type indicates ischemia in the vertebrobasilar basin. The cause of death of newborns are respiratory disorders and bouts of asphyxia after birth, shock.

Paresis of the diaphragm (Cofferat's syndrome) develops with an injury to the brachial plexus (n. frenicus), the spinal cord at the level of C-C^. It can be isolated or in 75% of children combined with upper paresis or total paralysis of the arm. Damage to the phrenic nerve is more common in left-sided Duchenne-Erb paresis.

The leading symptom in the clinic of paresis of the diaphragm is a syndrome of respiratory disorders: shortness of breath, aggravated by a change in position, arrhythmic breathing, bouts of cyanosis. When examining a newborn, asymmetry of the chest is revealed, a lag in the act of breathing of the affected half, paradoxical breathing (retraction of the abdominal wall on inspiration and its protrusion on expiration); during auscultation on the side of the paresis, weakened breathing and often crepitant wheezing are heard. In patients with paresis of the diaphragm, due to a decrease in pressure in the pleural cavity and insufficient ventilation, it may develop, a feature of which is an extremely severe and protracted course. Possible swelling in the neck on the side of the paresis (venous outflow is difficult). The X-ray picture is characteristic: on the side of the lesion, the dome of the diaphragm is high, deep rib-diaphragmatic sinuses, and on the healthy side, the dome of the diaphragm is somewhat flattened due to compensatory emphysema. There may be a shift of the mediastinal organs in the opposite direction, which is often accompanied by signs of heart failure (tachycardia, deep

host of heart sounds, systolic murmur, liver enlargement). Sometimes paresis of the diaphragm does not give a clear clinical picture, but is detected only radiographically and, conversely, mild forms of paresis of the diaphragm can be X-ray negative. Cofferat's syndrome is detected immediately after the birth of a child or when his condition worsens. With mild forms of paresis of the diaphragm, spontaneous recovery is possible. In severe paresis, in most cases, diaphragm function is fully or partially restored within 6-8 weeks. The prognosis worsens when paralysis of the diaphragm is combined with total paralysis of the upper limb.

Paresis and paralysis of Duchenne-Erb

develop with damage to the spinal cord at the level of GACyi or the brachial plexus. The clinical picture of Duchenne-Erb palsy is quite typical: the affected limb is brought to the body, extended at the elbow joint, turned inward, rotated at the shoulder joint, pronated in the forearm, the hand is in palmar flexion and turned back and outward. The head is often tilted and turned. The neck seems short, with a large number of transverse folds, sometimes with stubborn wetting. The rotation of the head is due to the presence of spastic or traumatic torticollis. Muscle tone is reduced in the proximal sections, as a result of which it is difficult to abduct the shoulder, turn it outward, raise it to a horizontal level, flex at the elbow joint and supinate the forearm.

When the child is placed face down in the palm of the hand, the paretic limb hangs down, and the healthy arm is separated from the body by a deep longitudinal fold (a symptom of Novik's "doll's hand"), in the armpit there is sometimes an abundance of folds in the form of an island ("axillary island") and a skin constriction in the proximal department of the paretic shoulder (in the presence of it, it is necessary to exclude a fracture of the shoulder). Passive movements in the paretic limb are painless (!), Moro, Babkin and grasping reflexes are reduced, there is no tendon reflex of the biceps muscle. With passive movements of the paretic arm in the shoulder joint, a “clicking” symptom (Fink’s symptom) can be detected, subluxation or dislocation of the head of the humerus is possible due to a decrease in the tone of the muscles that fix the shoulder joint (confirmed radiologically). Pathological positioning of the shoulder and forearm leads to the formation of intrarotatory contracture of the shoulder and pronator contracture of the forearm (Volkmann's contracture). In severe lesions of Su and Cvi, pyramidal tracts may be involved in the process, which causes the appearance of a symptom of pyramidal insufficiency in the leg on the side of the lesion (increased knee and Achilles reflexes, less often an increase in muscle tone in the adductor muscles of the thigh). Proximal Duchenne-Erb palsy often occurs on the right, may be bilateral, combined with damage to the phrenic nerve and cerebral symptoms. Often a positive symptom of tension of the nerve trunks.

