Birth injury. Birth trauma of a newborn: a problem of obstetrics and neonatology

Lecture №1 TOPIC 1.1. TREATMENT OF DISEASES IN NEWBORN

Asphyxia. Birth trauma. Encephalopathy

Pathology of newborns is one of the urgent problems of pediatrics. The neonatal period of life is given special attention, associated with the physiological characteristics of a newborn child, a peculiar pathology and high mortality. In the structure of morbidity in newborns, asphyxia and lesions of the central nervous system occupy the first place in frequency, followed by congenital malformations, hemolytic disease newborns, purulent-septic diseases, pneumonia.

ASPHYXIA OF THE NEWBORN

Asphyxia of the newborn- a syndrome characterized by the absence or individual irregular and inefficient respiratory movements of the child in the presence of cardiac activity. Violation of gas exchange is accompanied by a lack of oxygen in the blood (hypoxemia) and tissues (hypoxia), the accumulation of excess carbon dioxide (hypercapnia) and underoxidized metabolic products with the development of acidosis. With asphyxia, the function of vital organs is disrupted: the central nervous and cardiovascular systems, the liver.

Classification:

I. By reason of occurrence, they distinguish:

1. Fetal asphyxia, which is based on circulatory disorders

2. Asphyxia of a newborn, which is based on the disorder

II. By time of occurrence:

1. Primary occurring after ligation of the umbilical cord

2. Secondary arising in the following hours and days of a newborn's life.

Primary asphyxia (hypoxia) observed in newborns at birth. Hypoxia, which appears in a child some time after birth, is called secondary.

To risk factors development of asphyxia of the fetus and newborn include:

1) in the antenatal (intrauterine) period - prolonged gestosis of pregnant women, the threat of abortion, polyhydramnios or a small amount of amniotic fluid, post-term or multiple pregnancy, bleeding and infectious diseases in the 2nd-3rd trimesters of pregnancy, severe somatic diseases of the mother, intrauterine growth retardation fetus;

2) in the intranatal period (during childbirth) - abnormal fetal presentation, premature detachment of the placenta, premature birth, long anhydrous period, protracted labor, discrepancy between the fetal head and the size of the mother's small pelvis, prolapse, knots and entanglement of the umbilical cord, the use of obstetric forceps; diseases of the heart, lungs and brain in the fetus;

drugs used by a pregnant woman (antidepressants, reserpine, magnesium sulfate, adrenoblockers).

Secondary (acquired) hypoxia may develop as a result of aspiration, pneumopathy, birth trauma of the brain and spinal cord, ineffective resuscitation in the treatment of primary asphyxia, congenital heart, lung and brain defects.

Clinical picture primary asphyxia. The state of the newborn is assessed using the Virginia Apgar score for the five most important clinical signs.

The state is assessed by the sum of points and points for each attribute separately. Healthy newborns have an overall score of 8-10 points.

According to the WHO classification, there are two degrees of asphyxia: moderate - the total score is 6-5 points and heavy 4-1 points.

moderate degree asphyxia is characterized by not pronounced cyanosis skin, clear, but slow heartbeats, rare and shallow breathing, satisfactory muscle tone, preserved response to the introduction of a nasal catheter (or to irritation of the foot).

At severe asphyxia, a state of deep inhibition is observed. The skin integuments in newborns are pale, the mucous membranes are cyanotic, there is no breathing, the heart sounds are muffled, sharply slowed down (up to 60-80 beats per minute), arrhythmic. Muscle tone and reflexes are significantly reduced or completely disappear.

Assessment of signs of live birth. It is carried out immediately after the birth of the child. Signs of live birth are: spontaneous breathing, heartbeat, pulsation of the umbilical cord, voluntary muscle movements. In the absence of all four signs of a live birth, the child is considered stillborn and is not subject to resuscitation. If a child has at least one of the signs of a live birth, he must immediately (!) Provide primary and resuscitation care, without waiting for the end of the 1st minute of life, when the first Apgar score will be performed. The volume and sequence of resuscitation measures depend on the severity of spontaneous breathing, heart rate and skin color.

An Apgar score is performed at the end of the 1st and 5th minutes of life to determine the severity of asphyxia and the effectiveness of resuscitation. In the future, if continued resuscitation is required, the assessment is repeated every 5 minutes until the 20th minute of life.

Complications of asphyxia

Early (in the first hours and days of life) - cerebral edema, cerebral hemorrhage, heart failure, pulmonary hypertension, impaired renal and hepatic function, anemia)

Late-infectious (pneumonia, sepsis, meningitis), neurological (hydrocephalic syndrome, encephalopathy)

Treatment

Primary resuscitation in the delivery room. The goal is to achieve the highest possible Apgar score by the 5-20th minute of life.

Resuscitation is based on strict observance generally accepted resuscitation principles formulated by P. Safar (1980) as the ABC rule, where:

BUT - airways- release, maintenance of free patency of the airways;

B- breath- breathing, provision of ventilation - artificial (IVL) or auxiliary (IVL);

C- cordial, circulation- restoration or maintenance of cardiac activity and hemodynamics.

Principle A is:

1) in ensuring the correct position of the newborn (the head end of the bed should be lowered by 15 °, the position of the child should be with the head slightly thrown back);

2) aspiration of contents from the mouth, nose and, in some cases, from the trachea (amniotic fluid aspiration);

3) carrying out endotracheal intubation and sanitation of the lower sections respiratory tract.

Principle B includes:

1) tactile stimulation (in the absence of a cry within 10-15 seconds after birth, the child is transferred to the resuscitation table);

2) using a jet stream of oxygen;

3) carrying out auxiliary or artificial ventilation of the lungs (if necessary) using a bag Ambu and mask or bag and endotracheal tube, starting with the supply of air-oxygen mixture (Fi0 2 - 20-21%). A properly fitted mask fits snugly to the face, covers the mouth, nose and edge of the chin, but does not cover the eyes.

Principle C includes:

1) indirect massage hearts;

2) the introduction of medicines.

To determine the volume of primary resuscitation of newborns, the assessment of the state of the child according to the Apgar scale is traditionally used. The most informative is the determination of the parameters that make up the "cardiorespiratory" component of the scale: the number of heartbeats, the nature of breathing, the color of the skin.

When assessed: heart rate - 2 points, respiration - 2 points, skin color - 1 point- Resuscitation is not required.

When assessing: heart rate - 2 points, breathing - 1 point, skin color - 1 point - it is necessary, after a thorough sanitation of the upper respiratory tract, to carry out auxiliary ventilation of the lungs with a mask of 20-21% oxygen for 2-5 minutes.

When assessed: heart rate - 2 (1) points, respiration - 1 point, skin color - 0 points, it is necessary to conduct a control sanitation of the tracheobronchial tree (TBD) under the control of direct laryngoscopy, to assess the nature of the contents in the catheter. In the absence of contents or a meager amount of aspirate, mask ventilation can be performed. The presence of an abundant amount of amniotic fluid, blood, green staining of the contents requires the sanitation of the TBD and the solution of the issue of tracheal intubation and mechanical ventilation. The presence of thick meconium in the LBT, which hinders effective sanitation, requires lavage (instillation) of the LBT with warm saline at the rate of 0.2–0.5 ml/kg and mechanical ventilation. The multiplicity of lung lavage is determined by the nature of the resulting lavage water (without meconium admixture).

When assessed: heart rate - 1 (2) points, respiration - 0 points, skin color - 0 points- it is necessary to intubate the trachea, sanitize the TBD and take the child on a ventilator.

Heart Rate Estimation and action tactics are as follows.

Ø If the heart rate is less than 60-80 beats / min, closed heart massage and lung ventilation are required. With an increase in heart rate, ventilation should be continued. In order to maintain adequate circulation, the effort applied during closed lung massage should be such that the heart rate is 120 bpm. The ratio of ventilation and indirect massage is 1: 3.

Ø If there is no effect within 10 s against the background of ongoing resuscitation (HR 80-60 bpm) and 100% oxygen supply, chest compressions and ventilation should be continued. This situation shows:

1) tracheal intubation and artificial lung ventilation;

2) the introduction of medicines through the endotracheal tube, into which a special catheter is placed, extending 1 cm below the end of the endotracheal tube:

0.01% adrenaline solution- 0.1-0.3 ml/kg (1 ml 0.1% adrenaline solution dilute in 9 ml 0.9% sodium chloride solution),

in the absence of effect through the umbilical catheter - 0.01% adrenaline solution or atropine(eliminates sinus bradycardia) at a dose of 0.1-0.3 ml / kg. When the heart rate reaches more than 80-100 bpm, closed heart massage stops. Ventilation is continued until the heart rate reaches 100 beats/min and the newborn has spontaneous breathing.

