Professional Documents
Culture Documents
onfirmed;
at methodical meeting
of hospital pediatrics 1 department
hief of department
professor _____________V. A. Kondratyev
______ _________________ 2013 y.
METHODICAL INSTRUCTIONS
FOR STUDENTS` SELF-WORK
WHILE PREPARING FOR PRACTICAL LESSONS
Educational discipline
module
Substantial module
Theme of the lesson
pediatrics
2
8
Course
Faculty
5
medical
Birth trauma
Dnepropetrovsk, 2013
Definition
Injury of organs and tissues of a fetus which happens during the birth.
The most severe injuries are those with cerebral hemorrhage and they
require special treatment
Birth tumor
Cephalohematoma
Interbrain traumatic
hematoma
Hemorrhage
Paralysis of diaphragm
nerve (, 4 or 5)
Fracture of clavicle
Paralysis of Erb
Intraventricular
hemorrhage
Subdural hemorrhage
Subarachnoid
hemorrhage
Adiponecrosis
Neurosonography
Computer tomography
Magnetic-resonant
tomography.
hemorrhages or fractures at the newborn. The usage of obstetric instruments can enhance the
action of these forces, or cause damage independently. Appropriate use of obstetric
instruments can reduce asphyxia occurance. Though foot position leads to the greatest risk
and damage, extraction by Cesarean section doesn't guarantee that the baby won't be
damaged.
Features that predispose to the birth trauma
First labor
Small mother`s height
Pelvic anomalies at mother
Overdue or prompt childbirth
Long standing of prelying part of the fetus in one plane
Lack of waters
Wrong fetal position (for example, sciatic)
Use of forceps or vacuum extractor
Turn and fetal extraction
The infant with very low weight at the birth or deep prematurity
Fetus with the big head
Anomalies of fetal development
BT localization.
Classification of BT according to the classification: BT of soft tissues (muscles,
subcutaneous fatty cellulose, cephalohematoma), cerebral BT (injury of the skull bones,
intracranial hemorrhage: subdural, subarachnoid, intracerebral (parenchymatous),
intraventricular), BT of bones (fractures of the clavicle, tubular bones - humeral, femoral),
BT of the spinal cord, BT of peripheral nervous system (damage of the posterior nerve roots,
peripheral nerves).
Patogenesis of different forms of BT.
Causes of soft tissue damage: actual damage throughout the birth process, a squeezing
at the time of delivery, owing to fetal monitoring (plasing of electrodes on hairy part of the
head), a squeezing of the fetal head at the time of delivery, use of obstetric tools.
Damage of sterno-cleudo-mastoideus muscle (SCM). It is considered that SCMdamages to childbirth can be the cause of the congenital muscular torticollis.
Injury of skull bones. Compressional fractures are usually caused by the use of forceps
at the time of delivery. Fractures of the occipital bone are often caused by the difficult labour
at sciatic presentation and have poor prognosis. Forces which lead to the skull fractures, can
also cause closed injuries of the brain or ruptures of blood vessels that leads to subcutaneous
or intracranial bleedings. Fractures can be located below the level of cephalohematoma and
can lead to the attacks of hypotension or death.
Damage of the spinal cord is possible if the fetus has a big head. Children who have
sciatic presentation, are also belong to the risk group if have vaginal labor. The low
estimation by Apgar scale can display damage of the brain stem and/or a spinal cord.
Epidural hemorrhage is the most frequent injury of the brain which results in brain edema
and temporary denervation.
Paralysis of the diaphragmal nerve (C3, 4 or 5) can be result of overstretching of lateral
neck muscles. It is usually unilateral and often caused by the damage of the humeral plexus
(75% of patients).
Damage of the humeral plexus can be at traction of the head, neck, hands or trunk.
Hypotonic infants are especially sensitive to an excessive divergence of the segments of
bones and to the excessive extension.