Lower distal paralysis of Dejerine-Klumpke occurs with spinal cord injury at the level of Suc-T | or middle and lower bundles of the brachial plexus. There is a gross violation of the function of the hand in the distal section: the function of the flexors of the hand and fingers, the interosseous and vermiform muscles of the hand, thenar and hypothenar muscles is sharply reduced or absent. Muscle tone in the distal parts of the arm is reduced, there are no movements in the elbow joint

Tave, the hand has the shape of a "seal's foot" (if the lesion of the radial nerve predominates) or a "clawed foot" (with a predominant lesion of the ulnar nerve). On examination, the hand is pale, with a cyanotic tinge (symptom of "ischemic glove"), cold to the touch, the muscles atrophy, the hand flattens. The movements in the shoulder joint are preserved, the Moro reflex is reduced, the Babkin reflexes and grasping reflexes are absent. Damage to the cervical sympathetic fibers is characterized by the appearance of the Bernard-Horner syndrome (ptosis, miosis, enophthalmos) on the affected side.

Total paralysis of the upper limb (Kerer's palsy)

observed when Su-T is damaged | segments of the spinal cord or brachial plexus, often unilateral. It is clinically characterized by the absence of active movements, severe muscle hypotension (may be a “scarf” symptom), the absence of congenital and tendon reflexes, and trophic disorders. As a rule, Bernard-Horner syndrome is noted.

Duchenne-Erb palsy and Kehrer's palsy if they are combined with a violation of the integrity of the spine (dislocation, fracture, etc.), they can be complicated Unterharnscheidt's syndrome: with a sharp turn of the head, a spasm of the vertebral artery occurs, ischemia of the reticular formation develops, a clinic of spinal shock occurs, which can cause death; in milder cases, there is diffuse muscular hypotension, acrocyanosis, coldness of the hands, feet, paresis of the upper extremities, bulbar disorders. When the condition improves, neurological symptoms regress.

Thoracic spinal cord injury (Tj-T/n) clinically manifested by respiratory disorders as a result of dysfunction of the respiratory muscles of the chest: the intercostal spaces sink at the moment when the diaphragm inhales. Involvement of the spinal cord segments at the T3-T6 level is clinically manifested by spastic lower paraparesis.

Injury to the lower thoracic segments of the spinal cord is manifested by the symptom of a "flattened abdomen" due to weakness of the muscles of the abdominal wall. The cry in such children is weak, but with pressure on the abdominal wall it becomes louder.

Spinal cord injury in the lumbosacral region is manifested by lower flaccid paraparesis while maintaining normal motor activity upper limbs. Muscle tone lower extremities reduced, active movements are sharply limited or absent. On examination: the lower limbs are in the “frog position”, when the child is placed in a vertical position, his legs hang down like whips, there are no support reflexes, automatic gait and Bauer reflexes, knee and Achilles reflexes are depressed, a symptom of “puppet leg” is observed. As a result of a violation of the synergism of individual muscle groups in children, paralytic clubfoot occurs, in which, unlike congenital, one can passively bring the foot into the correct position. Often, subluxations and dislocations of the hips are formed for the second time. When the sacral segments are involved in the process, the anal reflex disappears, gaping of the anus, urinary incontinence (urination in frequent drops outside the act of urination) and feces can be observed. In the subsequent progress

trophic disorders are caused: gluteal muscles (“punctured ball” symptom), smoothness of the folds on the thighs, atrophy of the muscles of the lower extremities, development of contractures in the ankle joints.

Local symptoms in injuries of the thoracic and lumbar spine: tension of the paravertebral muscle ridges, deformities like kyphosis or kyphoscoliosis, protrusion of the "spinous process" of the damaged vertebra, ecchymosis over the site of the lesion.