Ø If the heart rate remains less than 100 bpm, you should:

1) repeat the introduction of adrenaline, if necessary, this can be done every 5 minutes, but no more than 3 introductions;

2) introduce drugs that replenish the BCC, if there are signs of hypovolemia (pallor of the skin against the background of inhalation of 100% oxygen, a weak pulse with good heart rate, arterial hypotension, muscular hypotension, a symptom of a "white spot" for 3 s or more, a drop in CVP, the absence of the effect of ongoing resuscitation) or acute blood loss. Dosage of the chosen drug (5% albumin solution, 5% glucose solution, 0.9% saline solution, 6% infucol solution) is 10-15 (20) ml/kg into the vein of the umbilical cord for 5-10 minutes, in premature babies - for 30-60 minutes;

3) in the absence of effect - the introduction prednisolone at the rate of 1-2 mg/kg or hydrocortisone- 5-10 mg/kg.

4) 4% sodium bicarbonate solution at a dose of 2-4 ml / kg intravenously for 2 minutes in a 5-fold dilution for 0.9% saline with confirmed decompensated metabolic acidosis .

Resuscitation measures are carried out with obligatory observance temperature regime in the resuscitation room (26-28 °C), control of the child's body temperature (from 36.4 to 37.0 °C), as well as oxygen saturation using a pulse oximeter.

Resuscitation measures in the delivery room are terminated if, during the first 20 minutes after birth, against the background of adequate resuscitation measures, the child's cardiac activity is not restored.

Treatment in the post-resuscitation period includes several stages.

Ø Care. The child needs to be provided with a thermoneutral environment. Newborns born in a state of severe asphyxia should be nursed in incubators; with moderate asphyxia, nursing in cribs is possible (on the first day with additional heating), it is necessary to exclude sound and pain stimuli.

Ø Feeding. The first feeding begins with a food tolerance test (saline in the volume of a single feeding). After suffering moderate asphyxia, enteral feeding usually begins after 6-12 hours, with severe asphyxia, the timing is individual.

Ø Oxygen therapy. It is carried out by various methods (nasal catheters, mask, oxygen tent, mechanical ventilation).

Ø Planned infusion therapy. If necessary, it is optimal to start it 40-50 minutes after birth.

Usual volume of infusion therapy 10% glucose solution on the 1st day is 60-80 ml/kg and provides the minimum physiological need for water and calories in the first 2-3 days of life.

Ø Medical therapy. The main groups of drugs used in the acute posthypoxic (postresuscitation) period:

antihypoxants and anticonvulsants (20% GHB solution- 50-100 mg/kg; 0.5% solution of seduxen- 0.2-0.4 mg/kg, phenobarbital- 5-20 mg/kg day);

antioxidants (5, 10% oil solution vitamin E- 0.2 ml/kg, 0.1 ml/kg, respectively; aevit- 0.1 ml/kg; 0.25% cytochrome C solution or cytomac- 1 ml/kg);

corrective metabolic disorders (4% sodium bicarbonate solution) are calculated individually;

cardiotonic to restore central and peripheral hemodynamics, 0.5% dopamine solution, 4% dopmin solution the dose of drugs is calculated individually;

with persistent arterial hypotension, it is possible to prescribe hydrocortisone at a dose of 1 mg/kg every 8 hours;

diuretic drugs are prescribed to stop cerebral edema. Saluretics are used (1% lasix solution- 1-2 mg/kg, verospiron- 2-4 mg/kg day);

hemostatic drugs, it is necessary to prescribe vitamin K- 1-2 mg/kg; according to indications fresh frozen plasma- 10-15 ml/kg, angioprotectors - 12.5% ​​solution of dicynone, etamsylate- 10-15 mg/kg.

By the end of the early neonatal period for the rehabilitation of the central nervous system are assigned:

nootropic drugs that normalize the processes of neurometabolism and blood circulation in the central nervous system: phenibut, pantogam up to 100 mg/day in 2 divided doses (sedation) or piracetam- 50-100 mg/kg day, picamilon- 1.5-2.0 mg / kg per day in 2 doses, aminalon- 0.125 mg 2 times a day, encephabol- 20-40 mg/kg daily;

drugs that improve cerebral circulation (in the absence of intracranial hemorrhage) - trental, cavinton, vinpocetine- 1 mg/kg, tanakan- 1 cap. / kg 2 times a day.

Monitoring program. Several times a day, the child's body weight is monitored. The increase in body weight against the background of infusion therapy is dangerous. From the first hours of life, the hourly diuresis of the newborn is determined. It should be 0.3-0.5 ml / kg h on the first day, 1.5-2 ml / kg h on the 2-3rd day. It is desirable to achieve diuresis by the 5-6th hour of the child's life. Control of respiratory rate, heart rate, blood pressure helps to prevent fluid overload of the vascular bed. The newborn child is shown biochemical research blood serum, hemostasis system, urine.

BIRTH INJURY

Under birth trauma the newborn is understood to be traumatized during childbirth. CNS birth injury is diagnosed in 8-10% of newborns. In clinical practice, to refer to perinatal pathology of the brain, the term " perinatal encephalopathy", and in last years for newborns from the end of the 1st week of life - hypoxic-ischemic encephalopathy(HIE) (for children of the first days of life, the terms "hypoxia" and "asphyxia" are retained). Injuries to the brain and spinal cord are found as the main or concomitant disease in 80% of dead newborns.

Classification of birth injuries

Injury of the nervous system (central and peripheral)

Soft tissue injury (birth tumor, cephalohematoma)

Injury to the skeletal system (fractures, dislocations)

Injury internal organs(compression, breaks)

Etiology. The main cause of CNS birth injury is acute or prolonged hypoxia fetus, which can appear in the prenatal period, during childbirth and after the birth of a child.

Occur as a result:

Pathologies and complications of the birth act (discrepancy between the size of the fetus and the size of the mother's pelvis, pathological presentation, rapid, prolonged labor, asphyxia, prematurity)

Obstetric interventions and operational impact.

Intracranial birth injury due to the severity of the prognosis, it occupies a special place among birth injuries. It can appear both in children who have undergone rough mechanical stress during childbirth, and in those born in relatively normal labor or born by caesarean section.

The term “perinatal damage to the CNS (birth injury of the CNS, intracranial birth injury)” means deep pathomorphological changes, primarily in the brain in the form of hemorrhages (intracranial hemorrhages) and tissue destruction (hypoxic-ischemic encephalopathy). Intracranial hemorrhages (ICH) are divided by origin into traumatic and hypoxic.

There are intracranial hemorrhages:

epidural - between hard meninges and bones of the skull;

subdural - under the dura mater;

subarachnoid - in the pia mater;

intracerebral - in the substance of the brain;

intraventricular - in the ventricles of the brain.

The main causative factors VChK can be:

Ø birth trauma (not always obstetric!);

Ø perinatal hypoxia and hemodynamic (especially pronounced arterial hypotension) and metabolic disorders caused by its severe forms;

Ø perinatal disorders of coagulation and platelet hemostasis;

Ø intrauterine viral and mycoplasmal infections, causing both damage to the walls of blood vessels, and the liver, brain;

Ø irrational care and iatrogenic interventions (ventilation with strict parameters, rapid intravenous infusions, uncontrolled excessive oxygen therapy, lack of pain relief during painful procedures, careless care and performing manipulations that are traumatic for the child, drug polypharmacy.

clinical picture. The most typical manifestations of any ICH in newborns are: 1) a sudden deterioration in the general condition of the child with the development various options depression syndrome, apnea attacks, sometimes with intermittent signs of hyperexcitability; 2) changes in the nature of the cry and loss of sociability (during examination); 3) bulging of a large fontanelle or its tension; 4) abnormal movements of the eyeballs; 5) violation of thermoregulation (hypo- or hyperthermia); 6) vegetative-visceral disorders (regurgitation, pathological weight loss, flatulence, unstable stool, tachypnea, tachycardia, peripheral circulatory disorder); 7) movement disorders; 8) convulsions; 9) disorders of muscle tone; 10) progressive posthemorrhagic anemia; 11) metabolic disorders (acidosis, hypoglycemia, hyperbilirubinemia); 12) the addition of somatic diseases that worsen the course and prognosis of birth brain injury (pneumonia, cardiovascular insufficiency, meningitis, sepsis, adrenal insufficiency, etc.).

