Birth Injury FAQ

What is Birth Trauma?

The term ‘Birth trauma’ is used to describe any cuts, fractures, or other injuries sustained by a newborn baby during labor or delivery. Birth trauma is more common in developing nations, but at least 2% of live births in the U.S. are adversely affected by non-congenital physical injuries.

Birth trauma occurs more frequently among larger-than-average babies, particularly when the mother’s pelvic area may be too small to birth the baby without the assistance of hands, forceps, or vacuums to ease their passage through the birth canal. In these situations, neonatal injuries can occur if a doctor uses too much physical force while handling the baby or is not careful with birthing instruments.

Data suggests the most common conditions contributing to birth trauma include:

• Babies heavier than 8 lbs 13 oz
• Babies born prior to the 37th week of pregnancy
• The mother’s pelvis may have the wrong shape or size for a safe delivery
• Difficult labor or delivery (dystocia)
• Prolonged labor
• Abnormal fetal position at birth (baby is in a head-up, buttocks-first, or breech, position)

The most common traumatic injuries include:

• Caput Succedaneum – a condition marked by scalp swelling, typically during or shortly after birth. Caput succedaneum can also be caused by the use of vacuum extraction devices during a protracted delivery.
• Cephalohematoma – an accumulation of blood below the protective membrane that covers an infant’s skull. This condition manifests as lumps on a baby’s head, usually several hours after delivery. The lumps feel soft and may show signs of post-partum growth. Though most do not require medical attention, some may cause jaundice.
• Bruising and Broken Bones – Bruising may occur due to the physical stresses of the passage through the birth canal or the use of forceps during delivery which can on a newborn’s head or face, especially when medical staff use too much force. In addition, vacuum extraction may cause lacerations or bruising on a baby’s scalp. Broken bones can occur with improper use of birth-assisting tools or when an infant is tugged too forcefully. In extremely rare instances, a physician or someone on the medical staff may drop a newborn.
• Subconjunctival Hemorrhage – bleeding that occurs when small blood vessels in the baby’s eyes break. This does not cause permanent damage to the eyes and typically clears within a matter of days as the body reabsorbs the blood.
• Bell’s Palsy – occurs when a baby’s facial nerve is damaged during labor or birth usually caused by pressure on the infant’s face during the passage through the birth canal. However, facial paralysis can be caused by large amounts of pressure from forceps during delivery. Bell’s palsy is usually most evident when babies cry and the facial muscles on the damaged side remain dormant while the eye remains open. If the nerve is bruised, treatment will usually be unnecessary and the damage will improve with time. For severe cases, surgery may be necessary.
• Oxygen Deprivation – this type of birth of trauma can occur if the placenta separates prematurely or if the umbilical cord becomes entangled around the baby’s neck and reduces oxygen flow to the brain. This can lead to partial or total blindness or even permanent disabilities like cerebral palsy.
• Fractures – most common birth trauma, usually affecting the collarbone and usually occurring during breech births.

Not all birth traumas are life-threatening; conversely, most heal on their own without serious medical intervention. Many can be avoided when medical professionals are proactive and properly assess birthing situations.

How Can Birth Trauma Affect a Child’s Behavior?

Children living with CP are subject to a multitude of co-factors – some of which are behavioral.  Many of these challenges are not immediately apparent and will not present until the child matures and more complex skills are required and expected of the child. For instance, a child may not experience or exhibit certain organizational or behavioral control issues at the age of five when those skills are not expected, however at the age of 16 it may become apparent that certain skills are indeed hampered.