The most severe type of natal spinal cord injury is a partial or complete rupture of the spinal cord (mainly in the cervical and upper thoracic regions). Characteristic signs are flaccid paresis (paralysis) at the level of the lesion and spastic paralysis below the level of the lesion, dysfunction of the pelvic organs (involuntary urination and defecation or constipation) with the addition of a urinary tract infection. With an injury with a rupture of the spinal cord in the first hours and days of life, neurological symptoms may be the same as with hemorrhages, cerebral edema, shock, and the child may die within a few hours even before the appearance of "spinal" neurological symptoms.

Diagnosis and differential diagnosis

The diagnosis of natal spinal cord injury is based on a thorough history and typical clinical presentation. To confirm the diagnosis, an X-ray of the spine is necessary (identification of traumatic injuries), X-ray of the chest (for the diagnosis of paralysis of the diaphragm).

X-ray of the spine is carried out in two projections. To detect subluxation of the atlas, a direct x-ray is taken with the child's head slightly thrown back (by 20-25 °), and the x-ray beam is centered on the region of the upper lip.

Craniography and examination by an ophthalmologist are indicated for suspected combined trauma of the brain and spinal cord, especially in case of damage to the upper cervical segments.

Electromyography reveals preganglionic (presence of denervation potentials) and postganglionic (electromyogram without pathology) disorders in paralysis.

It should be remembered that with flaccid paresis of spinal origin, unlike central paralysis, there are no tendon reflexes and there are trophic disorders.

Differential diagnosis of paralysis of the upper limbs should be carried out with:

Fracture of the collarbone;

epiphysiolysis;

Osteomyelitis of the shoulder (in this case, there is swelling of the joint, crepitus, pain during passive movements in the area of ​​the shoulder joint; X-ray examination is necessary, in which by the 7-10th day of life an expansion of the joint space is detected, and subsequently - bone changes; in addition, there are symptoms, in the blood - neutrophilic leukocytosis with a shift to the left; sometimes a joint puncture is performed for diagnostic purposes);

Congenital hemihypoplasia (there is a craniofacial asymmetry with underdevelopment of half of the body and the same limbs).

In addition, traumatic injuries of the spinal cord must be differentiated from malformations of the spinal cord (lack of positive dynamics against the background of complex treatment); Marines-cou-Segren's syndrome (neurosonography or computed tomography is indicated to detect cerebellar atrophy and examination by an ophthalmologist in dynamics to detect cataracts); with congenital myopathies (minimal positive dynamics during treatment, electromyography and histological examination of biopsied muscles are decisive in the diagnosis); arthrogryposis, infantile myofibromatosis.

Treatment

If a birth injury of the spinal column and spinal cord is suspected, the first measure is the immobilization of the head and neck. This can be done with a cotton-gauze collar of the Shants type, and with an objective detection of fractures of the cervical vertebrae, subluxations and dislocations, by traction with a mask with a load of 150-330 g until the pain syndrome disappears (Fig. 10.2). The simple and effective method immobilization, proposed by O.M. Yukhnova et al. (1988), using an annular cotton-gauze bandage of the pelota type: measure the circumference of the child's head with a centimeter tape, make an annular cotton-gauze bandage (Fig. 10.3) so that its inner diameter is 2-3 cm less than the circumference of the head child. The head of the child is placed in this bandage, the neck is given a functionally advantageous position and the child is swaddled along with the bandage. This procedure is optimally done already in the delivery room. The term of immobilization is 10-14 days. Immobilization is also possible with the help of a vacuum mattress.

In order to relieve the pain syndrome, 0.1 mg / kg is prescribed 2-3 times a day, and with severe pain- fentanyl 2-10 mcg/kg every 2-3 hours, morphine or promedol at the same dose as (0.1 mg/kg, although this can be increased to 0.2 mg/kg).

Vikasol is administered intramuscularly (if vitamin K was not administered at birth).

Gentle care is important, careful swaddling with the obligatory support of the head and neck of the child by the mother or nurse; feeding - from a bottle or through a probe until the pain syndrome is relieved and the child's condition stabilizes.

In the subacute period, treatment is prescribed aimed at normalizing the function of the central nervous system (nootropil,), improving trophic processes in muscle tissue (ATP, vitamins Bb Bl and from the end of the 2nd week - vitamin B)