Birth Trauma and CP Flashcards
(26 cards)
1
Q
Discuss birth trauma
-Incidence (2)
-Risk factors (7)
A
- Incidence
6-8:1000 live births - Risk factors
-LBW
-LGA
-Prematurity
-Prolonged / rapid labour
-Instrumental deliveries
-Vaginal breech
-Abnormal traction during delivery
2
Q
Discuss cephalhaematoma
-Pathophysiology (4)
-Presentation (5)
-Management (2)
A
- Pathophysiology
-Subperiosteal collection of blood.
-Doesn’t cross suture lines so is self contained
-Relatively common
-Associated with prolonged labour or instrumental delivery - Presentation
Parietal usually.
Can be bilateral
Largest on second day.
Boggy mass 48-72 hrs post delivery
Exaccerbates jaundice - Management
Resolves in days to months
Rarely needs drainage
3
Q
Discuss subgaleal haemorrhage
-Pathophysiology
-Presentation
-Management
A
- Pathophysiology
-Occurs between galea aponeurosis and periosteum
-Associated with prematurity, ventouse (90%), may have underlying coagulopathy
-40% associated with skull fracture, Intracranial haemorrhage
Can hold up to 250mL (Almost all 3kg baby’s blood volume) - Presentation
-Boggy appearance and pitting skull oedema
-Anterior displacement of the ears
-Flick sign (Thrill or crepitus)
-Fetal irritability
-Periorbital oedema
-Hypovolemic shock - Management
-Blood transfusion
-FFP and coagulation factors
-Phototherapy if Jaundice
4
Q
Discuss cephalhaematoma
-Pathophysiology (4)
-Presentation (5)
-Management (3)
A
- Pathophysiology
-Subperiosteal collection of blood.
-Doesn’t cross suture lines so is self contained
-Relatively common
-Associated with prolonged labour or instrumental delivery - Presentation
Parietal usually.
Can be bilateral
Largest on second day.
Boggy mass 48-72 hrs post delivery
Exaccerbates jaundice - Management
Resolves in days to months
Rarely needs drainage
Photo therapy if jaundice
5
Q
Discuss subgaleal haemorrhage
-Pathophysiology (5)
-Mortality rate (1)
-Incidence (2)
-Risk factors
A
- Pathophysiology
-Occurs between galea/epicranial aponeurosis and periosteum
-Potential space that can accommodate 250mL (90mL/kg babies blood volume)
-Results from rupture of the emissary veins
-40% associated with skull fracture, Intracranial haemorrhage - Mortality rate
-12-25% - Incidence
-0.6:1000 deliveries
-6:1000 ventouse deliveries - Risk factors
-60-90% from ventouse deliveries
-Nulliparity OR 4
-Poor cup placement - over to one side, Not over flexion point
-Failed vaccum extraction OR 16
6
Q
Discuss facial palsy
-Pathophysiology
-Presentation
-Management
A
- Pathophysiology
-Unilateral facial weakness.
-Can be bilateral but then likely congenital cause
-Associated with forceps delivery or pressure on maternal ischial spine - Presentation
-Unilateral facial weakness with ipsilateral eye remaining open - Management
-Eye drops if eye permanently open
-Resolves in 1-2 weeks
7
Q
Discuss facial palsy
-Pathophysiology (3)
-Presentation (1)
-Management (2)
A
- Pathophysiology
-Unilateral facial weakness.