Treatment. Newborns with ICH need protective regime: reducing the intensity of sound and light stimuli, the most gentle examinations, swaddling and performing various procedures, minimizing painful appointments, "temperature protection", preventing both cooling and overheating, the participation of the mother in the care of the child. The child should not starve. Children are fed depending on the condition - either parenterally or through a permanent transpyloric or single tube. Moreover, in the first days of the ICH, not only sucking out of the chest, but also bottle feeding is an excessive burden for the child. In parenteral nutrition, rhythm is very important, preventing volume overload and hypertension, but, on the other hand, preventing hypovolemia, hypotension, dehydration, and hyperviscosity.

It is necessary to monitor the main parameters of vital activity. According to indications - surgical treatment. Medical treatment - see treatment of HIE.

Prevention primarily consists in the prevention of premature birth of a child and, if possible, in the prevention, early detection and active treatment all those conditions that are high risk factors for ICH.

Hypoxic-ischemic encephalopathy (HIE)- brain damage caused by perinatal hypoxia, leading to motor disorders, convulsions, mental developmental disorders. It occupies the 1st place in frequency among brain lesions and all pathological conditions of newborns, especially in premature babies. Clinical symptoms in newborns and young children depends on the number of damaged nerve cells and significantly - from concomitant disorders: pulmonary, cardiovascular and metabolic.

Injury of the nervous system (central and peripheral)

Soft tissue injury (birth tumor, cephalohematoma)

Injury to the skeletal system (fractures, dislocations)

Injury to internal organs (compression, ruptures)

Etiology. The main cause of birth injury of the CNS is acute or prolonged fetal hypoxia, which can occur in the prenatal period, during childbirth and after the birth of a child.

Occur as a result:

Pathologies and complications of the birth act (discrepancy between the size of the fetus and the size of the mother's pelvis, pathological presentation, rapid, prolonged labor, asphyxia, prematurity)

Obstetric interventions and operational impact.

Intracranial birth injury due to the severity of the prognosis, it occupies a special place among birth injuries. It can appear both in children who have undergone rough mechanical stress during childbirth, and in those born in relatively normal labor or born by caesarean section. Symptoms of CNS damage are combined with disorders of the function of internal organs, metabolic disorders and suppression of the body's immune responses.

Hypoxic-ischemic encephalopathy (HIE). It occupies the 1st place in frequency among brain lesions and all pathological conditions of newborns, especially in premature babies. Clinical symptoms in newborns and young children depend on the number of damaged nerve cells and significantly on concomitant disorders: pulmonary, cardiovascular and metabolic.

Characteristics of the periods of intracranial birth trauma

Diagnosis Intracranial birth injury is confirmed using a study of cerebrospinal fluid, echoencephaloscopy, rheoencephalography, computed tomography (CT), MRI.

Treatment.

Treatment of encephalopathy of the newborn should be complex and staged. A complex approach implies the combined use of the following methods of treatment, staged - the alternation of courses of inpatient, outpatient and spa treatment.

Treatment in the acute period is carried out in the intensive care unit or in the intensive care unit with subsequent transfer, if necessary, to a specialized neuropsychiatric unit. The following principles are observed:

Ø ensure compliance with the security regime- the head of a newborn with perinatal CNS damage should be given an elevated position;

Ø carry out oxygen therapy, timely correction of respiratory disorders;

Ø carry out drug therapy.

In the first 3-5 days spend:

Ø antihemorrhagic therapy: 1% solution of vikasol at the rate of 1 mg / kg per day (0.1 ml kg), 12.5% ​​solution of dicynone, etamsylate - 10-15 mg / kg per day (0.1-0.2 ml / kg) intravenously or intramuscularly;

Ø dehydration therapy: 1% solution of lasix 1-2 mg/kg, veroshpiron 2-4 mg/kg daily intramuscularly or intravenously, manitol - 0.25-0.5 g/kg once intravenously drip slowly;

Ø with hypertension-hydrocephalic syndrome - glucocorticoid hormones- dexamethasone - 0.1-0.3 mg/kg daily for 7 days, followed by a dose reduction by 1/3 every 3-5 days; with normal KOS indicators, it is shown purpose of diacarb according to the scheme of 15-80 mg / kg daily with potassium preparations and alkaline drink from the 5-7th day of life;

Ø antioxidant and metabolic therapy: aevit - 0.1 ml / kg day intramuscularly or 5% oil solution (0.2 ml / kg day) or 10% vitamin E solution (0.1 ml / kg day); cytochrome C - 1 ml/kg intravenously; cerebral angioprotectors - actovegin - 0.5-1.0 ml intravenously or intramuscularly, 10% mildronate solution - 0.1-0.2 ml / kg day intravenously or intramuscularly, 1% solution of emoxipine (Mexidol) 0.1 ml / kg day intramuscularly, 20% solution of Elkar (levocarnitine) - 4-8 (10) drops 3 times a day;

Ø antihypoxant (anticonvulsant) therapy: 20% solution of GHB - 100-150 mg / kg (0.5-0.75 ml / kg) intravenously drip or intramuscularly, 0.5% solution of seduxen - 0.20.4 mg / kg (0.04 -0.08 ml / kg) intravenously or intramuscularly, phenobarbital - 20 mg / kg day with a transition to 3-4 mg / kg day intravenously or orally;

Ø correction of central and peripheral hemodynamics: titration of 0.5% solution of dopamine, 4%o solution of dopmin - 0.5-10 (15) mcg / kg min or dobutamine, dobutrex 2-10 (20) mcg / kg min. Patients with low blood pressure, which may be one of the early signs of adrenal insufficiency, should be administered intramuscularly or intravenously dexamethasone at a dose of 0.5 mg/kg or hydrocortisone - 5-10 mg/kg once;

Ø post-syndromic and post-symptomatic therapy.

By the end of the early neonatal period, in order to improve the function of the central nervous system, the complex of therapeutic measures includes:

Ø nootropic drugs, having both a sedative effect (phenibut (noofen), pantogam - 20-40 mg / kg per day, but not more than 100 mg / day in 2 doses), and a stimulating effect (piracetam - 50-100 mg / kg per day, picamilon - 1, 5-2.0 mg/kg day, encephabol - 20-40 mg/kg day in 2 doses, aminalon - 0.125 mg 2 times a day);

Ø neuroprotective antihypoxants: Cerebrolysate solution - 0.5-1.0 ml intramuscularly for 10-15 days (contraindicated in convulsive readiness, arousal syndrome), glycine - 40 mg / kg daily orally in 2 doses, gliatilin - 40 mg / kg daily intravenously, intramuscularly ;

Ø drugs that improve cerebral circulation(appointed in the absence of hemorrhages): trental, cavinton, vinpocetine - 1 mg / kg daily intravenously, tanakan - 1 cap. / kg 2 times a day, sirmeon - 0.5-1.0 mg / kg daily orally in 2 doses;

Ø in disorders accompanied by increased muscle tone with signs of spasticity, drugs of muscle relaxant action are prescribed - mydocalm - 5 mg / kg daily, baclofen, trapofen - 1 mg / kg 2-3 times a day;

Ø to improve the conduction of excitation in neuromuscular synapses and restore neuromuscular conduction the treatment includes vitamins B 1, B 6, 0.5-1.0 ml intramuscularly for 10-15 days, 0.5% solution of galantamine - 0.18 mg / kg per day, 0.05% solution of prozerin - 0, 04-0.08 mg / kg intramuscularly 2-3 times a day, sometimes Dibazol is prescribed at 0.5-1.0 mg orally 1 time per day.

Exercise therapy and therapeutic massage(stimulating, relaxing) is prescribed early, from the age of 3 weeks of a child's life.

Physiotherapy procedures- their choice depends on the clinical manifestations (with high muscle tone - sinusoidal simulated currents, thermal procedures such as paraffin and ozocerite applications, at low - electrophoresis with calcium on the spine, etc.).

speech therapy classes are carried out from the end of the neonatal period to stimulate pre-speech development and fine motor skills.

Spinal cord injury. Clinical symptoms depend on the level and degree of damage due to hemorrhage, edema, compression, dystrophic processes. Injuries of the upper cervical region cause bulbar disorders: choking when swallowing, decreased pharyngeal and palatine reflexes, respiratory arrhythmia, and impaired cardiac activity. If the brain is damaged at the level of the V cervical and I thoracic vertebrae (C s -Th,), flaccid paralysis of the hands occurs, spastic syndrome may develop in the lower extremities. Injuries of the thoracic region are accompanied by dysfunction of the pelvic organs (urinary and fecal incontinence), flaccid paralysis of the lower extremities is possible.

Treatment.

In the treatment of traumatic injuries of the spinal cord, the following principles should be observed.

Ensure compliance with the security regime: immobilize spinal column(laying "pellot", Shants collar, plaster (polyvinyl chloride) bed.

