Strategies to Improve Management of Shoulder Dystocia Under the AHRQ Safety Program for Perinatal Care

OBJECTIVE

To assess implementation of safety strategies to improve management of births complicated by shoulder dystocia in labor and delivery units.

DESIGN

Mixed-methods implementation evaluation.

SETTING/LOCAL PROBLEM

Labor and delivery units (N = 18) in 10 states participating in the Safety Program for Perinatal Care (SPPC). Shoulder dystocia is unpredictable, requiring rapid and coordinated action.

PARTICIPANTS

Key informants were labor and delivery unit staff who implemented SPPC safety strategies.

INTERVENTION/MEASUREMENTS

The SPPC was implemented by using the TeamSTEPPS teamwork and communication framework and tools, applying safety science principles (standardization, independent checks, and learn from defects) to shoulder dystocia management, and establishing an in situ simulation program focused on shoulder dystocia to practice teamwork and communication skills. Unit staff received training, a toolkit, technical assistance, and unit-specific feedback reports. Quantitative data on unit-reported process improvement measures and qualitative data from staff interviews were used to understand changes in use of safety principles, teamwork/communication, and in situ simulation.

RESULTS

Use of shoulder dystocia safety strategies improved on the units. Differences between baseline and follow-up (10 months) were as follows: in situ simulation (50% vs. 89%), teamwork and communication (67% vs. 94%), standardization (67% to 94%), learning from defects (67% vs. 89%), and independent checks (56% vs. 78%). Interview data showed reasons to address management of shoulder dystocia, various approaches to implement safety practices, and facilitators and barriers to implementation.

CONCLUSION

Successful management of shoulder dystocia requires a rapid, standardized, and coordinated response. The SPPC strategies to increase safety of shoulder dystocia management are scalable, replicable, and adaptable to unit needs and circumstances.

Medico-legal implications of hypothermic neuroprotection in the newborn

Hypoxic-ischemic encephalopathy (HIE) continues to be a significant source of long term neurological sequelae in infants born at or near term. In the past decade, selective head or whole body cooling has shown promising benefit in ameliorating some of the brain injury from intrapartum asphyxial insults and has become standard care in most developed countries. A decision to offer neuroprotective hypothermia (NPH) may engender subsequent litigation because it presupposes an acute intrapartum injury. Conversely, failing to offer cooling may be interpreted as a violation in the standard of care. In this paper, we review the clinical aspects of NPH and the medico-legal scenarios often seen after acute birth injury.

Obstetrical brachial plexus injury (OBPI): Canada's national clinical practice guideline

OBJECTIVE

The objective of this study was to establish an evidence-based clinical practice guideline for the primary management of obstetrical brachial plexus injury (OBPI). This clinical practice guideline addresses 4 existing gaps: (1) historic poor use of evidence, (2) timing of referral to multidisciplinary care, (3) Indications and timing of operative nerve repair and (4) distribution of expertise.

SETTING

The guideline is intended for all healthcare providers treating infants and children, and all specialists treating upper extremity injuries.

PARTICIPANTS

The evidence interpretation and recommendation consensus team (Canadian OBPI Working Group) was composed of clinicians representing each of Canada's 10 multidisciplinary centres.

OUTCOME MEASURES

An electronic modified Delphi approach was used for consensus, with agreement criteria defined a priori. Quality indicators for referral to a multidisciplinary centre were established by consensus. An original meta-analysis of primary nerve repair and review of Canadian epidemiology and burden were previously completed.

RESULTS

7 recommendations address clinical gaps and guide identification, referral, treatment and outcome assessment: (1) physically examine for OBPI in newborns with arm asymmetry or risk factors; (2) refer newborns with OBPI to a multidisciplinary centre by 1 month; (3) provide pregnancy/birth history and physical examination findings at birth; (4) multidisciplinary centres should include a therapist and peripheral nerve surgeon experienced with OBPI; (5) physical therapy should be advised by a multidisciplinary team; (6) microsurgical nerve repair is indicated in root avulsion and other OBPI meeting centre operative criteria; (7) the common data set includes the Narakas classification, limb length, Active Movement Scale (AMS) and Brachial Plexus Outcome Measure (BPOM) 2 years after birth/surgery.

CONCLUSIONS

The process established a new network of opinion leaders and researchers for further guideline development and multicentre research. A structured referral form is available for primary care, including referral recommendations.