-Can be bilateral but then likely congenital cause
-Associated with forceps delivery or pressure on maternal ischial spine - Presentation
-Unilateral facial weakness with ipsilateral eye remaining open - Management
-Eye drops if eye permanently open
-Resolves in 1-2 weeks
8
Q
Discuss brachial plexus injury
-Types (2)
-Nerves affected in each type
-Incidence of each type
-Management
-Prognosis
A
- Types
-Erbs palsy C5-6
-Klumpke’s palsy C7-T1 - Incidence of each type
-Erbs >90%
-Klumpke’s <1% - Management ad prognosis
-Most heal without treatment in 3-4 months
-Physiotherapy
-Erbs 90% resolve
-Klumpke’s 40% resolve
9
Q
Discuss cerebral palsy
-Incidence (1)
-Definition (3)
-Cause (2)
A
- Incidence
-2:1000 lie births - Definition
-Group of disorders characterised by motor and postural dysfunction
-Permanent and non progressive
-Commonly associated with cognitive impairment - Causes
-Many usually unidentified factors
-More likely due to delivery event if preterm
10
Q
Discuss the correlation of apgar scores and development of CP
A
-5 minute APGAR <7 increased risk CP
-10 minute APGAR <4 - 5% of babies develop CP
-75% of babies who develop CP have normal APGARS
11
Q
Discuss risk factors for cerebral palsy
-Fetal (3)
-Obstetric (4)
-Neonatal (3)
A
- Fetal risk factors
-PTB <34/40 - 5%
-LBW <1500g
-Multiple pregnancy 5% of triplets 1% of twins - Obstetric risk factors
-Chorioamnionitis
-Antepartum haemorrhage
-Placental insufficiency
-Perinatal asphyxia - Neonatal
-Intraventricular haemorrhage
-Periventricular leucomalacia
-HIE (Biggest RF)
12
Q
Discuss the correlation of APGAR scores and development of CP
A
-5 minute APGAR <7 increased risk CP
-10 minute APGAR <4 - 5% of babies develop CP
-75% of babies who develop CP have normal APGARS
13
Q
Discuss the correlation of APGAR scores and development of CP (3)
A
-5 minute APGAR <7 increased risk CP
-10 minute APGAR <4 - 5% of babies develop CP
-75% of babies who develop CP have normal APGARS
14
Q
Discuss cerebral palsy presentation
A
- 95% have mild/moderate symptoms
-Associated with muscle issues and movement, spacity, weakness and balance issues
-Increased problems with cognition, social interactions, ADHD, anxiety
-Becomes more obvious at school age
-50% need additional educational assistance - 5% have severe impairment
-Difficulty living independently - 92% live to >20
15
Q
Discuss hypoxic ischemic encephalopathy
-Definition (3)
-Causes (1)
-Clinical manifestation (4)
-Incidence (1)
A
- Definition
-No universal definition
-Is a subset of neonatal encephalopathy
-Requires evidence of hypoxia on cord gases, low apgars and early evidence of cerebral oedema on imaging. - Causes
-Results from intrapartum hypoxia and acidosis
-Not all metabolic acidotic babies develop HIE - Clinical manifestations
-Abnormal level of conscience
-Seizures
-Difficulty with breathing - initiating and maintaining
-Depression of tone and reflexes - Incidence
-1.5:1000 live births
16
Q
Discuss hypoxic ischemic encephalopathy
-Grades
-Characteristics of each grade
-Prognosis of each grade
A
- Grade 1 - mild
-Hyper alterness
-Irritability
-Jittery
-Normal EEG - Grade 2 - moderate
-Obtundation
-Hypotonia
-Strong distal flexion
-Multifocal seizures
Prognosis:
-20-30% death or major neurological sequalae - Grade 3 - severe
-Coma
-Frequent seizures
Prognosis:
Majority of cases = death or severe neurological sequalae - Overall prognosis
-14% of HIE develop CP
17
Q
Discuss diagnosis for HIE (3)
A
- EEG
-Do son after birth to look for seizure activity
-Of prognostic value - Cranial USS
-Use to detect cerebral oedema
-Can show brain lesions associated with CP (periventiricular leukomalacia, IVH) - MRI
-Gold standard
-Early imaging before 96 hr helps to show cause of hypoxia
-MRI around 10days shows full extent of brain injury
-Good for prognosis
18
Q
Discuss cooling as management of HIE
-Method of cooling
-Who should be cooled
-Pathophysiology behind management
-Efficacy of cooling
A
- Method of cooling
-Reduce temp to 34 degrees within 6hrs of birth and maintain for 72hrs with slow rewarming - Who should be cooled
-Moderate or severe HUE
- >36/40
-Evidence of acidosis pH <7 BE >16
-APGAR <5 - Pathophysiology behind management
-Ischemia causes primary neuronal death
-Upon re-establishment of circulation there can be secondary neuronal death in a zone around the initial neuronal death.
-Cooling aims to avoid / decrease this secondary neuronal death - Efficacy
-NNT in moderate HIE = 6
-NNT in severe HIE = 7
19
Q
What are the poor prognostic markers for HIE (6)
A
- Persistent seizures
- Persistent abnormal neurological exam
- Poor feeding by 2 weeks of age
- Limited evidence of recovery on EEG
- Abnormal MRI findings suggesting basal ganglia changes or cerebral atrophy
- Poor postnatal head growth
20
Q
Outline the steps of neonatal resus
A
- Assess infant for tone, breathing, crying
- Dry and take to resus site - resusitare
- Keep warm
- If poor breathing effort or HR <100 start positive pressure ventilation with room air
21
Q
Discuss subgaleal haemorrhage
-Presentation (7)
-Management ()
A
- Presentation
-Mean onset 1-6hrs post delivery
-Diagnosis is clinical. Don’t delay for imaging
Generalised signs:
-associated with blood loss and low 5 min apgar in setting of no asphyxia
Localised signs:
-Generalised skull swelling and scalp laxity, pitting oedema infront of ears
-Ballotable lesion that crosses suture lines
-Anterior displacement of the ears and periorbital oedema
-Crepitius or fluid thrill - flick test +
-Hypovolemic shock - Management
-Medical emergency.