Injury of bones. Changes are most often observed at sciatic presentation or the
transverse fetal position at infants with macrosomia, but can sometimes be observed after
Cesarean section. Usually it is caused by the traction and rotation of extremities.
Clinical symptoms
For the confirmation of the birth trauma careful medical examination of the infant
should be carried out with the consultation of neurologist. It is necessary to evaluate
symmetry of the structure and function, integrity and amplitude of movements of the joints
and to perform research of craniocerebral nerves.
Birth trauma of soft tissues.
Cephalohematoma ICD X code X: 12.0
Cephalohematoma is a subperiosteal hemorrhage, hence always limited to the surface
of one cranial bone. No discoloration of the overlying scalp occurs, and swelling is not
usually visible until several hours after birth because subperiosteal bleeding is a slow
process. An underlying skull fracture, usually linear and not depressed, is occasionally
associated with cephalohematoma. Most cephalohematomas are resorbed within 2 wk3 mo,
depending on their size. They may begin to calcify by the end of the 2nd wk.
ephalohematomas require no treatment, although phototherapy may be necessary to
ameliorate hyperbilirubinemia. Incision plus drainage is contraindicated because of the risk
of introducing infection in a benign condition. A massive cephalohematoma may rarely result
in blood loss severe enough to require transfusion.
The subaponeurotic hematoma is located in the space between a skull periosteum and
the tendinous helmet with distribution from eyebrow arches and to the occipital region. This
hematoma can extend through the skullcap Its growth can be not visible for hours or days, or
be manifested as hemorrhagic shock and, even, death. The hairy part of head skin can have
excavations like edema; round eyes and auricles there can be bruises.
Caput succedaneum is a diffuse, sometimes ecchymotic, edematous swelling of the
soft tissues of the scalp involving the portion presenting during vertex delivery. It may extend
across the midline and across suture lines. The edema disappears within the first few days of
life. Analogous swelling, discoloration, and distortion of the face are seen in face
presentations. No specific treatment is needed, but if extensive ecchymoses are present,
hyperbilirubinemia may develop. Molding of the head and overriding of the parietal bones
are frequently associated with caput succedaneum and become more evident after the caput
has receded, but they disappear during the first weeks of life.
Adiponekroz (focal necrosis of subcutaneous fatty cellulose) well located dense
knots, infiltrates of 1-5 cm in size in subcutaneous fatty cellulose of buttocks, backs,
shoulders, extremities. Occurs on 1-2 week of life. Skin over infiltrate or isn't changed, or
cyanotic, violet-red or red color. The general condition of the child is satisfactory,
temperature is normal.
Etiology of the disorder: local trauma, natal hypoxia, cooling. Prognosis
favorable. Infiltrates disappear independently without treatment in some weeks, sometimes3-5 months. Treatment usually should not be administered, sometimes thermal procedures are
prescribed (Sollyux, dry bandages with cotton wool), at widespread process vitamin E can be
administered.
Damage of the sterno-cleido-mastoideus muscle (SCM)
MKB code X: 15.2
SCM can be affected during delivery. Induration of SCM can be palpated at the birth or
(most often) can develop after the first 2-3 weeks of life.
Erythema, abrasions, ecchymoses, and subcutaneous fat necrosis of facial or scalp
soft tissues may be noted after forceps or vacuum-assisted deliveries. Their location depends
on the area of application of the forceps. Ecchymoses may be seen after manipulative
deliveries and occasionally in premature infants for no discernible reason.
Birth trauma of bones.
