Conception - pregnancy - delivery

1st week

(Early) neonatal period :

birth 1st week

late neonatal period :

birth 4th week
 Survive from death
Survive from sequallae
Cause of Death
death proportion (%)

Birth Asphyxia 21.1

Birth Trauma 10.6
Tetanus neonatorum 14.1
Sepsis,meningitis 7.2
Pneumonia 19.0
Diarrhae 1.5
Prematurity 10.3
Congenital malformation 11.1
Others 5.1
Injuries of newborn associated to the delivery
Excluded to :
Amniocenthesis injury
Intra uterine transfusion
Fetal venous puncture
Injuries related to resuscitation
 The fatal type significantly
due to obstetric practice
and technology 3,7 per 100,000
live birth.
The non fatal type varies
the injury type
2-7 per 1000 live births
 Necessitates careful physical
+ neurologic examination
 1. Primiparity
2. Small maternal stature
3. Maternal pelvic anomalies
4. Prolonged or extremely rapid labor
5. Deep transverses arrest
6. Oligohydramnion
7. Abnormal presentation
8. Use of mid forceps or vacuum extraction
9. Version and extraction
10. VLBW infant or extreme prematurity
11. Fetal macrosomia
12. Large fetal head
13. Fetal anomalies
1. Soft tissue injuries
2. Head surface
3. Neck and shoulder
4. Extremity
5. External genital
6. Intra abnominal injuries
7. Intra cranial injuries
A. Head and neck injury

B. Cranial nerve, spinal card and peripheral

nerve injuries

C. Bone injuries

D. Intra abdominal injuries

E. Soft-tissue injuries
 Erythema

Petechiae

Ecchymosis and hematoma

Aberration and laceration

Subcutaneus fat necrosis

 Caput succedaneum
Vacuum caput
Subconjunctival bleeding
Facial bone fracture
Petechiae
Hematoma
Ecchymosis
Laceration
Pheripheral facialis nerve parese
 Brachial plexus
Paralysis/Parese Duchene-ERB
Paralysis/Parese Klumppke
Paralysis/Parese nerve phrenicees

Clavicula fracture
1. Associated with fetal monitoring
2. Extracranial hemorrhage
a) Classification :
1. Cephalhematoma
2. Subgaleal hematoma
3. Caput succedaneum
4. Vacuum caput
b) Management :

3. Intracranial hemorhage
1. Cranial nerve injury
facial nerve injury

2. Cervical nerve root injuries

a. Phrenic nerve palsy (C3,4 or 5)
b. Brachial plexus injuries
 C5-6 roots injuries
80% of plexus brachialis injury
Biceps reflex (-)
Radial reflex (-)
Moro (-)
Grasp reflex (+)
Pathognomonis : Porter sign
Radiology : DD/bone fracture
Physiotherapy :
Fixation : arm abduction 90, shoulder exorotation wrist 90,
lower arm suppination extention of hand.
 C7 th1 roots injuries
2,5% of brachial plexus injuries
Internal arm muscle disturbances
Biceps reflex (+)
Radial reflex (+)
Moro reflexs (-) / assymetry
Grasp replex (-)
Incase of sympathic nerve included :
Horner Syndrome (ptosis,myosis,
ecophthalmos,head/facial anhydrosis
homolateral
Physiotherapy : netral position
 C3,4,5 root injuries
Respiratory distress, cyanosis, tachypnea
Radiology :
* diaphragma elevation
* shift of mediastinum & heart
Fluoroscopy
* seesaw movement
* Shiftened of mediastinum
Therapy : NICU ventilator, surgery
 Breech delivery
Male : scrotal
capsula testis
Female : labia majora injury
Edema
aberration
hematoma
hematocele
Conservative therapy
 Rare
Malpresentation

Soft tissues
Humerus fracture
Femur fracture
Coxsae dislocation
Radial articulation dislocation
 Extremely rare

Uncovered by bone tissue

Liver
Spleen
Adrenal gland
 Intracranial haemorrhage
Cause : * mechanical
* hypoxic
* combined
Hypoxic trauma more difficent
to be avoided
CNS immaturity
Cerebral circulation
autoregulation
Classification
1. Subdural
2. Primary subarachnord
3. Intracerebral
4. Periventricular - intraventricular
Hypoxic birth trauma :
HIE necrosis
cerebral cortex atrophy
periventricular leucomalacia
basal ganglia degeneration

Prognosis : Severity of encephalopathy

Serve 40% death,
10% neurological disturbance,
mental retardation, vision disturbance,
hearing impairment, celebral paresis
Anomalies occured since the gestation
period

Classification :

Major
Minor

Genetic
Non genetic
 Chromosome aberration

Single mutant gene

Multifactorial inheritance
~ Numerical Trisomy
Tetrasomy
Monosomy

~ Structural Deletion
Inversion
Translocation
~ Autosome dominant

~ Autosome Recessive

~ X-linked inheritance
~ Thalassemia
~ Sickle cell anemia
~ Haemophilia
~ Cystic fibrosis
~ G6PD deficiency
1. Infection : TORCH
2. Environment : Mercury
3. Drug-poison : ~ Thalidomide
~ Warfarin
4. Habit : ~ Alcohol
~ Retinoic acid
5. Nutrient : ~ Folic Acid
6. Mechanical : ~ Deformity due to amniotic band
Cause Inc :
Genetic abnormalities
- Multifactorial inheritance 0.6 CHD, anencephaly
- Single mutant genes 0.1 Polycystic Kidney
- Chromosomal abnormalities 0.1 Down syndrome
- Uncertain inheritance 0.3 Polydactyly

Uterus Factors 0.1 Breech presentation

amniotic bands
Drugs taken by mother 0.01 Warfarin
Maternal conditions 0.1 D.M
Unknown etiology 1.1 Omphelocele

Total 2.41%
 Malformation

Deformation Disruption

Figure 3. An initiating malformation may give rise to secondary

deformation or disruption , and vice versa. The terminology,
such as malformation sequence, refers to the initiating defect and
its consequences. When the nature of the initiating defect is
unresolved between the three types, the term malformation is
generally utilized.
 Nature of Problem

Malformation Disruption
Deformation
(poor formation) (mechanical) (destructive)

Multiple Single
localized Localized
defect defec

Malformation Malformation, Deformation, Disruption,

syndome malformation deformation disruption
sequence sequence sequence

Malformation
association

Figure 4. Most patient with multiple structural defect will fall into one
of there five categories. The prognosis management, and recurrence risk
counseling may vary considerably among these vategories.
 SINGLE LOCALIZED ANOMALY
in early morphogenesis

SECONDARY ANOMALIES

PATTERN OF MULTIPLE ANOMALIES

in later morphogenesis

Figure 1. Sequence designates a single localized anomaly plus its

subsequently derived structural consequences, as depicted above.
Non genetic type :
Optimal perinatal services
Rehabilitation
Operative surgery
Supportive treatment
Pra-conseptional conselling

Genetic type :
Optimal perinatal service
Rehabilitation
Operative surgery
Supportive treatment
Genetic councelling
Pra-conceptional councelling