Feed through a tube. Even in the presence of a sucking reflex, feed through a tube until the condition stabilizes.

Provide oxygen therapy. The method of oxygen therapy is determined by clinical and laboratory data.

Conduct infusion therapy. It is necessary to correct violations of CBS, electrolyte balance and carbohydrate metabolism.

Provide drug therapy:

Ø for the purpose of cupping pain syndrome in case of spinal injury, a 50% solution of analgin is prescribed intravenously or intramuscularly - 0.1 ml; at severe pain- fentanyl at the rate of 2-10 mcg / kg or morphine, promedol - 0.1-0.2 mg / kg every 2-3 hours;

Ø in case of excitation syndrome and convulsions, sedatives are used, excluding narcotic drugs;

Ø dehydration is carried out with saluretics: lasix - 1 mg/kg, veroshpiron - 2-4 mg/kg daily; osmodiuretics: mannitol, mannitol, sorbitol - 5-6 ml / kg;

Ø antihemorrhagic therapy includes: vitamin K - 12 mg / kg, 12.5% ​​solution of dicynone, etamsylate - 10-15 mg / kg, fresh frozen plasma - 10-15 ml / kg;

Ø antioxidant therapy includes: aevit - 0.1 ml/kg, vitamin E - 10% oil solution - 0.1 ml/kg, cytochrome C - 1 ml/kg;

Ø Normalization of the central and peripheral circulation is carried out by titrating adrenaline, atropine - 0.05-1.0 mcg / kg min, 0.5% dopamine solution, 4%o dopmin solution - 0.5-10 (15) mcg / kg min, dobutrex, dobutamine - 2.0 - 10.0 (20) mcg / kg min;

Ø To normalize the function of the spinal cord by the end of the acute period, the appointment of nootropic drugs with a sedative effect is indicated: phenibut, pantogam - 40 mg / kg per day, but not more than 100 mg / day in 2 doses or a stimulating effect: piracetam - 50-100 mg / day kg day, picamilon - 1.5-2.0 mg/kg day in 2 doses, aminalon - 0.125 mg 2 times a day, encephabol 20-40 mg/kg day;

Ø In order to improve neuromuscular conduction, Dibazol, Galantamine, Prozerin are used, and for myelination nerve fibers from the end of the 1st week of life, vitamins B 1, B 6 are prescribed, from the end of the 2nd week - vitamin B 12 - 0.5-1.0 ml in a general course of up to 15-20 injections.

Conduct physical therapy. From the 8-10th day of life, the appointment of physiotherapy in the form of electrophoresis on the cervical region with a 0.5-1.0% solution of aminophylline or nicotinic acid is shown in a course of 10-12 procedures.

Do gymnastics and massage. They are shown when acute processes subside.

Upper paralysis brachial plexus is the result strong stretching or direct compression of the nerve trunk, the muscles innervated by the roots of the V and VI cervical segments are affected.

Clinic:

Ø "flabby shoulder symptom" (shoulder drooping)

Ø sluggish drooping of the limb (in the position of bringing to the body and turning the hand

outward, while the arm is bent at the elbow joint, hand and fingers - “a symptom of a puppet handle”)

Ø sluggish reflexes, decreased muscle tone.

Treatment:

Ø includes first dry warm compresses, creating complete rest of the injured limb using plaster cast, aluminum or plastic splint with a slightly raised shoulder girdle with the shoulder laid aside and rotated outward and the forearm bent at a right angle in the supination position). The bandage is left for 3-6 weeks;

Ø After the second week proceed to light massages, passive and active movements, and by the end of the first month - electrical stimulation, examining the excitability of muscles with galvanic and faradic current. Active movements are facilitated by fixing a healthy arm to the body;

Ø Vitamin B1 is prescribed intramuscularly at 10 mg per day and Dibazol at 0.0005 g once a day for 10-15 days.

Ø If within 6 months conservative treatment does not give a result, they resort to surgical microsurgical intervention (suturing of damaged nerves if necessary).

birth tumor- This is a physiological phenomenon that is characterized by edema and circulatory disorders in the soft tissues of the presenting part of the fetus. It is important to distinguish a birth tumor in a newborn from a cephalohematoma in time, since this determines the tactics of rendering medical care. A birth tumor is formed at the site of the birth canal parts of the body: on the back of the head, in the forehead, buttocks, genitals. At the same time, local edema is determined, soft to the touch, painless. If a birth tumor has formed on the head, then it spreads beyond the boundaries of the bone, capturing the parietal, frontal or occipital region. Puffiness without a sharp border passes to the surrounding tissues. The birth tumor disappears without a trace after 2 days.

cephalohematoma – subperiosteal hemorrhage located in the region of the parietal, rarely occipital, frontal or temporal bones. It occurs as a result of intense pressure and displacement of the integument and bones of the cranial vault during childbirth. Initially, an inconspicuous hematoma after 2-3 days begins to contour well and increases in size. Usually, a cephalhematoma is unilateral, less often bilateral, never extends beyond the boundaries of the bone on which it is located. The cephalhematoma has wide base, surrounded by a dense roller (thickening of the periosteum), soft to the touch, fluctuates when the pulsation of the tissues is palpated. Usually this is a hemorrhage under the periosteum of the parietal, occipital or frontal bones. Much less often, a cephalhematoma is formed between the periosteum and aponeurosis, bone and dura mater (internal cephalhematoma). The cephalhematoma resolves in 6-8 weeks.

Treatment.

Ø vitamin K 1 mg/kg, calcium gluconate 1 ml/kg;

Ø cold, pressure bandage,

Ø with prolonged, intense cephalohematoma, surgical treatment

Skeletal damage with the exception of a fracture of the clavicle in normal childbirth are rare.

Clavicle fracture- the most common type of birth fractures. The characteristic localization of the fracture is the middle third of the clavicle. Fracture of the clavicle occurs in 11.7 newborns per 1000.

Main Clinical signs clavicle fracture:

Ø anxiety of the child in the first hours and days of life;

Ø swelling of soft tissues in the clavicle area due to edema and hematoma;

Ø deeper neck crease on the side of the injury;

Ø lack of free movement of the hand on the side of the injury;

Ø crepitus and deformation of the clavicle on palpation;

Ø absence of the Moro reflex on the side of the fracture.

Features of the course of a subperiosteal fracture of the clavicle (like a "green branch")

Ø motor activity and Moro reflex are preserved;

Ø displacement of fragments is not observed;

Ø In the future, callus is found in the form of a tumor.

Subperiosteal fractures have few symptoms and often go unnoticed.

Basic principles of treatment of a clavicle fracture:

1. With displaced fractures: immobilization of the fracture area with a soft bandage of the Deso type with a cotton-gauze roller in the armpit for 5-7 days (until the formation of callus).

2. In case of fractures without displacement: careful swaddling of the child, excluding traumatization of the damaged collarbone.

Basic care for asphyxia, birth injuries:

- various damage to the fetus that occurs during the birth act. Among the birth injuries of newborns, there are injuries of soft tissues (skin, subcutaneous tissue, muscles), skeletal system, internal organs, central and peripheral nervous system. Birth trauma in newborns is diagnosed taking into account the mother's obstetric and gynecological history, characteristics of the course of labor, examination data of the newborn and additional studies (EEG, ultrasound, radiography, ophthalmoscopy, etc.). Treatment of birth injuries of newborns is carried out differentially, taking into account the type and severity of the injury.

Classification of birth trauma of newborns

Depending on the location of the damage and the predominant dysfunction, the following types of birth trauma of newborns are distinguished:

1. Birth injuries of soft tissues(skin, subcutaneous tissue, muscles, birth tumor, cephalohematoma).

2. Birth injuries of the osteoarticular system(cracks and fractures of the clavicle, humerus and femur; traumatic epiphysiolysis of the humerus, subluxation of the C1 and C2 joints, damage to the bones of the skull, etc.)

3. Birth injuries of internal organs(hemorrhages in the internal organs: liver, spleen, adrenal glands).

4. Birth injuries of the central and peripheral nervous system in newborns:

• intracranial birth trauma (epidural, subdural, subarachnoid, intraventricular hemorrhages)
• birth injury of the spinal cord (bleeding into the spinal cord and its membranes)
• birth trauma of the peripheral nervous system (damage to the brachial plexus - Duchenne-Erb paresis / paralysis or Dejerine-Klumpke paralysis, total paralysis, paresis of the diaphragm, damage to the facial nerve, etc.).

Causes of birth trauma in newborns

An analysis of the causes of birth trauma in newborns allows us to identify three groups of factors that increase the likelihood of its occurrence: those related to the mother, to the fetus, as well as to the course and management of childbirth.

