Birth Trauma

Birth trauma (BT) is a term that refers to infant injuries caused by excessive force during delivery, as well as the long-term consequences of the injury, such as cerebral palsy, hypoxic-ischemic encephalopathy (HIE), seizures, and intellectual disabilities.

Traumatic birth injury (birth trauma) is a subset of birth injury caused by physical pressure during delivery; these injuries specifically impact the baby’s tissues and organs (1). Birth trauma is often caused by mechanical force, but it can also be caused by the overuse of delivery drugs, mismanaged abnormal presentation, and other complications.

Doctors can avoid birth trauma by following best care practices and skillfully handling labor and delivery complications (1).

Traumatic birth injuries are caused by situations during labor and delivery that put excessive physical pressure on the baby’s body. This often comes as a result of a discrepancy between the size of the mother’s birth canal and the size or position of the baby during labor and delivery (1). While many traumatic birth injuries heal themselves and do not lead to long-term health complications, more serious birth trauma can lead to permanent disabilities and conditions.

Below are some of the most common causes of birth trauma:

Forceps and vacuum extractors are two tools that may be used during delivery to help guide the baby out of the birth canal if labor is not progressing naturally.  Forceps are large tongs that are applied to each side of the baby’s head to help position and pull the baby through the birth canal. A vacuum extractor is a small suction cup that is placed on the baby’s head to help guide the baby through the birth canal. Both of these tools rely on traction (force).

Forceps are large tongs that are applied to each side of the baby’s head to help position and pull the baby through the birth canal. A vacuum extractor is a small suction cup that is placed on the baby’s head to help guide the baby through the birth canal. Both of these tools rely on traction (force).

While forceps and vacuum extractors can help move the baby along during the delivery process, they are very risky tools (2). Physicians often lack the skills necessary to properly use these instruments. Forceps and vacuum extractors must be precisely positioned on the baby’s head, traction must not be applied for too long, and there should not be too much traction used to pull the baby out (2). If misused, forceps can cause trauma to the skull and spinal cord, which can lead to brain bleeds and hemorrhages.

Similarly, the pressure of the suction cup used during vacuum extraction can cause brain bleeds, lacerations, and brachial plexus injuries (2).

Traumatic birth injuries from forceps and vacuum extractor misuse can lead to hypoxic-ischemic encephalopathy (HIE), seizures, and cerebral palsy.

Pitocin (synthetic oxytocin) and Cytotec (synthetic prostaglandin) are two drugs used to aid in the induction and progression of labor by initiating contractions. However, the use of both Pitocin and Cytotec can be very dangerous to both the mother and baby because of the intense contractions that often occur as a result of these drugs (3).

If used in improper doses, or if used when ill-advised, contractions can become excessively strong and frequent, a condition known as hyperstimulation (tachysystole). When a baby is subject to hyperstimulation (often combined with prolonged periods of pushing and forcing), the excessive pressure applied to the baby’s body increases the likelihood of traumatic birth injury (4).

In addition, hyperstimulation caused by labor drugs puts the baby at risk for cord compression and uterine rupture, which can both lead to traumatic birth injury and/or oxygen deprivation (3).

Under normal circumstances, a baby is in the cephalic (vertex) position before delivery. In the cephalic position, the baby’s head is at the lower part of the abdomen in preparation for childbirth; subsequently, a head-first birth occurs. However, some babies present differently before delivery. In these cases, abnormal presentations may place the baby at risk of experiencing birth trauma (5).

While there are many presentations that can be problematic for vaginal delivery, there are three specific presentations that can cause traumatic birth injuries if mismanaged.

Breech presentation

Breech presentation occurs when a baby’s buttocks or legs are positioned to descend into the birth canal first. If vaginal delivery is attempted when a baby is in breech position, the risk of traumatic birth injuries – such as brain bleeds and spinal cord fractures – is elevated. In addition, other complications such as umbilical cord prolapse or compression can cause oxygen deprivation and severe injury. Most experts recommend C-section delivery for all types of breech positions because it is the safest method of delivery and it helps avoid birth trauma and other injuries (6).

