Incidence of neonatal sixth nerve palsy in relation to mode of delivery

Forceps Delivery-Related Ophthalmic Injuries: A Case Series

PURPOSE

To report a case series of neonatal ophthalmic trauma induced by forceps-assisted vaginal delivery.

METHODS

Retrospective, non-comparative case series focusing on presentation and long-term outcomes.

RESULTS

Eleven cases of ophthalmic injury secondary to forceps delivery (7 male, 4 female) from October 1997 to July 2014 are presented. Eight cases were born at a single center from January 2006 to July 2014, a rate of 1 case per 413 forceps-assisted deliveries. Follow-up ranged from 2 months to 17 years. Three cases had self-limiting eyelid bruising only. There was one case each of vitreous hemorrhage and hyphema, which resolved spontaneously. There were two cases of oculomotor nerve palsy associated with intracranial hemorrhage, both requiring surgical ptosis repair at 3 and 5 weeks old, respectively. There was one case of facial nerve palsy. Four cases sustained corneal trauma, manifesting as corneal edema in three cases at birth. The fourth of these cases presented at age 4.5 years with corneal scarring and amblyopia. Resulting astigmatism in these four cases ranged from 3.5 to 7.5 diopters and best-corrected visual acuity ranged from 6/12 to 6/36 Snellen at last follow-up.

CONCLUSIONS

Although rare, ophthalmic trauma secondary to forceps-assisted delivery can result in a wide spectrum of anatomical injuries, which may be self-limiting or cause significant long-term visual impairment. The authors recommend awareness among obstetricians and pediatricians of these injuries, and referral to the ophthalmologist of any newborn delivered by forceps with evidence of compressive trauma such as scalp or eyelid bruising to rule out the presence of more serious ophthalmic trauma.

Hector Landouzy on facial paralysis in newborn children: the case studies of a 19th-century French hospital physician

Marc-Hector Landouzy (1812-1864) was one of the first to describe facial paralysis in newborn, through a series of case studies. By examining these four cases in the context of Landouzy's life, publications and professional circumstances, this study shows how case studies were an important part of the scientific revolution within medicine in the 19th century. Landouzy, soon followed by others, used the growing clinical populations of Parisian hospitals, patho-anatomy and cutting-edge physiologic techniques to help describe a previously ignored disease among newborns. His case studies, in particular, are a valuable example of the emerging interest in children as a clinical population and of early interest in child neurology.

The role of forceps rotation in maternal and neonatal injury

OBJECTIVE

Our purpose was to assess the impact of forceps rotation on maternal and neonatal injury.

STUDY DESIGN

In this retrospective case-controlled study performed at the University of Texas Medical Branch at Galveston all forceps deliveries with a rotation of >/=90 degrees performed between July 1992 and September 1995 were identified (n = 113). For controls 167 forceps deliveries with rotations of </=45 degrees were randomly selected. Control deliveries occurred during the same time period and were matched to within 2 weeks of gestational age as well as to nulliparous versus parous status. The majority of deliveries were low; however, some midforceps deliveries were also included.

RESULTS

Forceps rotations of >/=90 degrees accounted for 0.8% of all deliveries. A major fetal injury, defined as a skull fracture, subdural hematoma, brachial plexus or a sixth or seventh cranial nerve injury, occurred in 10.2% of deliveries with rotations of </=45 degrees and in 9.7% with rotations of >/=90 degrees. The only permanent injury was a brachial plexus palsy that occurred with a forceps rotation of 45 degrees. Rotations of >/=90 degrees were not associated with umbilical arterial acidemia below 7.0 or 7.1 compared with rotations of </=45 degrees. Rotations of >/=90 degrees were associated with longer maternal hospital stays (P =.009). Neither lacerations of the birth canal, third- or fourth-degree episiotomies, or fall in the maternal hematocrit correlated with the degree of forceps rotation.

CONCLUSIONS

Advanced degrees of forceps rotations do not result in any clinically significant increase in infant or maternal morbidity relative to that encountered with lesser degrees of forceps rotation.

A practice pathway for the initial diagnostic evaluation of isolated sixth cranial nerve palsies

PURPOSE

To define a practice pathway for the evaluation of sixth-nerve palsies (SNPs) and to determine its cost-effectiveness and validity in a retrospective chart review.

METHODS

A Medline search of the English-language literature from 1966 to 1995 was performed to define the available clinical evidence and develop the practice pathway. The authors retrospectively reviewed 407 charts with the diagnosis of SNP seen at three centers. Information obtained included: etiologic diagnosis if known; development of new neurologic or ophthalmologic findings; and results and costs of neuroimaging studies, if performed.

RESULTS

Of the 407 patients, 98 underwent computed tomography scans and 212 underwent magnetic resonance imaging of the head. Eighty cases were non-isolated, 317 were isolated SNP, and ten could not be classified from chart information. Of the 317 cases of isolated SNP, 49 were classified as traumatic; 5, congenital; 158, vasculopathic; 63, nonvasculopathic; and 42, progressive or unresolved. Following the recommendations of the practice pathway, the 158 patients classified as having vasculopathic SNP would not have undergone neuroimaging studies, realizing a savings of $100,000 in this study population of 407 patients.

CONCLUSION

The recommendations of the practice pathway are supported by review of the literature and the retrospective review of these cases. However, a prospective study with a matched control group is needed to demonstrate regional and specialty-specific variations in care and to strengthen the clinical certainty of the pathway recommendations.