Predisposing "maternal" factors may be early or late reproductive age, preeclampsia, narrow pelvis, hypoplasia or hyperanteflexia of the uterus, diseases of the pregnant woman (cardiovascular, endocrine, gynecological, etc.), post-term pregnancy, occupational hazards, etc.

The most extensive group of causes leading to birth trauma in newborns is the circumstances associated with the fetus. Birth trauma can be provoked by breech presentation of the fetus, oligohydramnios, incorrect (asynclitic or extensor insertion of the head), prematurity, large fetal size, fetal abnormalities, intrauterine hypoxia and asphyxia, etc.

Anomalies of labor activity can lead to the birth trauma of a newborn: prolonged or rapid labor, labor stimulation with weak labor activity, discoordinated or excessively strong labor activity. A serious group of causes of birth injuries in newborns is the incorrect or unreasonable use of obstetric aids (turning the fetus on a leg, applying obstetric forceps, using a vacuum extractor, performing a caesarean section, etc.).

As a rule, when birth injuries occur in newborns, there is a combination of a number of adverse factors that disrupt the normal biomechanics of childbirth.

Birth trauma in newborns: symptoms, diagnosis, treatment

Birth injuries of soft tissues

The most common manifestations of birth trauma in newborns are damage to the skin and subcutaneous tissue. These include scratches, abrasions, petechiae, ecchymosis in various parts of the body. Such lesions are detected by visual examination of the newborn by a neonatologist; they are usually not dangerous and require only local antiseptic treatment and imposition of an aseptic bandage. Minor birth injuries of soft tissues disappear by the end of the first week of a newborn's life.

A type of birth trauma in newborns is a birth tumor, which is characterized by local swelling of the soft tissues of the head. The birth tumor has a soft elastic consistency, cyanotic color with multiple petechiae and ecchymosis. Its occurrence is usually associated with prolonged labor in the cephalic presentation or the imposition of obstetric forceps. The birth tumor does not require treatment, it disappears on its own after 1-3 days.

A more severe type of birth injury in newborns is damage (hemorrhage, rupture) of the sternocleidomastoid muscle, usually its lower third. In this case, a small tumor of moderately dense or doughy consistency is determined at the site of damage. Damage to the sternocleidomastoid muscle may not be detected immediately, but after about a week, when the child develops torticollis. In the treatment of a birth injury of the sternocleidomastoid muscle in newborns, a corrective position of the head is used with the help of rollers, dry heat, electrophoresis of potassium iodide, massage; in case of inefficiency - surgical correction.

Cephalhematoma, as a kind of birth trauma of newborns, is characterized by hemorrhage under the periosteum of the parietal or occipital bones of the skull. Typical features cephalohematomas are elastic consistency, lack of pulsation, painlessness, fluctuation, the presence of a roller along the periphery. In the future, newborns with cephalohematoma may experience jaundice caused by increased extravascular production of bilirubin. Cephalhematoma decreases in size by 2-3 weeks of life, and completely resolves by the end of 6-8 weeks. Complications of subperiosteal birth trauma in newborns include anemia, calcification, and suppuration of cephalohematoma. Children with large (more than 6 cm in diameter) cephalohematomas need an X-ray of the skull to rule out bone fractures. Since cephalohematomas in premature babies are often associated with intrauterine mycoplasmosis, PCR or ELISA diagnostics is required.

In most cases, birth injuries of soft tissues in newborns pass without consequences.

Birth injuries of the skeletal system

Among birth injuries of the osteoarticular system in newborns, injuries of the clavicle and bones of the extremities are more common. They always refer to purely obstetric types of damage. Subperiosteal fractures of the clavicle without displacement are usually detected 3-4 days after childbirth by the presence of a fusiform dense swelling - forming callus. A fracture of the clavicle with displacement is accompanied by the inability to perform active movements, pain, crying with passive movement of the arm, swelling and crepitus over the fracture site.

A type of birth trauma of the skeletal system of newborns is traumatic epiphysiolysis of the humerus. Its manifestations are pain, swelling and crepitus in the area of ​​the shoulder or elbow joints, limited range of motion in the affected arm. The outcome of such an injury may be paresis of the radial nerve, the formation of flexion contracture in the joints. Treatment consists of immobilization of the limb, physiotherapy, massage.

Birth injuries of internal organs

Damage to internal organs occurs as a result of mechanical impact on the fetus during an abnormal course of childbirth. The most common hemorrhages are in the liver, spleen and adrenal glands. Clinical manifestations birth trauma of internal organs in newborns develop on the 3-5th day due to internal bleeding. When a hematoma ruptures, abdominal distension occurs, intestinal paresis develops, muscle hypotonia (or atony), depression physiological reflexes, arterial hypotension, persistent regurgitation and vomiting.

If a birth injury of the internal organs is suspected, the newborn is given a survey radiography of the abdominal cavity, ultrasound of the abdominal organs and ultrasound of the adrenal glands. Treatment consists in carrying out hemostatic and symptomatic therapy; if necessary - laparoscopy or laparotomy with revision of internal organs.

With an adrenal hemorrhage, a child may develop acute or chronic adrenal insufficiency. The prognosis for birth trauma of internal organs in newborns is determined by the volume and severity of the lesion, the timeliness of detection of damage.

Birth injuries of the central and peripheral nervous system

Damage to the nervous system in newborns is the most extensive group of birth injuries. As part of this review, we will focus on birth trauma of the spinal cord and peripheral nervous system; detailed description intracranial birth injuries of newborns will be given in the corresponding article.

Birth injuries of the spinal cord in newborns may include hemorrhage, sprain, compression, or rupture of the spinal cord at various levels, associated with or without a spinal fracture. Severe injuries are characterized by the clinic of spinal shock: lethargy, muscular hypotension, areflexia, weak cry, diaphragmatic breathing. The death of children can come from respiratory failure. In more favorable cases, there is a gradual regression of the phenomena of spinal shock; hypotension is replaced by spasticity; develop autonomic disorders(vasomotor reactions, sweating), trophic changes in muscle and bone tissue. Mild birth injuries in newborns are accompanied by transient neurological symptoms: changes in muscle tone, reflex and motor reactions.

Diagnosis is facilitated by examination of the child by a pediatric neurologist, X-ray or MRI of the spine, electromyography, lumbar puncture, and examination of cerebrospinal fluid. Treatment of a birth injury of the spinal cord in newborns includes immobilization of the area of ​​damage, dehydration and antihemorrhagic therapy, restorative measures (orthopedic massage, exercise therapy, electrical stimulation, physiotherapy).

Birth injuries of the peripheral nervous system in newborns combine damage to roots, plexuses, peripheral and cranial nerves.

Given the localization, the paresis of the brachial plexus (obstetric paresis) can be upper (proximal), lower (distal) or total. Upper Duchenne-Erb paresis is associated with damage to the plexuses and roots originating in the C5-C6 segments, which is accompanied by dysfunction of the proximal upper limb. In this case, the child takes a characteristic position with the arm brought to the body, extended at the elbow joint, turned inward at the shoulder and pronated at the forearm; with a hand bent in the palm and a head tilted to the sore shoulder.

With lower obstetric paresis of Dejerine-Klumpke, plexuses or roots originating from C7-T1 are affected, resulting in dysfunction of the distal arm. Manifestations include muscle hypotonia, hypesthesia, limitation of movements in the wrist and elbow joints, fingers, a symptom of "clawed paw". With a total type of obstetric paresis, the arm is completely inactive, muscle hypotension is pronounced, and muscle atrophy develops early.

Diagnosis and localization of damage is specified using electromyography. Treatment of a birth injury of the brachial plexus in newborns consists in immobilizing the arm with a splint, performing massage, exercise therapy, physiotherapy (ozocerite, paraffin, electrical stimulation, electrophoresis), and drug therapy.

With paresis of the diaphragm, the newborn develops shortness of breath, paradoxical breathing, cyanosis, bulging of the chest on the affected side. The identification of paresis is facilitated by fluoroscopy and chest x-ray, in which high standing and inactivity of the dome of the diaphragm are determined. Against this background, children may develop congestive pneumonia. Treatment of birth trauma consists of transcutaneous stimulation of the phrenic nerve; if necessary - mechanical ventilation until adequate spontaneous breathing is restored

Paresis of the facial nerve is associated with damage to the trunk or branches of the facial nerve. In this case, the child has facial asymmetry, lagophthalmos, upward displacement of the eyeball when crying, asymmetry of the mouth, and difficulty in sucking. Birth trauma in newborns is diagnosed on the basis of clinical signs, electroneurography, registration of evoked potentials. Often, paresis of the facial nerve resolves without special treatment; in other cases, thermotherapy, drug therapy is carried out.