Management of birth-associated subtrochanteric femur fractures

In daily clinical practice most orthopedic surgeons suffer from doubt about treatment of rare injuries. The aim of this study is to enlighten the management of birth related femoral subtrochanteric fractures of neonates. Four birth-related femoral subtrochanteric fractures of neonates were treated and followed up. Difficult caesarian breech delivery seems to be a risk factor. All patients were treated with Pavlik harness and union was achieved by the fourth week. None of the patients suffer any angulation or limb length discrepancy. Adequate management of this type of fractures lead to good results.

Preventing deaths from complications of labour and delivery

The process of labour and delivery remains an unnecessary and preventable cause of death of women and babies around the world. Although the rates of maternal and perinatal death are declining, there are large disparities between rich and poor countries, and sub-Saharan Africa has not seen the scale of decline as seen elsewhere. In many areas, maternity services remain sparse and under-equipped, with insufficient and poorly trained staff. Priorities for reducing the mortality burden are provision of safe caesarean section, prevention of sepsis and appropriate care of women in labour in line with the current best practices, appropriately and affordably delivered. A concern is that large-scale recourse to caesarean delivery has its own dangers and may present new dominant causes for maternal mortality. An area of current neglect is newborn care. However, innovative training methods and appropriate technologies offer opportunities for affordable and effective newborn resuscitation and follow-up management in low-income settings.

Brachial plexus birth palsy: Management during the first year of life

Brachial plexus birth palsy (BPBP) is defined as an injury to any nerve root of the brachial plexus during difficult delivery. BPBP is relatively rare; its incidence has remained constant over the last few decades, mostly due to unpredictable risk factors, such as shoulder dystocia. Both diagnosis and assessment of spontaneous recovery is based on clinical examination. Electromyography is difficult to interpret in the newborn and is therefore not meaningful. MRI of the cervical spine requires sedation or general anesthesia. Searching for a pre-ganglion tear prior to surgery is indicted. Prognosis depends on the level of the injury (pre- or post-ganglion), size and severity of the post-ganglion tears, speed of recovery, and quality of initial management. Although spontaneous recovery is frequent, some children suffer various degrees of sequelae, up to complete loss of function of the affected upper limb. Recent publications have improved general knowledge and indications for surgery. However, some aspects, such as indication and timing of nerve repair continue to be debated.

Frequency, causes and outcome of neonates with respiratory distress admitted to Neonatal Intensive Care Unit, National Institute of Child Health, Karachi

OBJECTIVE

To determine the frequency, aetiology and outcome of respiratory distress in neonates in intensive care unit.

METHODS

The descriptive cross-sectional study was conducted at the Neonatal Intensive Care Unit, National Institute of Child Health, Karachi, from October 2009 to March 2010. It comprised neonates aged day 0 to 28 who were admitted to Neonatal Intensive Care Unit. The neonates were screened first for respiratory distress and presence of one or more signs and symptoms. History, examination and investigations were carried out to find out various aetiologies of respiratory distress. Outcome was measured in terms of discharge and death. Data was analysed using SPSS12.

RESULTS

Of the 205 neonates in the study, 120(58.6%) were boys and 85(41.4%) were girls The overall mean age was 70.58±110.02 hours and the mean gestational age was 36.32±2.72 weeks while the mean weight was 2.41±2.4kg. Respiratory rate >60/min was found in all (100%) the neonates. In terms of signs and symptoms, 125(60.9%) had grunting, 205(100%) had subcostal retractions and nasal flaring, and 81(40%) had cyanosis. The aetiologies observed were birth asphyxia, sepsis, transient tachypnoea of the newborn, pneumonia, meconium aspiration syndrome and respiratory distress syndrome in 22(10.75%), 37(18.05%), 29(14.1%), 36(17.6%), 34(16.7%) and 47(23.0%) neonates respectively. The incidence of neonates with respiratory distress was 68(33.3%).

CONCLUSIONS

The frequency of respiratory distress among the neonates was high, while mortality was high in neonates with respiratory distress, especially in pre-term and low birthweight neonates. Early diagnosis and management is important for better outcome.

Obstetrical trauma--therapeutic dilemmas?

Obstetrical trauma is frequent among newborns alive and could represent a cause of perinatal death. The aim of this paper consists of presenting the authors experience regarding the diagnosis and treatment of skeletal and thoracic-abdominal organs related to traumatic birth.