-Involve senior paeds immediately
-Serial head measures may be useful but shouldn’t be considered reassuring
-Blood transfusion and aggressive fluid resus
-FFP and coagulation factors
-Phototherapy if Jaundice
22
Q
Discuss prevention strategies for subgaleal haemorrhage
-Appropriate patient selection (3)
-Proper technique (10)
-Medical prophylaxis (1)
A
- Appropriate patient selection
-Absolute contra-indication if <34/40
-Relative contraindication if <36/40
-Absolute contra-indication in infants with bleeding disorders - Proper technique
-Should be done by someone with adequate training or with supervision
-Cup should be placed on flexion point
-Cup should be /3cm (ideally 6cm) from anterior fontanelle
-Cup should be placed evenly across sagittal suture
-Steady traction with contractions and maternal effort only
-Good decent of head
-Avoid prolonged traction
-Abandon if time longer than 20mins and not delivered (consider changing tact after 15mins)
-Abandon if more than 3 pulls and head not yet on perineum (Can do more if birth imminent)
-Abandon if > 3 pop offs - Medical prophylaxis
-IM Vit K for all neonates with instrumental delivery
23
Q
Discuss neonatal surveillance for subgalial haemorrhage
-Levels of neonatal surveillance (3)
-Indication for monitoring at each level (3)
-What each level requires in terms of surveillance
A
- Intensity of surveillance should be based on perceived risk of SGH
- Level 1 neonatal surveillance
Indaction:
Minimum surveillance level for all infants delivered by instrumental or second stage CS
Monitoring
-Baseline obs and activity at 1 hr of age
-Structural assessments at 1-6hrs then at 24hrs post birth
-Avoid hats so changing head size and appearance can be noted
-If signs of SGH then escalate to level 2 surveillance
-If concern secondary to neonatal behaviour (irritable, poor feeding, pallor) escalate to level 2 - Level 2 neonatal surveillance
Indication:
-Total extraction time >20mins, >3 pulls, >2 pop offs
-5 min apgar <7
-At clinical request
-Level one surveillance causing concern
Monitoring:
-Take cord bloods
-Check Haemocrit and plts
-Continue formal neonatal SGH obs for 12 hrs - hrly x 2 then 2 hrly - Level 3 neonatal surveillance
Indications:
-Clinical suspicion following delivery
-Abnormalities noted on level 2 surveillance
Monitoring:
-Review by paeds with consideration for admission to NICU for ongoing investigation and management
24
Q
Discuss responsibility of neonatal resus
-Who should attend low risk births (3)
-Who should attend high risk births (3)
-Who decides who should be there
A
- Who should attend low risk births
-There should always be someone who is trained in neonatal resus
-Staff members trained in basic neonatal resus
(Resus steps up to CPR)
-Health practitioners with advanced resus skills should be available but not required at the birth - Who should attend high risk births
-Health practitioners with advanced resus skills (Intubation, vascular cannulation, use of drugs and fluids)
-The health practitioner should only be responsible for care of the baby (not the mother)
-More than one experienced health practitioner with training should be at the birth. - Who decides who should be there?
-The responsibility falls to the accoucher managing the birth to decide based on RF
25
Discuss the responsibilities of medical practitioners at neonatal resus
-Who decides on skill level required
-What should skill levels requirement be based on
-What should happen if ongoing care is needed post resus
1. Who decides
Requirement for staff skilled in advanced resus is at the discretion of the medical staff
2. Things to consider for need of skills
-Fetal risk factors
-Maternal risk factors
-Intrapartum risk factors
-Whether a skilled practitioner can be there urgently if required. If not then should be in attendance as a precaution or tx woman
3. Ongoing care post resus
-The responsible clinician should be free from other responsibilities
-There should be a clear hand over of duty and information
26
What are the criteria which suggests intrapartum CP (6)
1. Low apgar scores
2. High umbillical arterial lactates / low pH <7.0 BE >12
3. Early onset of HIE grades 2 and 3
4. Early imaging supporting an acute non-focal cerebral anomaly
5. Spastic quadraplegic or dykinetic CP
6. No other reason for CP