To more rare species birth injuries of newborns include injuries of the pharyngeal, median, radial, sciatic, peroneal nerve, lumbosacral plexus.

Prevention of birth trauma in newborns

Prevention of birth injuries in newborns involves assessing the degree of risk of their occurrence even at the stage of pregnancy, to the maximum careful attitude to the child in the process of childbirth, refusal from the unreasonable use of benefits for the extraction of the fetus and operative delivery.

Birth trauma is the destruction of tissues or organs of the fetus during childbirth, resulting from local action mechanical forces to the fruit.

In the perinatal period, changes may occur that resemble birth trauma in their clinical and morphological manifestations. These include hemorrhages in the brain and its membranes, under the liver capsule and in other organs, as well as necrosis (infarctions) resulting from hypoxia, hemorrhagic diathesis, or other causes. To designate them in the literature, the term birth injury (birth injury - English, geburtsschaden - German) is adopted.

Significant difficulties arise in determining the nature of such injuries as hemorrhages in the membranes and substance of the brain and spinal cord. According to the summary data, the ratio of traumatic and non-traumatic hemorrhages in the brain and its soft membranes is 1:10.

Allocate also obstetric trauma, which occurs as a result of various obstetric manipulations with improper management of childbirth.

In recent years, the number of cases of birth trauma has decreased and is 3-10%. Skull trauma accounts for 97.5% of all cases of fatal birth trauma. Birth injuries to the brain, liver and other organs are found in 20-40% of perinatal autopsies.

Causes of birth trauma

Birth trauma can occur when there is a discrepancy between the size of the mother's pelvis and the fetus, especially its head. On the part of the mother, the cause of the discrepancy may be a narrowing of the pelvis, tumors of the pelvic bones or cervix, rigidity of the soft tissues of the birth canal. On the part of the fetus, the cause of the discrepancy may be an excessively large head (giant fetus, hydrocephalus, macrocephaly with chondrodystrophy), an increase in the abdomen with ascites, or a significant size of the liver and spleen. Injuries can occur with anomalies of presentation. So, if 4.1% of children get injured with parietal presentation, and 14.4% with pelvic presentation, then 35.7% of injuries occur with facial insertion, and 100% with frontal presentation.

The development of birth trauma is facilitated by acute and chronic diseases and intoxication of the pregnant woman, pathological course pregnancy, as well as prematurity and postmaturity of fetuses. In these cases, the violation of the development of the fetus is expressed, in particular, in insufficient formation of elastic fibers and incomplete development of collagen fibers. Rapid or, conversely, prolonged labor with weakness of labor activity, multiple pregnancy also contribute to birth trauma. Hypoxia of various origins during childbirth, accompanied by venous congestion, swelling to loosening of tissues, reduces mechanical strength and leads to their rupture.

The pathogenesis of birth trauma can be understood by considering the biomechanics of fetal birth. In the process of childbirth, two forces act on the fetus. One of them is the pressure of the bottom and walls (body) of the uterus, which tightly covers the fetus, straightens the spine and moves the fetus along the birth canal. This contributes to the tension abdominals and maternal diaphragm. Another force hinders the progress of the fetus. It is due to the resistance of the presenting parts of the fetus from the soft and bony parts of the generic kakala. Of some importance is the active movement of the fetus.

In cephalic presentation, as a result of the action of the mentioned forces, the head, moving in the cavity of the small pelvis, makes a turn (“screws into the pelvis”) and undergoes a configuration. The configuration consists in the displacement of the bones of the skull relative to each other. In this case, the head takes a shape that facilitates its passage through the birth canal, although there is almost no decrease in its volume. The configuration is more pronounced, the more significant and prolonged the action of forces on the head and the higher the displacement (extensibility, elasticity) of the sutures connecting the bones of the skull. If the configuration is performed within certain limits and not too quickly, the stretching of the soft tissues is not accompanied by damage. In the origin of the most common injury - rupture of the cerebellar tenon - the main significance, apparently, is the aforementioned "screwing" of the head into the pelvic cavity. This changes the relative position of the right and left halves of the head and, in particular, the pyramids of the temporal bones. As a result, there is an overstretching of the cerebellar plaque stretched between them and its rupture. An increase in the cranio-caudal and fronto-occipital dimensions of the head is also important. The resulting tension of the sickle of the brain leads to the contraction of the nape upward and injury to both the sickle and the nape.

At breech presentation when it is necessary to quickly remove the fetus, the likelihood of birth trauma to the head is higher. In addition, under these conditions, trauma to the neck organs is possible.

special analysis require rare cases of birth trauma of the skull in children extracted by caesarean section. Intracranial hemorrhages and other injuries are not traumatic, but hypoxic or otherwise. There are also true injuries (rupture of the cerebellar plaque), formed when a caesarean section is performed in the first stage of labor with an inserted head.

With birth trauma and head injuries, the greatest pathogenetic significance is the general disorder of cerebral circulation in the form of vascular dystonia, edema, venous plethora and hemorrhages. In the limited space of the skull, intracranial pressure rises, which further impairs blood and cerebrospinal fluid circulation, causes dystrophy and death of neurons, and can lead to "brain death". One should not exaggerate the thanatological role of mechanical "infringement medulla oblongata» bleed or tonsils of the cerebellum.

The pathogenesis of birth defects

In pathogenesis birth injuries acute and chronic hypoxia, circulatory disorders, infections, changes in blood clotting, congenital heart defects with hypertension of a large circle, aneurysms of cerebral vessels and others are important. Often, hemorrhages in the brain, focal edema, necrosis develop. At the same time, neurological changes are associated not only with general disorders of cerebral circulation, but also with focal brain lesions. It must be borne in mind that a hemorrhage in the brain or its membranes can develop both during the birth of a child and in the first few days after birth.

Survival of birth trauma

A sign of post-mortem injury is the absence of hemorrhage in its area. However, the presence of a hemorrhage does not always indicate its lifetime. The fact is that the fetus that died in utero continues to be exposed to the action of generic forces. This could lead to injury. At the same time, despite cardiac arrest, some movement of blood through the vessels of the fetus continues as a result of increased pressure on its trunk with reduced pressure on the born head. Postmortem hemorrhage is possible, since in the vessels of the fetus that died during hypoxia, the blood remains liquid. The formation of hemorrhages during birth trauma of a dead fetus occurs if the presenting part is injured, especially the head. In particular, subdural hemorrhages are not uncommon in post-mortem rupture of the cerebellar tentorium. Signs of the postmortem nature of the injury in this case are not big sizes hemorrhage located in the area of ​​the gap.