MATERIAL AND METHODS

Between 2000 and 2010, 33 patients with trauma at birth were included in the study. The type of the lesion and the therapeutical approach and results were analyzed.

RESULTS

Two categories of results were clearly differentiated: excellent for obstetric trauma involving limbs and soft parts and negative, disappointing results with 10 deaths in 12 cases treated for obstetric trauma of abdominal organs.

CONCLUSIONS

Bone and soft tissue birth trauma are relatively easy to identify and treat, but the medical approach of thoraco-abdomnial organs birth trauma need clinical experience and technical possibilities.

Preventive nursing of neonatal clavicular fracture in midwifery: a report of six cases and review of the literature

PURPOSE

To summarize and analyze the obstetric factors and medical care for neonatal clavicle fracture during delivery.

MATERIALS AND METHODS

In 4,456 vaginal deliveries, only six newborns were found with a clavicle fracture in our hospital from October 2002 to October 2011.

RESULTS

Clinical findings showed that dystocia and improper midwifery manoeuvres are the two major reasons which lead to newborn clavicular fractures.

CONCLUSION

More attention should be paid to non-violent traction and proper treatment of shoulder dystocia.

Characteristics and outcome of brachial plexus birth palsy in neonates

AIM

To relate pregnancy characteristics to extent and reversibility of brachial plexus birth palsy (BPBP) in neonates.

METHODS

Retrospective case-control study: newborns with a registered diagnosis of BPBP (n = 168) 1990-2005 were compared to data from a randomly selected control group (n = 1000). Characteristics were related to the level of injury, reversibility and outcome.

RESULTS

Among 51,841 newborns, 168 cases with BPBP were found (incidence 3.2/1000 newborns/year). Extent and reversibility of lesion did not differ with respect to characteristics of mothers, foetuses or deliveries. Children with C5-C6 and C5-C6-C7 injuries had complete recovery in 86% and 38%, respectively. Global injuries (C5-Th1) always had permanent disability. Accelerators (foetal weight gain >35 g/day after 32 weeks of gestation) and foetuses with estimated weight deviation ≥ +22% at 32 weeks were at seven- and ninefold increased risk of BPBP. Parous women were at doubled risk as compared to nulliparous women.

CONCLUSION

Maternal and foetal characteristics influence risk of BPBP, but not the extent of injury or reversibility of injury. Because of the high risk of permanent disability and modest risk of low Apgar or pH among newborns with BPBP, the recommendation of prompt delivery may need to be re-evaluated.

Care of the infant of the diabetic mother

Gestational diabetes mellitus (GDM) from all causes of diabetes is the most common medical complication of pregnancy and is increasing in incidence, particularly as type 2 diabetes continues to increase worldwide. Despite advances in perinatal care, infants of diabetic mothers (IDMs) remain at risk for a multitude of physiologic, metabolic, and congenital complications such as preterm birth, macrosomia, asphyxia, respiratory distress, hypoglycemia, hypocalcemia, hyperbilirubinemia, polycythemia and hyperviscosity, hypertrophic cardiomyopathy, and congenital anomalies, particularly of the central nervous system. Overt type 1 diabetes around conception produces marked risk of embryopathy (neural tube defects, cardiac defects, caudal regression syndrome), whereas later in gestation, severe and unstable type 1 maternal diabetes carries a higher risk of intrauterine growth restriction, asphyxia, and fetal death. IDMs born to mothers with type 2 diabetes are more commonly obese (macrosomic) with milder conditions of the common problems found in IDMs. IDMs from all causes of GDM also are predisposed to later-life risk of obesity, diabetes, and cardiovascular disease. Care of the IDM neonate needs to focus on ensuring adequate cardiorespiratory adaptation at birth, possible birth injuries, maintenance of normal glucose metabolism, and close observation for polycythemia, hyperbilirubinemia, and feeding intolerance.

[Clinical study on acupuncture and Tuina for treatment of birth brachial plexus injury]

OBJECTIVE

To compare the difference of therapeutic effect between acupuncture combined with Tuina and Nobex for treatment of birth brachial plexus injury.

METHODS

Forty cases with birth brachial plexus injury were randomly divided into a acupuncture combined with Tuina group (group A) and a Nobex group (group B), 20 cases in each group. The group A was treated with acupuncture at 3 points, i. e. Jianyu (LI 15), Jianliao (TE 14), Jianzhen (SI 9) on shoulder, Binao (LI 14), Shouwuli (LI 13), Quchi (LI 11), etc. combined with Tuina using a single thumb and rolling method, and the group B was treated with intramuscular injection of Nobex. The clinical effects and the changes of the symptom, scores and the electromyogram were observed before and after treatment.