Fracture of a clavicle. MKB-H code: 13.4
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This bone is fractured during labor and delivery more frequently than any other bone;
it is particularly vulnerable with difficult delivery of the shoulder in vertex presentations and
the extended arms in breech deliveries. The infant characteristically does not move the arm
freely on the affected side; crepitus and bony irregularity may be palpated, and discoloration
is occasionally visible over the fracture site. The Moro reflex is absent on the affected side,
and spasm of the sternocleidomastoid muscle with obliteration of the supraclavicular
depression at the site of the fracture can be noted. Infants with greenstick fractures may not
have any limitation of movement, and the Moro reflex may be present. Fracture of the
humerus or brachial palsy may also be responsible for limitation of movement of an arm and
absence of a Moro reflex on the affected side. The prognosis is excellent. Treatment, if any,
consists of immobilization of the arm and shoulder on the affected side. A remarkable degree
of palpable callus develops at the site within a week and may be the initial evidence of the
fracture.
BT of nervous system.
Classification
A. BT of the central nervous system:
Intracranial hemorrhage.
Injury of bones of the skull.
Damage of the spinal cord.
B. BT of peripheral nervous system:
Damage of cervical nerve roots
a. Paralysis of a diaphragmal nerve (C3, 4 or 5)
b. Damage of the brachial plexus
(a) Injury of the fifth and sixth cervical spinal nerves (Erb paralysis).
(b) Damage of the seventh and the eighth cervical and the first thoracis spinal nerves
(Klyumpke paralysis).
(c) Total brachial plexus injury.
Injury of the cranial nerves (unilateral damages of branches of facial (VII) and vagal
(X) nerve)
a. Injury of a facial nerve.
(a) Injury of the central nerve
(b) Injury of a peripheral nerve
(c) Damage of the branch of a peripheral nerve
b. Injury of the laryngeal nerve
Cerebral birth traumas.
According to the classification intracranial hemorrhages are divided into subdural,
epidural, subependimal and multiple small cerebral, subarachnoidal, intra-and periventricular.
Causes of hemorrhages: mechanical actions, hypoxia (small diapedese hemorrhages are
characteristic: subarachnoidal and subependimal intraventricular).
Subdural of hemorrhage. MKB code X: 10.0 More often observes at long or
prompt childbirth. The subdural hematoma and edema of nearby tissues causes ventricular
dislocation, increase of intracranial pressure.
Clinical picture. Vascular shock (white asphyxia), hypertensive-hydrocephalic
syndrome, seizures, a tremor of big amplitude, asymmetry of congenital and tendon reflexes,
strengthening of the muscular tone. Subdural hemorrhages are one of the frequent causes of
neonatal mortality owing to the squeezing of the vital centers in the medulla oblongata
(respiratory and cardiomotor) and subcortical region.
depression, shock, or hypothermia, may deteriorate rapidly to death within several hours
before any neurologic signs are obvious. Alternatively, the course may be protracted, with
symptoms and signs appearing at birth or later in the 1st wk; immobility, flaccidity, and
associated brachial plexus injuries may not be recognized for several days. Constipation may
also be present. Some infants survive for prolonged periods, their initial flaccidity,
immobility, and areflexia being replaced after several weeks or months by rigid flexion of the
extremities, increased muscle tone, and spasms.
The differential diagnosis includes amyotonia congenita and myelodysplasia
associated with spina bifida occulta. Ultrasonography or MRI confirms the diagnosis.
Paralysis of a diafragmalny nerve (SZ, 4 or 5) MKH Code X: 14.2
Phrenic nerve injury (3rd, 4th, 5th cervical nerves) with diaphragmatic paralysis must
be considered when cyanosis and irregular and labored respirations develop. Such injuries,
usually unilateral, are associated with ipsilateral upper brachial palsy. Because breathing is
thoracic in type, the abdomen does not bulge with inspiration. Breath sounds are diminished
on the affected side. The thrust of the diaphragm, which may often be felt just under the
costal margin on the normal side, is absent on the affected side. The diagnosis is established
by ultrasonography or fluoroscopic examination, which reveals elevation of the diaphragm
on the paralyzed side and seesaw movements of the two sides of the diaphragm during
respiration.
