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Birth Injuries and Brain Disorders

Operative deliveries, whether vaginal or abdominal, are more likely to result in birth injuries than are spontaneous deliveries. Birth injuries have been reported to occur in 27 of 1,000 live births, which results in 8-10 deaths in 100,000 live births. Furthermore, for every recorded neonatal death secondary to birth injury, 20 survivors endure permanent morbidity. Some of these injuries are preventable with proper obstetric technique, whereas others will occur even with the most meticulous attention to indication and method; some even antedate labor birth injuries and malpractice.

Fractures of the clavicle (2/1,000 live births) or long bones more commonly occur with vaginal breech delivery or shoulder dystocia. Fracture of the clavicle is often her-aided by an audible crack and can be confirmed by palpation or radiography after delivery. Long-bone fractures typically are less common and occur in the midshaft region secondary to manipulation during either vaginal.

Skull fractures are uncommon but should be considered with soft-tissue injury or cephalohematoma. They can sometimes be identified by palpation, but more commonly by radiography. There are three types: linear, depressed, and ping-pong (usually found in children, these fractures are so named because they resemble the indentation the finger can make in a ping-pong ball).

Facial nerve palsy usually results from pressure over the stylomastoid foramen, where the nerve exits the skull. Forceps delivery, particularly with rotation greater than 45 degrees, increases the risk of this injury. Surprisingly, facial nerve palsy.

Brachial plexus injury occurs when excessive lateral traction is applied to the fetal neck region during cephalic, breech, or cesarean birth. Injury to the upper plexus (C~5 to C-7) results in Erb's palsy with a limp arm (no Moro response) and pronation of the forearm; the grasp reflex is usually maintained. Most of these lesions are mild and responsive to conservative treatment.

Cephalohematomas occur in 0.2-2.5% of live births secondary to laceration of the subperiosteal vessels by movement of the scalp soft tissues above the more rigid bone. Generally, the development of a cephalohematoma is limited to a single cranial bone.

Cerebral palsy is a nonprogressive motor disorder that may be accompanied by epilepsy, mental retardation, or both. The incidence of 1-2 in 1,000 term infants has not changed in the past 20 years. There is a continuing misperception that birth asphyxia accounts for a significant portion of infants with cerebral palsy, despite a lack of supportive evidence. In a stepwise logistic regression analysis of data from the Collaborative Perinatal Project, no factor in labor or delivery was a major predictor of cerebral palsy. The leading predictors were maternal mental retardation, birth weight less than 2,000 g, fetal malformation, and breech presentation.

Obstetric Anesthesia and Analgesia

Obstetric anesthesia and analgesia refer to the multiple techniques used to alleviate pain associated with labor and delivery. Relief of discomfort and pain during labor and delivery is an essential part of good obstetric care. There are several significant differences between nonobstetric or surgical anesthesia and obstetric anesthesia. First and foremost, there are two patients to consider.

Systemic Agents

Although the use of regional anesthesia is increasing, obstetricians still commonly use parenteral narcotics and tranquilizers for pain relief during labor. These agents are especially useful in women who have contraindications to regional anesthesia (eg, patient refusal or coagulopathy) or when an anesthesia provider is not available. All narcotics have the disadvantages of causing delayed gastric