RESULTS

The total effective rate of 90.0% (18/20) in the group A was better than that of 55.0% (11/20) in the group B, with a significant difference between the two groups (P < 0.05). The effective rate of the electromyogram improvement in the group A was 90.0% (18/20), which was better than 45.0% (9/20) in the group B (P < 0. 05), and the symptom scores in the group A were lower than those in the group B (P < 0.01).

CONCLUSION

Acupuncture combined with Tuina can improve the recovery of nerve and upper extremity function and its therapeutic effect is superior to that of intramuscular injection with Nobex.

Traumatic luxation of the nose in a newborn: case report and review of the literature

During delivery the delicate structures of the face are predominantly exposed to external force effects and hence deformities on the nose can emerge as a birth-related trauma in newborns. As self-straightening of the nasal septum commonly occurs, a conservative therapy is recommended for most cases. We report on a case where a birth-related trauma of the nose leaded to acute breathing problems in a newborn with insufficient oxygenation. An overview about the available literature is given. A cautious reposition of the nose proved to be an appropriate management for short- and long-term development.

[Neonatal traumatic epiphyseolysis of the humeral head. A rare occurrence]

Neonatal traumatic epiphyseolysis of the humeral head is rare, and only a few cases are reported in the literature. We present a case of a 13-day-old female newborn with malposition and relaxation of the left upper limb. The clinical examination showed distinct range of motion particularly for abduction. Magnetic resonance imaging (MRI) indicated epiphyseolysis of the humeral head. Closed reposition followed by immobilisation was done. The following MRI showed correct axis with adaption of the humeral head. Later, malposition of the axis with angulation in the ventromedial position was seen. This status was not followed by renewed repositioning. The x-ray examination 5 months later and MRI 9 months later showed a centered position of the epiphysis. In conclusion, neonatal traumatic epiphyseolysis of the proximal humeral head occurs rarely but should be considered, particularly with unclear relaxation of the limb.

Optimizing shoulder dystocia management to prevent birth injury

A practical clinical review of those aspects of shoulder dystocia management that are directly relevant to birth injury is presented. In contrast to more popular viewpoints, the tenets of this paper are that, with few exceptions, clinically relevant, permanent brachial plexus injury is nearly universally associated with shoulder dystocia, injury is causally related to mechanical stresses induced during shoulder dystocia delivery, and management algorithms can be optimized to reduce the incidence of mechanical birth injury from shoulder dystocia. Advantages of direct rotational manipulation of the fetus within the birth canal are emphasized, supported by critical analysis of maneuver-related outcomes research. The competing issue of potential asphyxial insult with prolonged shoulder dystocia is addressed in light of evidence for differential time-dependency between central and peripheral nerve injury as head-to-body interval increases. The importance of proper execution of shoulder dystocia maneuvers for maximizing favorable outcome of shoulder dystocia is iterated, as is coordination of teamed response by multiple healthcare providers. To avoid permanent neurologic sequelae from shoulder dystocia, clinicians are encouraged to be ever mindful of traction applied to the fetal head and neck, to become adept at performance of alternative maneuvers that instead concentrate on finesse rather than force, and to be more favorably disposed to the use of such maneuvers early and often in shoulder dystocia management algorithms.

Caput succedaneum and cephalohematoma: the cs that leave bumps on the head

Caput succedaneum and cephalohematoma are conditions that rarely evoke much concern in the NICU but deserve more attention. This article examines the two conditions, reviews the literature, discusses possible complications, and leaves the reader with a heightened awareness of these seemingly benign lesions.

Shoulder dystocia: the unpreventable obstetric emergency with empiric management guidelines

OBJECTIVE

Much of our understanding and knowledge of shoulder dystocia has been blurred by inconsistent and scientific studies that are of limited scientific quality. In an evidence-based format, we sought to answer the following questions: (1) Is shoulder dystocia predictable? (2) Can shoulder dystocia be prevented? (3) When shoulder dystocia does occur, what maneuvers should be performed? and (4) What are the sequelae of shoulder dystocia?