Children who suffered from birth trauma resulting in cerebral palsy may experience difficulties in the following areas:

• Other profound implications related to behavior or personality in children living with cerebral palsy
• Chronic health conditions are a significant risk factor for the development of an anxiety disorder and the prevalence rate of anxiety disorders among youths with chronic health conditions is higher compared to peers without chronic health conditions.
• Anxiety – Anxiety disorders are thought to be one of the most common psychiatric diagnoses in children and teens.
• Less endurance; tires more quickly, takes longer to understand information, reacts less quickly, and is easily overwhelmed with even small amounts of information
• “Executive Functions” – refers to difficulties relate to planning, organizing and strategizing behaviors
• Relationships with others – may have problems with judgment, problem solving and considering others’ ideas, unable to interpret the actions of others and therefore have great problems in social situations
• Memory difficulties; unable to organize and remember information; may get lost, forget names, miss instructions, and/or have trouble learning new information
• Organization/managing multiple tasks simultaneously/ Does not tolerate daily routine
• Less attention and concentration; trouble paying attention to someone who is talking; changing from one topic to another; trouble staying on task or completing a task
• Impulsiveness
• Changes in Social-Emotional Functions
• Dependent/regressive behaviors
• Mood Swings
• Depression or Anger
• Irritability/aggression
• Dis-inhibition/risk taking behaviors
• Irritability
• Easily frustrated
• Easily upset or angered
• Withdrawn or isolated

How Common Are Birth Defects?

According to data gathered from the Centers for Disease Control, cerebral palsy (CP) is the most common motor disability in childhood with international population-based studies suggesting estimates of CP ranging from 1.5 to more than 4 per 1,000 live births. About 1 in 323 children has been identified with CP according to estimates from (ADDM) Network.

In 2008 (most recent data compiled), the CDC’s Autism and Developmental Disabilities Monitoring (ADDM) CP Network included areas of Alabama, Georgia, Missouri, and Wisconsin. Based on children who were 8 years old and living in these four communities in 2008, the ADDM CP data showed that:

• CP was more common among boys than among girls.
• CP was more common among Black children than White children. Hispanic and White children were about equally likely to have CP.
• Most (77.4%) of the children identified with CP had spastic CP.
• Over half (58.2%) of the children identified with CP could walk independently.
• Many of the children with CP also had at least one co-occurring condition—41% had co-occurring epilepsy and 6.9% had co-occurring ASD.

Walking Ability

According to 2006 data from the ADDM CP Network, Black children with cerebral palsy were 1.7 times more likely to have limited or no walking ability compared with White children. Overall findings included:

• 41% of children with CP were limited in their ability to crawl, walk, run, or play
• 31% needed to use special equipment such as walkers or wheelchairs.
• 58.2% of children with CP could walk independently
• 11.3% walked using a hand-held mobility device
• 30.6% had limited or no walking ability

Evidence of Co-Occurring Developmental Disabilities

• Almost half (41%) of the children identified with CP by the ADDM CP Network had co-occurring epilepsy. Co-occurring epilepsy frequency was highest among children with cerebral palsy who had limited or no walking ability.
• Some (6.9%) of the children identified with CP also had autism spectrum disorder (ASD). Co-occurring ASD frequency was higher among children with non-spastic CP, particularly hypotonic CP.

Non-Spastic CP – a form of CP marked by weakened and unstable muscle tone

Some signs include:

• Sudden, jerky movements
• Variations of muscle tone, ranging from stiff to loose.

Hypotonic CP – marked by extremely loose and floppy muscle tone

Some signs include:

• Rag-doll appearance due to limp muscles
• The head may fall backwards, forward, or to each side involuntarily
• Respiratory problems
• Difficulty maintaining proper posture

Metropolitan Atlanta Developmental Disabilities Surveillance Program (MADDSP) in Atlanta shows for 2008 that:

• Approximately 60% of 8-year-old children with CP had another developmental disability
• More than 40% of children with CP had intellectual disability
• 35% had epilepsy
• Greater than 15% had vision impairment
• Nearly 25% of children with CP had both intellectual disability and epilepsy.

Risk Factors

• Low birth weight
• Premature birth
• Disruption of blood and oxygen supply to the brain
• Infections in the mother
• Being born a twin or other multiple birth
• Being conceived by in vitro fertilization or other assisted reproductive technology
• Having a mother who had an infection during pregnancy
• Having kernicterus (a type of brain damage that can happen when severe newborn jaundice goes untreated)
• Having complications during birth

Early Signs of Cerebral Palsy

From birth to 5 years of age, a child should reach movement goals―also known as milestones―such as rolling over, sitting up, standing, and walking. A delay in reaching these movement milestones could be a sign of CP. The following are some other signs of possible CP.