Paralysis of Erba. MKB code - X: 14.0
Paralysis to Klyumpka. MKB CODE - X: 14.1
Total brachial plexus injury. MKB-H code: 14.3
Brachial plexus injury is a common problem, with an incidence of 0.64.6 per 1,000
live births. Injury to the brachial plexus may cause paralysis of the upper part of the arm with
or without paralysis of the forearm or hand or, more commonly, paralysis of the entire arm.
These injuries occur in macrosomic infants and when lateral traction is exerted on the head
and neck during delivery of the shoulder in a vertex presentation, when the arms are extended
over the head in a breech presentation, or when excessive traction is placed on the shoulders.
Approximately 45% are associated with shoulder dystocia. In Erb-Duchenne paralysis, the
injury is limited to the 5th and 6th cervical nerves. The infant loses the power to abduct the
arm from the shoulder, rotate the arm externally, and supinate the forearm. The characteristic
position consists of adduction and internal rotation of the arm with pronation of the forearm.
Power to extend the forearm is retained, but the biceps reflex is absent; the Moro reflex is
absent on the affected side. The outer aspect of the arm may have some sensory impairment.
When the injury includes the phrenic nerve, alteration in diaphragmatic excursion may be
observed fluoroscopically. Klumpke paralysis is a rarer form of brachial palsy; injury to the
7th and 8th cervical nerves and the 1st thoracic nerve produces a paralyzed hand and
ipsilateral ptosis and miosis (Horner syndrome) if the sympathetic fibers of the 1st thoracic
root are also injured. MRI demonstrates nerve root rupture or avulsion.
Additional investigations at BT diagnostics.
There are used X-ray investigation, neurosonography, computer tomography (CT),
magnetic resonance tomography. These methods allow not only to diagnose damage, its
localization, distribution, but also to carry out differential diagnostics.
The occipital hematoma can imitate brain hernia, ultrasonic investigation of the skull
should be carried out.
Radiological researches are used for the diagnostics of skull injuries. Cranial KT will
indicate the presence of intra cranialhemorrhage or edema. Myelography should be
preformed if there is suspition on damage of the spinal cord.
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arm is paralyzed, the same treatment principles should be followed. Gentle massage and
range-of-motion exercises may be started by 710 days of age. Infants should be closely
monitored with active and passive corrective exercises. If the paralysis persists without
improvement for 36 mo, neuroplasty, neurolysis, end-to-end anastomosis, and nerve
grafting offer hope for partial recovery.
No specific treatment of phrenic nerve paralysis is available; infants should be placed
on the involved side and given oxygen if necessary. Initially, intravenous feedings may be
needed; later, progressive gavage or oral feeding may be started, depending on the infant's
condition.
The prognosis of facial nerve palsy depends on whether the nerve was injured by
pressure or whether the nerve fibers were torn. Improvement occurs within a few weeks in
the former instance.
The prognosis of clavicular fracture is excellent. Treatment, if any, consists of
immobilization of the arm and shoulder on the affected side. A remarkable degree of palpable
callus develops at the site within a week and may be the initial evidence of the fracture.
Satisfactory results of treatment of a fractured humerus are obtained with 24 wk of
immobilization during which the arm is strapped to the chest, a triangular splint and a
Velpeau bandage are applied, or a cast is applied. For fracture of the femur, good results are
achieved with traction-suspension of both lower extremities, even if the fracture is unilateral;
the legs, immobilized in a spica cast, are attached to an overhead frame. Splints are effective
for treatment of fractures of the forearm or leg. Healing is usually accompanied by excess
callus formation. The prognosis is excellent for fractures of the extremities.
Prevention of BT and its complications.
Appropriate use of obstetric tools.
Planned Cesarean section at the wrong fetal presentation, multiple pregnancy, clinically or
anatomic narrow pelvis.
Prevention of complications: timely identification and if it is necessary, treatment of bith
traumas.