STUDY DESIGN

Electronic databases, including PUBMED and the Cochrane Database, were searched using the key word "shoulder dystocia." We also performed a manual review of articles included in the bibliographies of these selected articles to further define articles for review. Only those articles published in the English language were eligible for inclusion.

RESULTS

There is a significantly increased risk of shoulder dystocia as birth weight linearly increases. From a prospective point of view, however, prepregnancy and antepartum risk factors have exceedingly poor predictive value for the prediction of shoulder dystocia. Late pregnancy ultrasound likewise displays low sensitivity, decreasing accuracy with increasing birth weight, and an overall tendency to overestimate the birth weight. Induction of labor for suspected fetal macrosomia has not been shown to alter the incidence of shoulder dystocia among nondiabetic patients. The concept of prophylactic cesarean delivery as a means to prevent shoulder dystocia and therefore avoid brachial plexus injury has not been supported by either clinical or theoretic data. Although many maneuvers have been described for the successful alleviation of shoulder dystocia, there have been no randomized controlled trials or laboratory experiments that have directly compared these techniques. Despite the introduction of ancillary obstetric maneuvers, such as McRoberts maneuver and a generalized trend towards the avoidance of fundal pressure, it has been shown that the rate of shoulder-dystocia associated brachial plexus palsy has not decreased. The simple occurrence of a shoulder dystocia event before any iatrogenic intervention may be associated with brachial plexus injury.

CONCLUSION

For many years, long-standing opinions based solely on empiric reasoning have dictated our understanding of the detailed aspects of shoulder dystocia prevention and management. Despite its infrequent occurrence, all healthcare providers attending pregnancies must be prepared to handle vaginal deliveries complicated by shoulder dystocia.

Intrapartum fetal emergencies

Labour is one of the shortest yet most hazardous journeys humans take during their lifetime. Currently, our methods of identifying those fetuses at particular risk of compromise during labour are limited. Antepartum tests of placental reserve give little information about an individual fetus's ability to cope with passage through the birth canal and some might already have received a silent insult earlier in the pregnancy that places them at increased risk. In addition to the normal processes of labour, other, more unpredictable factors can act to place the fetus in acute danger.

Part 2: Birth trauma: injuries to the intraabdominal organs, peripheral nerves, and skeletal system

Part 1 of this 2-part article, "Early Recognition and Treatment of Birth Trauma: Injuries to the Head and Face" provided readers with basic concepts related to birth trauma to the head and face. Part 2 focuses on the pathophysiology, etiology, diagnosis, treatment, and prognosis of birth injuries to the intraabdominal organs, the peripheral nerves, the spinal cord, and the skeletal system. Risk factors for birth injury to these areas are discussed along with key issues related to the nursing care of affected infants.

Part 1: early recognition and treatment of birth trauma: injuries to the head and face

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Sentinel Event Alert from July 21, 2004 states that there have been 47 cases of birth trauma-related perinatal death or permanent disability reported for JCAHO review since 1996. This report clearly illustrates the importance of birth trauma in clinical practice for neonatal and perinatal nurses. Estimates suggest that birth trauma occurs in 2% to 7% of all deliveries and is associated with an increase in both mortality and morbidity. Birth trauma to the head may result in minor superficial extracranial injuries, such as caput succedaneum and cephalohematoma, or more serious and potentially life threatening lesions such as subgaleal hemorrhages. The potential for deeper intracranial injury, such as subarachnoid or subdural hemorrhage exists; these may be isolated or associated with skull fractures and/or other extracranial injuries. Injury to the eye, nasal structures, and paralysis of the vocal cords may also result from birth trauma during a difficulty delivery. Part 1 of this 2-part article will focus on birth injuries to the head and face. Part 2 of the series will review more systemic birth injuries that may involve abdominal organs, the spine and skeletal system, and peripheral and facial nerves.

Part 2. Distinguishing physical characteristics and management of brachial plexus injuries

Brachial plexus injuries (BPI) are usually readily apparent at or shortly after birth. Failure of caregivers to recognize and appropriately treat BPI may contribute to the risk of life-long neuromuscular dysfunction for the infant and represents a serious medical-legal liability for the delivery provider. This article is the second in a series on BPI and provides a standard classification and a systematic guide to physical examination of the infant with suspected BPI. Conditions that mimic BPI are discussed along with diagnostic studies used to confirm this disorder. The natural history and predictors of outcome are presented along with a sample treatment protocol. Pictures and video clips are provided to enhance the reader's understanding of the consequences of this injury and the potential for improvement with surgical treatment. Useful Internet resources for parents, focused discharge planning, and guidelines for appropriate monitoring and follow-up are provided. Advantages of early referral and management by a multidisciplinary team at a brachial plexus specialty center are discussed.