Shoulder presentation (transverse lie)

Shoulder presentation (transverse lie) occurs when the arm, shoulder, or trunk of the baby enters the birth canal first. C-section delivery is almost always the safest method of delivery for a baby in this position. If vaginal delivery is attempted, cord complications, brain bleeds, and head trauma can occur, leading to traumatic birth injury (7).

Face presentation

Like the name suggests, face presentation occurs when the baby’s face is the presenting body part. In many vaginal deliveries of babies in face presentation, facial trauma, skull-molding, spinal cord injury, swelling of the neck and head, brain bleeds, and other severe traumatic birth injuries occur. Because of these risks, experts recommend a liberal use of c-sections when a baby presents with the face first (5). Brow presentation, in which the brow (forehead) presents first, is very similar to face presentation and can also lead to birth trauma if mismanaged (7).

Fetal macrosomia occurs when a baby is considered large for their gestational age. Macrosomia often results from maternal obesity, gestational diabetes, or post-term pregnancy.  Oftentimes, macrosomia is accompanied by a pregnancy complication known as cephalopelvic disproportion (CPD) in which there is a size mismatch between the mother’s pelvis and the baby’s head.

When either macrosomia or CPD occur, or when both occur together, vaginal delivery can be very difficult. C-section is often the recommended method of delivery in these cases. Attempted vaginal delivery may cause traumatic birth injuries such as brain bleeds, facial nerve injuries, or fractures of the clavicle. In addition, serious pregnancy complications such as cord compression and shoulder dystocia (see below) can arise, also resulting in injury to the baby if mismanaged (8).

Shoulder dystocia occurs when the baby’s shoulder gets stuck on the mother’s pelvis during delivery. When shoulder dystocia causes a failure of progression during labor, physicians often apply too much force to the baby’s head to try and deliver. This force can cause traumatic birth injuries such as brain bleeds and trauma to the skull and spinal cord (2).

Even if the force applied to the baby’s head is minimal, traumatic injuries to the shoulder and surrounding nerves such as Erb’s palsy and fractures can result (9). Because of these risks, C-section may be the safest way to deliver when shoulder dystocia is present (10).

Prevention of birth trauma requires proper medical care and appropriate assessment of the mother and baby.

If a pregnancy is high-risk, it is essential that physicians recognize this and take the proper precautions. The precautions needed to prevent birth trauma are dependent upon the specific clinical circumstances of the patient. When certain conditions are present, it may be very dangerous to deliver a baby vaginally.  In many instances, a C-section is required. Repeated attempts at vaginal delivery – especially in instances in which vaginal delivery is against the standard of care – can cause brain bleeds and other traumatic injuries that can cause hypoxic-ischemic encephalopathy and cerebral palsy.  When any signs of distress appear on the fetal heart rate monitor, the baby must be delivered as quickly as possible, and C-section delivery is usually the best and safest way to do this.

Birth trauma can usually be avoided if the medical team adheres to the following:

• Take a thorough history of the mother and perform proper evaluations in order to timely diagnose any issues that make the pregnancy and delivery high-risk.
• The team must be aware of the baby’s position at the time of delivery.
• Fetal heart rate monitoring must be initiated as soon as the mother arrives at the hospital with any pregnancy-related issues, and of course, fetal monitoring must be ongoing when the mother’s labor begins.
• The baby must be promptly delivered as soon as fetal distress is noted on the heart rate monitor. The safest way to do this is almost always by C-section delivery, and many conditions require a C-section, such as certain breech and face presentations, CPD, uterine rupture and placenta previa. All procedures – as well as the risks and alternatives – must be thoroughly explained to the mother.

The information presented above is intended only to be a general educational resource. It is not intended to be (and should not be interpreted as) medical advice.