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B. Clinical cases
Case 1
A female infant is born by normal vaginal delivery after induction for prolonged
pregnancy. The prenatal course was unremarkable. Apgar scores are 6 at 1 minute and 9 at 5
minutes. When attempting to breastfeed at 2 hours of life, she develops opisthotonos-like
posturing, hyperextending her neck and arching her back. Physical examination reveals an
infant lying on a warmer, sucking vigorously on a nurses finger. Her weight is 3,520 g, heart
rate is 130 to 150 beats/min, respiratory rate is 30 to 40 breaths/min, pulse oximetry level is
98% to 100% on room air, and rectal temperature is 37C (98.6F). The remainder of
physical findings are normal, except for the abnormal posturing, which occurs when she is
touched.
White blood cell count is 27.9 x 109/L (27,900/cu mm), with 45% segmented
neutrophils, 5% bands, 36% lymphocytes, 4% monocytes, and 10% atypical lymphocytes.
Measurement of hematocrit, platelets, chemistry screen 7, and liver-associated enzymes
yields normal findings, as does ultrasonography of the head. Lumbar puncture reveals redtinged cerebrospinal fluid that does not clear. The fluid contains 35,453/cu mm erythrocytes
and 77/cu mm leukocytes (86% mononuclear and 14% polymorphonuclear cells), a glucose
level of 2.11 mmol/L (38 mg/dL), and a total protein level of 1.59 g/L (159 mg/dL). Gram
stain of the fluid reveals no organisms.
Computed tomographic (CT) scan of the head revealed increased attenuation over the
superior aspect of the left cerebellar hemisphere and to a lesser extent over the right
cerebellar hemisphere, extending along the tentorium.
Questions
1. What is the definitive diagnosis?
2. Write down confirmation of the diagnosis.
3. What are the risk factors of this disorder in the neonates?
4. How to treat this condition?
Case 2
An infant boy is born to a 33-year-old mother at 41 weeks of gestation. The mother has
had herpes simplex virus (HSV) infection but no active lesions at the time of delivery.
Artificial rupture of membranes yielding clear fluid occurs 9 hours prior to delivery, and the
delivery is uncomplicated and spontaneous. The baby has Apgar scores of 7 and 8, and the
initial physical examination shows all normal findings. At 24 hours after birth, while feeding,
the baby turns blue and appears to stop breathing. He responds to tactile stimulation with
improved color. Another apneic episode occurs, at which time his pink color again changes to
blue. The infant responds to bag-and-mask resuscitation with immediate improvement in
pulse oximetry saturation from 40% to 98%.
Compete blood count, chemistry panel, and radiograph of the chest all yield normal
results. Arterial blood gas levels are normal, with an arterial oxygen pressure of 200 torr
while receiving free-flow oxygen. Blood cultures and surface cultures for HSV are obtained.
Because of multiple apneic episodes occurring over the next hour, with desaturation down to
40% requiring intervention with bag-and-mask ventilation, the infant is intubated.
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Lumbar puncture revealed frankly bloody fluid that did not clear during the procedure. The
cerebrospinal fluid (CSF) was xanthochromic and contained 460,000 erythrocytes and 748
leukocytes/mm3; the glucose level was 61 mg/dL (3.4 mmol/L) and protein level was greater
than 200 mg/dL (2,000 g/L); and no bacteria were seen on Gram stain. Fluid was sent for
polymerase chain reaction (PCR) testing for HSV.
Computed tomography (CT) of the head revealed blood filling the right lateral
ventricle and distending its posterior horn. There also was a small left subdural hematoma. A
repeat hematocrit performed 6 hours later showed a drop from 51% to 41%. Findings of
coagulation studies were within normal limits for a term newborn.