Pediatric spinal trauma: injuries in very young children

Injuries to the spine in very young children are comparatively rare. The prevalence of upper cervical injuries and spinal cord injuries is greater. Spinal cord injury is more common in young children and fracture is less common than in older children and adolescents. This is because of the anatomic and biomechanical differences in the growing spine including a more horizontal facet orientation, greater elasticity of the soft tissues, less muscular development, and relatively greater head size compared to the trunk. These features are more pronounced in the very young child. The clinical and radiographic evaluation of small children can be difficult. Unossified bone and physeal cartilage can be confused with fractures. The evaluation, safe transportation, and spinal clearance of the unconscious multiply injured child suspected of having spinal injury present special challenges.

Management of birth injuries

Birth injuries are a significant cause of neonatal morbidity and mortality. Although often associated with traumatic delivery, birth injuries often occur in normal spontaneous deliveries in the absence of any risk factors. This article discusses the diagnosis and management of the most common birth injuries that are encountered by health care providers who care for newborns.

[Shoulder dislocation in the newborn. Report of 12 cases and review of the literature]

Shoulder dislocation in the newborn is a rare entity. Therefore, a therapeutic regimen does not exist. This retrospective clinical study (1967-2003) includes 9 newborns with 12 dislocations of the shoulder. The data focus in particular on the therapeutic strategy and its success. The position of the joint and its functionality were monitored with a questionnaire. Publications from 1904 to 2003 were reviewed and served for comparison. Results of calculations showed that 0.018-0.07% of newborns suffer from shoulder dislocations. The diagnosis was made on average at the age of 22 days. Our data include four cases each of congenital and paralytic and two cases each of spastic and traumatic shoulder dislocations. All of them were initially treated conservatively, but because of inadequate results one patient finally had to be operated. In the follow-up of 19.4 years, none of them developed a redislocation and all shoulder functions were suitable for daily life. We propose that patients primarily be treated conservatively; however, if therapy fails, surgery has to be performed.

Refracture of the clavicle in an infant: case report and review of clavicle fractures in children

Perinatal clavicle fractures typically heal without complication, and subsequent refracture of the same clavicle during infancy or toddlerhood has not been reported. This is a case report of a fracture of the clavicle in a 9-month-old child who had previously suffered a fracture of the same clavicle at birth. A review of the evaluation and management of neonatal and post-neonatal clavicle fractures is also presented.

[Paralysis plexus brachialis--diagnostic and therapeutic protocol]

Traction injuries of the brachial plexus, if obstetrical, are diagnosed immediately upon birth based on clinical features, while the type and the degree of injury are confirmed by neurophysiological examination. In such cases, physical therapy is promptly applied and followed up until the age of three months, when, after consultation with neurosurgeon, either physical therapy is continued or surgery is performed. In traumatic injuries, based on clinical, neurological and neurophysiological findings, necessary surgical or pre- and postoperative physiatric interventions are performed. Timely diagnostics and therapy of brachial plexus injuries, followed by recovery of paralytic muscle motor function, enable motion coordination and prevention of contractures. From 2000-2004, 181 cases of brachial plexus birth trauma and 26 cases of brachial plexus traumatic lesions were diagnosed and treated in our institution. Among patients, there were 107 boys and 74 girls with birth injury of the brachial plexus, and 16 boys and 8 girls with traction injury of the brachial plexus sustained in traffic accident. Physical treatment involved combined thermo-, electro-, and kinesitherapy, with alignment of extremities. Upon completion of any treatment session and clinical and neurophysiological examinations, doctors' consultation determined whether to continue with physical therapy or to perform surgery followed by physical therapy with rehabilitation until achieving the maximal motor recovery. The analysis of results showed that functional and motor recovery was best if therapy was initiated immediately after the obstetrical injury or following the surgery. Therapeutic approach was individualized and depended on the level and degree of lesions. Thus, maximal motor and functional recovery of the injured extremity was achieved, with work therapy and professional orientation of such patients.

Management of birth injuries

Birth injuries are a significant cause of neonatal morbidity and mortality. Although they are frequently associated with traumatic delivery, birth injuries often occur in normal spontaneous deliveries in the absence of any risk factors. This article discusses the diagnosis and management of the most common birth injuries encountered by health care providers caring for newborns.