The term "birth trauma" combines violations of the integrity (and hence the region of functions) of the tissues and organs of the child that occurred during childbirth. Etiology. Birth trauma is a broader concept than obstetric trauma, obstetric benefit is one of the causes of birth trauma. Injury is determined not only by obstetric skills, but also by how the fetus enters into childbirth. Continuing intrapartum hypoxia, intranatal asphyxia increases the likelihood of birth traumatism even in the normal course of childbirth. Predisposing factors: gluteal and other abnormal presentations, macrosomia, large fetal head size, postmaturity, protracted and rapid labor, fetal developmental anomalies, small pelvis sizes, increased genital tract rigidity (elderly primiparas), obstetric aids (forceps, fetal rotation on the leg). clinical forms. 1) Soft tissue injury - petechiae and ecchymosis, abrasions in various parts of the body, they can be on the presenting part of the fetus during childbirth, applying forceps, taking blood from the fetus, mb as a result of resuscitation, with intravenous benefits. Minor damage requires treatment with aniline dyes. 2) Adiponecrosis - focal necrosis of the pancreas, well-limited dense nodes ranging in size from 1-5 cm. Appear for 1-2 weeks of life. The general condition of the child is not disturbed, the temperature is normal. The leading cause of adiponecrosis is considered to be the imposition of forceps and other injuries, intravenous hypoxia, and hypothermia. Infiltrates disappear spontaneously without treatment w-w several weeks, sometimes within 3-5 months. Sometimes opened with the release of a white crumbly mass. 3) Damage and hemorrhage in the sternocleidomastoid muscle - when applying forceps, manual aids, especially in breech presentation. Rupture of the muscle usually occurs in n/3 (sternal part). In the area of ​​damage - a hematoma, a tumor of doughy consistency. Sometimes diagnosed by the end of the first week, when torticollis develops - the head is tilted to the damaged side, and the chin is turned to opposite side. The diagnosis is made in violation of the position of the head, asymmetry of the face, a decrease in the auricle on the side of the lesion. Treatment - corrective position of the head, (roller) application of dry heat, physiotherapy, if surgical treatment is ineffective. 4) birth tumor - swelling of the soft tissues of the head during cephalic presentation or at the time of applying a vacuum extractor. Often blue in color. M.b. the cause of hyperbilirubinemia, passes within 1-2 days. 5) Hemorrhage under the aponeurosis - doughy swelling, swelling of the parietal and occipital regions of the head. Unlike cephalohematoma, it is not limited to one bone, but differs from a birth tumor - it can increase in intensity after birth. Risk factors are - a vacuum extractor, obstetric assistance in childbirth, can cause posthemorrhagic anemia, because it can contain up to 260 ml of blood, and then cause hyperbilirubinemia. It is necessary to do an x-ray to exclude fractures; m.b. infection. Dissolves within 2-3 weeks. 6) cephalohematoma - hemorrhage under periosteum to l bones of the cranial vault, may appear within a few hours after childbirth (more often in the parietal region, less often in the occipital bone). Initially, it has an elastic consistency, never passes to the adjacent bone, does not pulsate, is painful, fluctuates on palpation, the surface of the skin, as a rule, is not changed. For 2-3 weeks, it begins to decrease and is resorbed for 6-8 weeks. M.b. calcification, rarely suppuration. The reason is detachment of the periosteum when the head moves at the time of eruption, less often - cracks in the skull, therefore, an x-ray is taken with a cephalohematoma greater than 6 cm. Treatment - the first 3-4 days are fed with expressed milk from a bottle, vitamin K once in / m. Cephalhematomas larger than 6-8 cm are usually punctured at the end of the first week. 7) Palalysis of the facial nerve. When forceps are applied, damage to the nerve and its peripheral branches occurs. Clinic - omission and immobility of the corner of the mouth, its swelling, absence of the nasolabial fold, superciliary reflex, incomplete closure of the eyelids of the diseased side, asymmetry of the mouth when crying, lacrimation. 8) Birth injury of the spinal cord and brachial plexus. Etiology - damage to the spinal cord due to a forced increase in the distance between the shoulders and the base of the skull, which may be. with fixed shoulders and traction for the shoulders with a fixed head (with breech presentation), excessive rotation, when applying forceps. Pathogenesis - defect of the spine (subluxation in the joints of 1 and 2 cervical vertebrae, displacement of the vertebral bodies, fracture of the cervical vertebrae, anomalies in the development of the vertebrae); hemorrhage in the spinal cord and its membranes; ischemia in the basin of the vertebral arteries due to stenosis, spasm, swelling of the spinal cord; damage intervertebral discs. In the first place - circulatory disorders in the basin of the vertebral arteries with the development of ischemia in the region of the brain stem, cerebellum and cervical spinal cord. The clinic depends on the location of the damage. In case of damage to the cervical region - there is pain symptom, m.b. torticollis, hemorrhage over the site of injury. Damage C1-C IV - spinal shock: lethargy, weakness, diffuse muscular hypotension, hypo- and areflexia, tendon reflexes are sharply reduced, spastic tetraparesis below the injury site. SM respiratory disorders (tachypnea, respiratory arrhythmia, distended abdomen), m.b. apnea. Urinary retention or intermittent urinary incontinence, the child has a "frog" position. M.b. lesions III, VI, VII, IX, X craniocerebral insufficiency and vestibular portion of the VIII nerve. Diaphragm paresis (Cofferat's syndrome) - brachial plexus injury at level C III-CIV. It often occurs in combination with left-sided Duchenne-Erb palsy. The leading symptom is respiratory races: shortness of breath, arrhythmic breathing, bouts of cyanosis, asymmetry chest, lagging in the act of breathing of the affected side, weakening of breathing on the side of the lesion, cracking wheezing. The outcome is pneumonia, displacement of the mediastinal organs in the opposite direction, which is accompanied by a vascular week. Recovery within 6-8 weeks. Paresis and paralysis of Duchenne-Erb - with damage to the spinal cord at the level of C V-C VI or the brachial plexus. The affected limb is brought to the body, extended at the elbow joint, turned inward, rotated at the shoulder joint, the hand is in palmar flexion and turned back and outward. When the child is positioned face down in the palm of his hand, the paretic limb hangs down, and the healthy arm is separated from the body by a deep longitudinal fold ("Novik's puppet hand symptom"). Passive movements in the paretic limb b/b, Babkin's reflexes and grasping reflexes are reduced, there is no tendon reflex of the biceps mm. Lower distal palsy Dejerine-Klumpke - occurs with spinal cord injury at the level of C VII-TI or the middle and lower bundles of the brachial plexus. There is a violation of the function of the hand in the distal section - there is no function of the flexors of the hand and fingers, interosseous and worm-shaped mm of the hand, mm of the tenor and hypotenor. Muscle tone in the distal parts of the arm is reduced, there is no movement in the elbow joint, the hand is in the form of a "seal's foot". On examination, the hand is pale with a cyanotic tinge (“ischemic glove”), cold, the hand flattens, mm atrophies. Total paralysis of the upper limb (Kerer's paralysis) - with damage to C V-TI of the spinal m-g or brachial plexus, more often one-sided. There are no active movements, severe mm hypotension, absence of congenital and tendon reflexes, trophic regions. Thoracic injuries - TI-T XII Clinic for Respiratory Disorders, tk. f-ii breathing is violated: retraction of the costal spaces on inspiration, spastic lower paraparesis. Trauma of the lower thoracic segments - s-m "spread belly", the cry in children is weak, with pressure on abdominal wall the scream gets louder. Injury of the lumbosacral region - lower flaccid paraparesis while maintaining normal motor activity upper limbs. The muscle tone of the lower extremities is reduced, active movements are sharply reduced and are in the "frog" position. Outcome - with a mild injury to the spinal cord, spontaneous recovery may occur within 3-4 months, the paretic limbs are less active, especially the hands. In moderate course, when there is organic damage recovery is underway slow, required long treatment. With gross violations, muscle atrophy, contractures, scoliosis, hip dislocation, clubfoot develop, which require orthopedic treatment.

Birth trauma of the CNS. The role of additional research methods in diagnostics. Treatment in recovery period. Dispensary observation of children who have undergone birth trauma. Prevention.