Questions
1. What is the definitive diagnosis?
2. Write down confirmation of the diagnosis.
3. What are the causes of apnea during the first days after birth?
4. What is the major complication of this condition?
C. Tests
Question 1. Routine head ultrasonography in infants <1,500 g to detect intracranial
hemorrhage is best described as:
1. Performed between 7 and 14 days and at 36-40 wk
2. Performed for anemia
3. Performed for seizures
4. Performed at birth and at 40 wk
5. Performed between 7 and 14 days and at 1 yr of age
Answer A. Explanation: In addition, nonroutine ultrasonography should be performed for
symptoms of intraventricular hemorrhage (IVH) and for the follow-up of abnormalities noted
on the first
ultrasound.
Question 2. The management of post-hemorrhagic hydrocephaly includes all of the
following except:
A. Serial head circumferences
B. Serial head ultrasound examinations
C. External ventricular drainage
D. Ventricular-peritoneal shunt
E. Repeated lumbar punctures
Answer E. Explanation: Although repeat lumbar puncture (LP) is often done, most
physicians do not believe that they avoid the need for a ventricular peritoneal (VP) shunt.
Most cases of dilated ventricles after IVH do not necessitate later placement of a shunt.
Question 3. A 12-day-old, large-for-gestational-age infant is noted to have Erb palsy. You
should do all of the following except:
1. Refer for immediate neuroplasty
2. Refer for physical therapy
3. Reassure the family
4. Determine if the clavicle is fractured
5. Look for additional nerve involvement (phrenic)
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Answer A. Explanation: Most Erb palsies resolve rapidly with immobilization, rehabilitation,
and positioning. If there is no improvement between 3-6 mo, a referral for surgical evaluation
is indicated
Question 4. A term baby of an uncomplicated pregnancy is born limp, cyanotic, and apneic
after a difficult vaginal delivery. Possible considerations in the differential diagnosis include
all of the following except:
1. Prolapsed umbilical cord
2. Central nervous system trauma
3. Administration of morphine to the mother
4. Klumpke paralysis
Answer D. Explanation: Klumpke paralysis involves injury to the 7th and 8th cervical nerves
and the 1st thoracic nerve. It is usually unilateral, due to traction injury of the brachial
plexus. Administration of local anesthetic into the fetal scalp
Question 5. After intubation and resuscitation, the patient in Question 70 remains limp but
appears aware and looks around, although the baby does not cry when the toes are pinched.
The most likely diagnosis is:
1. Congenital botulism
2. Narcotic overdose
3. Transection of the spinal cord
4. Congenital myasthenia gravis
5. Neurosyphilis
Answer C. Explanation: Transection of the spinal cord may occur in vertex and breech
positions and may be noted with normal vertebral body anatomy. It would manifest as in this
patient, and also with shock, hypothermia, and bowel and bladder dysfunction. With time,
hypotonia resolves into hypertonia and hyperreflexia.
Question 6. An infant girl is born via spontaneous vaginal delivery at 28-week gestation
because of an incompetent cervix. Which of the following features of her clinical course in
the neonatal intensive care unit (ICU) is most likely to correlate with her clinical outcome 5
years from now?
A. Administration of surfactant
B. Apnea of prematurity
C. Grade IV intraventricular hemorrhage
D. Retinopathy of prematurity stage 1 on initial ophthalmologic examination
E. Umbilical artery catheterization
Answer C. Intraventricular hemorrhage is a complication in preterm infants. It is associated
with seizures, hydrocephalus, and periventricular leukomalacia. A grade IV bleed involves
the brain parenchyma, putting this child at higher risk for neurodevelopmental handicap.
Question 7. A 1-day-old infant who was born by a difficult forceps delivery is alert and
active. She does not move her left arm, however, which she keeps internally rotated by her
side with the forearm extended and pronated; she also does not move it during a Moro reflex.
The rest of her physical examination is normal. This clinical picture most likely indicates
A. Fracture of the left clavicle
B. Fracture of the left humerus
C. Left-sided Erb-Duchenne paralysis
D. Left-sided Klumpke paralysis
E. Spinal injury with left hemiparesis
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Answer C.