Randomised controlled trial of swaddling versus massage in the management of excessive crying in infants with cerebral injuries

BACKGROUND

Infants with neonatal cerebral insults are susceptible to excessive crying as a result of difficulties with self-regulation.

AIMS

To compare the effectiveness of swaddling versus massage therapy in the management of excessive crying of infants with cerebral insults.

METHODS

Randomised three-week parallel comparison of the efficacy of two intervention methods. Infants with symptoms of troublesome crying and their parents were randomly assigned to a swaddling intervention group (n = 13) or a massage intervention group (n = 12).

RESULTS

The amount of total daily crying decreased significantly in the swaddling group, but did not decrease significantly in the massage group. Infant behavioural profiles and maternal anxiety levels improved significantly in the swaddling group post-intervention. Parents in the swaddling group were more satisfied with the effectiveness of the intervention in reducing crying than parents in the massage group.

CONCLUSION

Results indicate that swaddling may be more effective than massage intervention in reducing crying in infants with cerebral injuries.

Suivi à long terme des épaules paralytiques obstétricales (à propos de 129 cas)

OBJECTIVES

To study shoulder impairment and disability caused by obstetrical brachial plexus palsy, their evolution under physical and surgical treatments, and the place of complementary explorations in persistent sequels.

METHODS

From 1991 to 2000, 129 patients (66 M, 63 F) were included in a retrospective study. Impairment was assessed by muscle recovery (deltoid, biceps, external rotators) and shoulder passive motion. Disability was assessed by Mallet functional test.

RESULTS

Full spontaneous recovery was noted in 20% of patients before the age of 3 months. Repair of the nerve lesion was undertaken in four children between the 18th and 24th months. Full recovery of deltoid and biceps was noted in three-fourth of whole cases before the 12th month, and of the external rotation in only 45% at this same age. Seventy-seven percent of patients showed stage >or= III of Mallet test (VI: 20%, IV: 32%; III: 25%) at a middle age of 3.5 years. A long-term follow-up showed an external rotation limited less than 20 degrees in 15 children. Investigation by RMN or Arthroscanner was realized for five patients, this reveals a deformation with subluxation of the humeral head in two cases. Ten children were operated (liberation of sub-scapula in nine cases associated to a tendinous transfer six times; humeral osteotomie in one case). This surgery has allowed the improvement of the functional state in all cases.

CONCLUSION

After-effects in shoulder are frequent especially the limitation of external rotation, which can lead to a deformation, and subluxation of the humeral head. The authors insist on the importance to push investigations in case of limitation of the passive external rotation to improve the therapeutic choice.

The postnatal management of the asphyxiated term infant

Investigations in animal models of hypoxic-ischemic injury have not translated into clinical trials of success because of the complex pathology of hypoxic-ischemic brain injury in neonates, the difficulty in defining the onset and duration and severity of the injury, the underlying predisposing disorders of the mothers or the infant, the side effects of many of the investigational drugs precluded clinical use, and many of the investigational agents interfered with only one step of the cascade of events that lead to brain injury. It is possible that a combination of therapeutic agents, including those that affect different levels of the cascade to cell death, will have the greatest neuroprotective effects. Modest hypothermia postpones secondary energy failure and can prolong the window while pharmacotherapeutic agents can be used. It is possible that in the future, sequential administration of agents or strategies that are initiated in the intrapartum period and continued postnatally will be the optimum method for treating infants who are at highest risk for brain injury following acute hypoxic-ischemic asphyxia.

Advances in postnatal neuroimaging: relevance to pathogenesis and treatment of brain injury

The human brain is susceptible to a wide variety of insults. The permanent residua of these abnormalities are represented in dysfunction of one or more areas of neurodevelopment. A full understanding of normal brain development, mechanisms of brain injury, and consequences for subsequent brain development is required to determine which infants are at risk for neurodevelopmental handicap, and to monitor the effects of new treatments and management regimens designed to prevent these disabilities. Advanced magnetic resonance techniques, such as quantitative morphometric magnetic resonance techniques, diffusion-weighted magnetic resonance techniques, and magnetic resonance spectroscopy applied to the study of early human brain development have given us a better understanding of the pathophysiologic mechanisms of brain injury and its effects on subsequent brain development. Magnetic resonance imaging has provided an invaluable tool for the study of the fetal and newborn brain in vivo.