In a baby 3 to 6 months of age:

• Head falls back when picked up while lying on back
• Seems to overextend back and neck when cradled in someone’s arms
• Legs get stiff and cross or scissor when picked up
• Feels stiff
• Feels floppy

In a baby older than 6 months of age:

• Has difficulty bringing hands to mouth
• Reaches out with only one hand while keeping the other fisted
• Doesn’t roll over in either direction
• Cannot bring hands together

In a baby older than 10 months of age:

• Crawls in a lopsided manner, pushing off with one hand and leg while dragging the opposite hand and leg
• Scoots around on buttocks or hops on knees, but does not crawl on all fours

Can Forceps Delivery Cause Brain Damage?

Forceps and vacuum extractors are medical devices commonly used to assist in the delivery of babies. Properly used these devices can help doctors to safely deliver babies. However they can also lead to mechanical injury trauma to the baby.

How does traumatic brain damage occur?

Doctors use medical devices to assist in the delivery of babies. Two types of devices for this purpose are forceps and the vacuum extractors.

• Forceps – which resemble salad tongs and are used to grip around the head of a baby in order to assist delivery through the birth canal. If the forceps are gripped too tightly, or if there is excessive force or twisting, the baby can experience serious damage.
• Vacuum extractor – a soft plastic cup is attached to the top of the baby’s head while gentle vacuum pressure is applied allowing medical staff to rotate or otherwise adjust the baby to allow for safe delivery.

When proper care is used, these devices are efficient in assisting in the delivery process. However, improper use can result in injury to the baby’s skull, face and brain. Used incorrectly, these devices can severely damage the brain, causing bleeding, and may result in Cerebral Palsy.

Because identification of the effects of CP may take some time, the baby may, at first appear normal. Eventually they may begin to exhibit signs of trauma such as turning blue due to respiratory issues, or exhibiting seizure activity. While Cerebral Palsy is a common result of birth injury, other injuries frequently occur, as well.

Common birth injuries attributed to the use of delivery assistance devices include:

• Erb’s Palsy – A condition that typically damages the nerves that control the muscles in the hand and arm.
• Shoulder Dystocia –In this condition, the baby requires manipulation to permit delivery. The delivering obstetrician might pull too aggressively, causing injury that may result in Cerebral Palsy or other neurologic injury.
• Brachial Plexus Palsy – -An injury results from excessive or improper pressure on the shoulder during delivery, which in turn damages the brachial plexus resulting in nerve sensation and arm movement difficulties.
• Klumpke’s Palsy – A variety of Brachial Plexus Palsy that injures the fingers and wrist, occurring during delivery in association with a shoulder dystocia.

What is Cerebral Palsy?

Cerebral palsy (CP)refers to a group of neurological disorders permanently affects the part of the brain that controls muscle movements thereby impacting body movement, muscle coordination, and balance. These ailments appear in infancy or early childhood. Although detecting may take months of years, the majority of children with cerebral palsy are born with it; early signs appearing before a child reaches the age of 3. In more than 80% of cases, symptoms are apparent within the first month of life. In instances where the infant’s brain is injured by low oxygen levels, there may be signs of this brain injury present at the time of delivery. CP is not progressive or hereditary.

The most common early physical indicators of CP include:

• a lack of muscle coordination when performing voluntary movements (ataxia)
• stiff or tight muscles and exaggerated reflexes (spasticity)
• walking with one foot or leg dragging
• walking on the toes, a crouched gait, or a “scissored” gait
• muscle tone that is either too stiff or too floppy.

Common neurological symptoms include:

• seizures
• hearing loss
• impaired vision
• bladder and bowel control issues
• pain and abnormal sensations

Treatments

Although cerebral palsy can’t be cured, treatment can serve to improve a child’s capabilities. In general, ary diagnosis and treatment will result in a better chance of children being able to overcome developmental challenges and learn new ways to accomplish challenging tasks. Typical treatment regimens include:

• occupational and physical therapy
• speech therapy
• drugs to counteract seizures,  relax spasms, and alleviate pain
• surgery for the correction of anatomical abnormalities
• the use of durable medical equipment such as orthotic devices, wheelchairs, walkers, and communication aids.