Intracranial hemorrhages - subdural, epidural, subarachnoid, peri and intraventricular, parenchymal and cerebellar. In addition, hemorrhagic cerebral infarctions are isolated, when hemorrhages occur in the deep layers of the white matter of the brain after ischemic (thrombosis or embolism) softening of the brain. Etiology: birth trauma, perinatal hypoxia associated with hemodynamic disorders and metabolic disorders (acidosis, LPO activation), impaired perinatal (vit K deficiency) and platelet hemostasis (hereditary thrombocytopathy), lack of ability to autoregulate cerebral blood flow in children with low gestational age, fetal viruses and mycoplasmal infections that cause damage to the walls of blood vessels, as well as to the liver, brain, irrational care and iatrogenic interventions (ventilators with strict parameters). The immediate cause of the birth injury of the head m-ga is the discrepancy between the size of the bone pelvis of the mother and the head of the fetus, rapid, protracted labor, improperly performed obstetric aids, traction behind the head, and the imposition of forceps. However, for a fetus that has experienced chronic intravenous hypoxia, even the normal mechanism of childbirth can be traumatic. Birth trauma and hypoxia are pathogenetically related to each other. Pathogenesis - subdural and epidural hemorrhages in the head, cerebellum, as a rule, have a traumatic genesis, especially if combined with manifestations of birth trauma - cephalohematoma, hemorrhage under the aponeurosis, fracture of the clavicle. Intraventricular (IVH) and periventricular (PVC), punctate hemorrhages are usually associated with hypoxia. Subarachnoid hemorrhages have both hypoxic and traumatic genesis. Causes of IVH - arterial hypertension and increased cerebral blood flow - rupture of the capillaries; arterial hypotension and decrease in cerebral blood flow - ischemic damage to capillaries; increased cerebral venous pressure - venous stasis, thrombosis; changes in the hemostasis system. Clinic. Typical manifestations of any IVH in n\r are: a sudden deterioration in the general condition of the child with the development of a syndrome of depression, apnea attacks, sometimes periods of hyperexcitability; change in the character of the cry and loss of sociability during examination; bulging of a large fontanelle or its tension; anomalies in the movement of the eyeballs; violation of thermoregulation, vegetative-visceral disorders (regurgitation, weight loss, tachypnea, tachycardia), pseudobulbar and motor r-va, convulsions, muscle tone disorders. Epidural hemorrhage - are localized to the inner lining of the bones of the skull and the dura mater and does not extend beyond the cranial sutures due to tight fusion in these places of the dura mater. After a short light interval from 3 to 6 hours, a “brain compression syndrome” develops, which at first manifests itself as a sharp anxiety for 6-12 hours, and then depression of consciousness develops up to coma 24 hours C-we: dilated pupil, on the side of the lesion, focal and diffuse clonic-tonic convulsions, hemiparasis on the side opposite to the hemorrhage, attacks of asphyxia, decreased blood pressure, congestive optic disc. The indication is neurosurgical treatment. Subdural hemorrhage - with deformation of the skull with displacement of its plates. Favorite localization - the posterior cranial fossa, less often - the parietal region. Source - veins flowing into the superior sagittal sinus and transverse sinus, vessels of the cerebellar tenon. The clinic depends on the localization: with supratentorial hemorrhage - 2-4 days, a period of imaginary well-being, although there may be jaundice, anemia, signs are moderately expressed increase in ICP. Then, hypertensive-hydrocephalic and dislocation syndromes sharply increase: anxiety, head enlargement, tension and bulging of the fontanelles, tilting of the head, stiff neck muscles, divergence of cranial sutures, pupil dilation on the side of the lesion, rotation of the eyeballs in the direction of the lesion, convulsions are possible Apnea attacks, bradycardia , stupor, coma. The diagnosis is made by neurosonography, CT. Neurosurgical treatment is indicated. If left untreated - encapsulation and compression of the brain. With subtentorial localization - (rupture of the cerebellum and hemorrhage in the posterior cranial fossa) - a serious condition from the moment of birth, violation of sucking, swallowing, compression of the brain stem: rigidity of the neck mm, anisocoria, eye aversion to the side, which does not disappear when the head is turned, vertical nystagmus, "floating eyeballs» In dynamics, lethargy, pallor, respiratory distress, bradycardia, and muscle hypotension are increasing. With early removal of the hematoma, the prognosis is favorable in 50%, the rest have neurological symptoms - hydrocephalus. With a rupture of the nameta, death in the first place of the newborn. Subarochnoid hemorrhage - violation of the integrity of the meningeal vessels. It is localized more often in the parietal-temporal region of the cerebrum and in the region of the cerebellum. In the clinic, meningeal, hypertensive-hydrocephalic s-m, as well as symptoms of prolapse depending on localization. The clinic occurs immediately after birth, or within a few days. Signs of general arousal appear (brain scream, convulsions, sleep inversion, anxious facial expression). Increased motor activity at the slightest irritation, increased innate reflexes, increased mm tone. Hypertension-hydrocephalic syndrome - tilting of the head, convulsive readiness, convulsions, prolapse of cranial nerves: strabismus, smoothness of the nasolabial fold, bulging fontanelles, divergence of sutures, an increase in head circumference. Somatic status - jaundice, hypo-, more often hyperthermia on the 3rd-4th day of life, anemia, weight loss. Diagnosis (see above) + lumbar puncture - a large number of erythrocytes in the cerebrospinal fluid, its xanthochromia, increased protein levels (proteinorrhachia) lymphocytic and macrophage cytosis CSF xanthochromia - uniform pink or red staining in the first and subsequent portions - an argument against "travel" blood . The prognosis is favorable. In / ventricular hemorrhages. M.b. one- and two-sided. Often in children up to 28 weeks of gestation. Occur in the first 2 days of life. According to ultrasound 4 degrees: 1 st - hemorrhage in the germinal matrix (with minimal or absent in / ventricular); 2 st - IVH with normal sizes of ventricles; 3 st IVH with acute deletion of at least one ventricle; 4 st - IVH with the presence of parenchymal (in the white in) hemorrhage. Clinic - a decrease in hematocrit for no apparent reason and the development of anemia; bulging of a large fontanel; change in motor activity; a drop in muscle tone, the disappearance of the sucking and swallowing reflex; apnea attacks; horizontal or vertical nystagmus, absence of pupillary light, decreased blood pressure. Clinic IVH develops in the first 30 hours of life. The prognosis depends on the clinic and the gestational age of the child, stage 1-2 resolves in most children, but cysts are noted in the future. 3-4 tbsp survival of children is 50-70 and 20-40%, respectively. Research methods - on the first day, all children admitted to the pathology department of the n/r undergo neurosonography of the brain (NSG), repeat according to clinical indications. When diagnosing IVH 3-4 stages in the NSG, monitoring includes ventriculometry of the lateral and 3rd ventricles, assess the patency of the CSF pathways and the interhemispheric fissure. Doppler study of the brain to detect signs of hyperfusion of stem structures. Early clinical signs of occlusion and subocclusion are associated with dysfunction of the brain stem and look like sudden onset lethargy, mm hypotension, apnea, less often convulsions. With occlusive hydrocephalus, the clinic may appear within a few weeks, which is seen much earlier with Doppler ultrasound, this is a reason for consulting a neurosurgeon. Conducting lumbar p-tion for diagnostic and therapeutic purposes (to restore the patency of the cerebrospinal fluid) An increase in protein in the cerebrospinal fluid to 2 g / l or more indicates a re-hemorrhage, or the development of an infection. B / cerebral hemorrhage - occur more often when the terminal branches of the anterior and posterior cerebral arteries are damaged. Lethargy, regurgitation, violation of mm tone, focal s-we, nystagmus, anisocoria, convulsions., violation of sucking, swallowing, see " open eyes". Decreased tendon reflexes. With deep brain fluid - groaning. Absence of swallowing and sucking, of congenital reflexes, sometimes only grasping, weak p-tion on examination, in the form of quiet crying, anisocoria, convulsions, more often clonic, bradycardia, is preserved. The course of birth trauma - acute period (7-10 days), subacute (3-4, sometimes up to 6 months), late recovery (from 4-6 months to 1-2 years). premature babies - options for the course of ICH: 1) asymptomatic or with a poor atypical clinic; 2) with dominance of signs of respiratory failure, apnea attacks; 3) prevalence in the clinic of s-ma of general oppression (muscular hypotension, adynamia, hyporeflexia, absence of sucking and swallowing reflexes, vomiting, bradycardia); 4) the predominance of symptoms of increased excitability (hyperexcitability, hyperreflexia, convulsions, athetosis, tremor), partial or complete loss of reflexes of congenital automatism, hypertensive-hydrocephalic s-m. Difficulties in diagnosis in preterm infants are due to the immaturity of the NS, antenatal brain damage, the appearance of brain damage in various diseases (SDR, infection, metabolic disorders). For specification of d-for additional methods of inspection are necessary. Treatment in the first days of life. 1) protective mode - the minimum number of manipulations, sound and light stimuli; 2) temperature protection, participation in the care of the mother, the child should not starve. They are fed in the factory from the state - parenterally, or through a transpyloric or one-time probe. 3) Monitoring of vital signs - blood pressure, pulse, respiratory rate, diuresis, hemoglobin oxygenation and tension carbon dioxide in the blood, monitor the parameters of CBS, sodium, potassium, calcium, glucose. It is advisable to install a vascular catheter, which allows parenteral nutrition and laboratory control. Thus, the basis of the treatment of ICH is supportive symptomatic treatment. Surgical treatment is necessary for children with rapidly progressing subdural hematoma, hemorrhages in the posterior fossa Drug and other therapy depends on the nature concomitant pathology, severity and location of bleeding. If a child with ICH has symptoms hemorrhagic disease neonates or consumption coagulopathy, then transfuse fresh frozen plasma. Routine plasma transfusion is not recommended for all children. Medical treatment for ICH alone is not carried out. There is no consensus in the literature on the appointment of dicynone, riboxin, vit E, muscle relaxants, nootropics. Everyone agrees only with the appointment of a prophylactic dose of vit K. It is especially important to conduct mechanical ventilation in children with ICH. It is very important to prevent hypoxemia or hypercapnia, to avoid rigid ventilation parameters (high peak inspiratory pressure), it is necessary to adapt the ventilation parameters to his spontaneous breathing. The use of muscle relaxants or ganglionic blockers to disable spontaneous breathing in a child is dangerous, because. reduces the rate of cerebral blood flow. Prevention: prevention of premature birth of a child, early detection and prevention of all those conditions that are risk factors. There is an indication of the prophylactic administration of the mother before childbirth (if there are risk factors for fetal asphyxia and n\r) of dexamethasone, phenobarbital, vit K, piracetam, as well as dicynone, indomethacin to the child to reduce the risk and severity of ICH. Dexamethasone - stabilizes the vascular endothelium. Currently, there is no routine prescription of these drugs for professional use.