Question 8. A30-day-old, former 24-weeks gestation, 600 g neonate had a difficult initial
respiratory course complicated by a tension pneumothorax. She had serial head ultrasound
evaluations during the first weeks of life. All previous studies revealed a normal immature
brain. Now, the head ultrasound reveals an abnormality. Among the following, which is most
likely?
A grade II intraventricular hemorrhage
B grade IV intraventricular hemorrhage
C aqueductal stenosis
D periventricular leukomalacia
E vein of Galen aneurysm
Answer D. Periventricular leukomalacia (PVL) is characterized by focal necrotic lesions in
the periventricular white matter. Cranial ultrasound can detect focal echo denisities and/or
cystic lesions surrounding the lateral ventricles that are diagnostic of PVL. Other imaging
techniques may be needed to detect more diffuse injury. These lesions are rarely found in
infants greater than 32 weeks gestation. Premature infants are predisposed to the
development of PVL due to the complex interaction between the cerebral vasculature and
regulation of cerebral blood flow that is gestatonal age dependent. Actively differentiating or
myelinating periventricular glial cells are also vulnerable to injury. The findings of PVL may
not be evident until 1 month of age or later. Congenital anomalies of the brain and
intraventricular hemorrhage usually are readily apparent on imaging in the first days of life.
Question 9. Aterm 4.3-kg infant is delivered vaginally to a 33-year-old woman with
juvenile-onset diabetes. The delivery was complicated by severe shoulder dystocia and the
infant experienced a brachial plexus injury with limited movement of the right arm. At 72
hours of age, the infant is noted to be tachypneic but he is pink and well perfused. Which of
the following is the most likely explanation for his tachypnea?
A respiratory distress syndrome (RDS)
B diaphragmatic paralysis
C pulmonary hemorrhage
D pneumothorax
E cystic adenomatoid malformation of the lung
Answer B. Brachial plexus injury results from stretching of the plexus and nerve roots. The
upper roots (C5 and C6) are most vulnerable to injury. Phrenic nerve injury on the same side
of the injury may occur, which results in diaphragmatic paralysis. This risks are highest for
brachial plexus injury if the infant is large for gestational age and/or if the labor and delivery
is complicated. Respiratory distress syndrome is uncommon in term infants and almost
always presents initially in the first 24 hours of life. Pulmonary hemorrhage, pneumothorax,
and cystic adenomatoid malformation can cause cyanosis and respiratory distress but have no
association with brachial plexus injury.
Question 10. A 5-day-old, large-for-gestational-age, 4,500-g boy has a bilirubin level of 21
mg/dL. There is no anemia or polycythemia, but on examination he has a large
cephalohematoma. The next therapeutic activity should be to:
A. Aspirate the hematoma
B. Perform an incision and drainage of the hematoma
C. Undertake prophylactic blood transfer
D. Administer phototherapy
E. Perform exchange transfusion
15
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7. Fetal and neonatal secrets. - second edition . / Ed. by R.A.Polin, A.R.Spitzer. - Elsevier.2006.
8. Key Topics in Neonatology / Ed. by R.H. Mupanemunda, M. Watkinson. - Oxford
Washington DC. -1999.
Protocol _____
V. A. Kondratyev
Reconsidered
Approved _________________20____.
hief of the department, professor
Protocol _____
V. A. Kondratyev
Reconsidered
Approved _________________20____.
hief of the department, professor
Protocol _____
V. A. Kondratyev
Reconsidered
Approved _________________20____.
hief of the department, professor
Protocol _____
V. A. Kondratyev
Reconsidered
Approved _________________20____.
hief of the department, professor
Protocol _____
V. A. Kondratyev
Reconsidered
Approved _________________20____.
hief of the department, professor
Protocol _____
V. A. Kondratyev
Reconsidered
Approved _________________20____.
hief of the department, professor
Protocol _____
V. A. Kondratyev
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