Prognosis

Each case of CP is unique and must be treated as such. CP does not always cause profound disabilities and is not known to negatively impact life expectancy. Quality of life can be enhanced using treatments to address individual reactions to the disease and, depending upon the severity of the case, those remedies may require life-long use. Those with severe cerebral palsy may require special medical, educational, and social services. Cerebral palsy can strain financial resources. Resources from the Centers for Disease control estimate average lifetime cost of cerebral palsy-related expenses for one person at $921,000.

What Causes Cerebral Palsy?

There are multiple factors that contribute to cerebral palsy, including lack of oxygen to the baby’s brain during labor and delivery. During labor and delivery, the mother is usually placed on a fetal monitor which monitors and records the baby’s heartbeat. If the baby suffers from a lack of oxygen, then there will be signs of this distress in the baby’s heart tracing as detected by the monitor.

Medical professionals are trained to know the necessary measures to take to relieve the distress. If these measures do not work to correct the lack of oxygen and relieve the distress, then immediate delivery of the baby is necessary to prevent brain injury. If there is a significant delay in recognizing the distress, the prolonged lack of oxygen can result in serious injury to the baby’s brain. This brain injury can later be diagnosed as cerebral palsy. Alternatively, when improperly used, delivery instruments such as forceps and vacuums can result in bleeding into the brain or skull fracture.

Congenital cerebral palsy results from brain injury during a baby’s development in the womb. It is present at birth, although it may not be detected for months. It is responsible approximately 70% of cases identified. An additional 20% are diagnosed with congenital cerebral palsy due to a brain injury during the birthing process. In many cases, the cause of congenital cerebral palsy is unknown.

Possible causes include:

• Infections during pregnancy have been proven to interfere with appropriate development of the fetal nervous system.  Known contributory infections include:
  • Rubella (German measles)
  • Cytomegalovirus (a herpes-type virus)
  • Toxoplasmosis (an infection caused by a parasite that can be carried in cat feces or inadequately cooked meat).
  • Other infections in pregnant women that may go undetected are being recognized now as an important cause of developmental brain damage in the fetus.

• Severe jaundice in the infant. Jaundice is caused by excessive bilirubin in the blood and is identified by a yellowing of the skin. The liver functions to filter out bilirubin, however a newborn’s liver may need several days to accomplish this effectively.  In rare case, severe jaundice can result in damaged brain cells. Other rare cases include Rh incompatibility between mother and infant where the mother’s body produces fetal-blood-cell-destroying antibodies which lead to jaundice and eventual brain damage.
• The physical and metabolic trauma of being born can precipitate brain damage in a fetus whose health has been threatened during development.
• Severe oxygen deprivation to the brain or significant trauma to the head during labor and delivery.

Some risk factors that increase the possibility that a child will later be diagnosed with CP include:

• Receiving a low Apgar score 10 to 20 minutes after delivery. An Apgar test is used to make a basic, immediate determination of a newborn’s physical health. For the test, the infant’s heart rate, breathing, muscle tone, reflexes, and color are evaluated and given a score from 0 (low) to 2 (normal).
• Breech births
• Vascular or respiratory problems in the infant during birth.
• A low birth weight (less than 2,500 grams, or 5 lbs. 7.5 oz.) and premature birth (born less than 37 weeks into pregnancy).
• Physical birth defects such as faulty spinal bone formation, groin hernias, or an abnormally small jaw bone.
• Being a twin or part of a multiple birth.
• A congenital nervous system malformation, such as an abnormally small head (microcephaly).
• Seizures shortly after birth.
• Bacterial meningitis or viral encephalitis
• Mothers who had bleeding or severe proteinuria (excess protein in the urine) late in their pregnancy have a higher chance of having a baby with CP, as do mothers who have hyperthyroidism or hypothyroidism, mental retardation, or seizures.