[Life-threatening subgaleal bleeding in a newborn infant]

Subgaleal haematoma, also called subaponeurotic haemorrhage, is a serious but rarely seen form of bleeding that can occur as a complication to vacuum-assisted delivery. Subgaleal haemorrhage may be much more copious than the more common subperiostal bleeding, and can almost exsanguinate the infant. A pressure bandage applied to the upper head can be lifesaving.

Ultrasound-guided needle aspiration of cranial epidural hematoma in a neonate: treating a rare complication of vacuum extraction

Epidural hematoma is a rare form of neonatal birth injury accounting for 2% of newborn intracranial hemorrhage. We report the first case of ultrasound-guided needle aspiration of a cranial epidural hematoma in a neonate who also suffered subgaleal and intraparenchymal hemorrhage as a complication of vacuum extraction.

[Nasal injuries during labor and in early childhood. Etiopathogenesis, consequences and therapeutic options]

Childhood and perinatal nasal traumatisms involve an anterior septal deviation or an anterior septal lysis. These complications induce a soft nasal tip. Nasal obstruction et oral ventilation are responsible for the development of facial and occlusal sequelae. A better knowledge of anatomy and physiopathology of nasal traumatisms is needed for an earlier treatment.

Advanced magnetic resonance imaging techniques in perinatal brain injury

Despite marked improvements in perinatal practice, perinatal brain injury remains one of the most common complications causing chronic handicapping conditions. Experimental advances have elucidated many of the cellular and vascular mechanisms of perinatal brain damage showing a correlation between the nature of the injury and the maturation of the brain. New diagnostic tools, such as quantitative three-dimensional magnetic resonance (MR) imaging, diffusion-weighted MR imaging and proton MR spectroscopy, are presented in this review article that allow to assess brain development, detect early brain injury and monitor effects of perinatal brain injury on subsequent brain development and brain plasticity. These techniques will guide future therapeutic interventions aimed at minimizing irreversible perinatal brain injury.

[Obstetrical injuries of the brachial plexus]

Although birth-related brachial plexus injury (BPI) was first described more than two centuries ago, it still represents therapeutic dillemma. Incidence is 0.37-2.0 per 1000 live births. The most frequent etiologic cause is extreme lateral traction and excessive fundal pressure in a case of shoulder dystocia. However, in last decade there are reports that cite of BPIs occurring prior to delivery in up to 46% cases--intrauterine maladaptation. In 1998. and 1999. at the Rehabilitation Department of Pediatric Hospital, Clinical University Center in Sarajevo 32 children with BPI were treated. The incidence is 2.67 per 1000 live births. There were 21 cases of Erb's palsy (65.63%), 2 cases of Klumpke's palsy (6.25%). Total plexus palsy was present in 9 children (28.63%), and Horner's Syndrome in 1 case. In 25.77% of cases (8 children) there was-no evidence of shoulder dystocia at delivery. Treatment of the brachial plexus injuries in newborn is still controversial. Proper immobilization in first 7-15 days is of great importance. In this study 25 children (78.13%), in average age of 4.6 days, were brought for examination with improper immobilization. The role of widely applied electrotherapy is controversial. Complete recovery is expected in about one half, and in this study it was achieved in 75% of cases (24 children). Consensus about timing od surgical approach does not exist still. However, there is strong agreement that decision about eventual surgical treatment should be based on clinical motor testing and that MRI should precede the surgery. Although the electrodiagnostic studies have proven to be of limited prognostic value in the evaluation of children with acute obstetrical brachial plexus injuries, electromyography should be performed prior the surgery in the aim of later comparison of the results. According to our data, at this particular moment in BiH surgical treatment in this age is not available, as well as use of MRI in diagnostics of BPIs.

[Interference therapy in children with birth injuries of the brachial plexus]

The effect of interference waves on natal injuries of the brachial plexus was studied in 31 patients. Positive trends were observed in muscular tone and performance, motor activity of the affected joints. Effectiveness of a course interference therapy reached 84.5%.

Neonatal care of infants with head and neck anomalies

This article reviews the most common serious head and neck congenital anomalies and traumatic injuries that present at or around the time of birth from the perspective of neonatal caregivers. The focus is on the steps necessary to manage these infants in the delivery room and during the first days of life. An organized multidisciplinary team approach is critical to success.