Birth Trauma

birth_traumaAuthor: Dr. Jeanne Ohm, DC, CEO for the International Chiropractic Pediatric Association

The effects, fre­quency and overt dam­age of birth trauma is per­haps the eas­i­est way to under­stand why all chil­dren need to be checked for spinal mis­align­ments and cra­nial distortions.

Rou­tine labor pro­ce­dures such as induc­ing labor, pain med­ica­tions, and restric­tive mater­nal posi­tions lead to fur­ther com­pli­ca­tions and the resul­tant use of force­ful pulling and oper­a­tive devices such as for­ceps, vac­uum extrac­tions and c-sections. Stan­dard obstet­ric man­a­ge­nent includes grasp­ing the infants head dur­ing birth usu­ally accom­pa­nied by some degree of pulling and rota­tion. Fur­ther inter­ven­tion includ­ing the appli­ca­tion of obstet­ric devises cre­ates an envi­ron­ment where an even more seri­ous injury is bound to happen.

Although the stud­ies sited below mostly deal with the exces­sive trauma caused by obstr­tri­clal, oper­a­tive devices it is impor­tant to note this com­ment by Dr. Abra­ham Tow­bin, med­ical researcher on spinal injury, He says, ‘the birth process, even under opti­mal, con­trolled con­di­tions is a trau­matic poten­tially crip­pling event for the fetus.’

More Stud­ies Needed
Birth trauma remains an under­pub­li­cized and, there­fore, an under­treated prob­lem. There is a need for fur­ther doc­u­men­ta­tion and espe­cially more stud­ies directed toward pre­ven­tion. In the mean­time, man­ual treat­ment of birth trauma injuries to the neu­ro­mus­cu­loskele­tal sys­tem could be ben­e­fi­cial to many patients not now receiv­ing such treat­ment, and it is well within the means of cur­rent prac­tice in chi­ro­prac­tic and man­ual medicine.From the abstract. Neglected spinal cord, brain stem and mus­cu­loskele­tal injuries stem­ming from birth trauma. Got­tlieb MS.J Manip­u­la­tive Phys­iol Ther 1993 Oct;16(8):537 – 43

Rela­tion­ship Between Trauma at Birth and Infant Diges­tive Dis­or­ders
Clin­i­cal, neu­ro­log­i­cal and roentgeno­log­i­cal com­plex inves­ti­ga­tions of 174 chil­dren with sim­i­lar birth injuries revealed patho­genetic rela­tions between birth trauma of the spine, the medulla and the func­tional obtu­ra­tions of the intesti­nal tract as pylorospasms, spastic-hypotonic dysk­i­ne­sia of the ileum and gas­troe­sophageal reflux. Fre­quent com­pli­ca­tions were aspi­ra­tion pneu­mo­nia, reflux oesophagi­tis, oesophageal steno­sis and the devel­op­ment of intesti­nal invagi­na­tion due to dys­rhyth­mic iliac peristalsis.

X-ray symp­to­ma­tol­ogy and dif­fer­en­tial diag­no­sis of func­tional obstruc­tion of the diges­tive tract in chil­dren induced by birth injuries of the spine and spinal cord Michailov MK, Akberov RF. Radiol Diagn (Berl) 1989;30(6):669 – 74

Birth Trauma and Learn­ing Dis­or­ders
This study cor­re­lates the pos­i­tive rela­tion­ship between obstet­ri­cally com­pli­cated births, cra­nial motion dis­or­ders and learn­ing dis­abil­i­ties. The rela­tion­ship of cran­iosacral exam­i­na­tion find­ings in grade school chil­dren with devel­op­men­tal prob­lems. Upledger JE.J Am Osteopath Assoc 1978 Jun;77(10):760 – 76 Related Arti­cles, Books, Link­Out

Trauma to the Head and Neck Result­ing in Mul­ti­ple Dis­or­ders
Birth trauma to the cer­vi­cal spine and cra­nium can result is dis­or­ders such as: headaches, vestibu­lar prob­lems, audi­tory trou­bles, visual dis­tur­bances, pharyn­go­la­ryn­gela dis­or­ders, vaso­moter and secre­tion dys­func­tion and psy­chic dis­tur­bances. Care to realign the neck achieves excel­lent results with many of these dysfunctions.

Ortho­pe­dic Med­i­cine a New Approach to Ver­te­bral Manip­u­la­tion by R. Maigne

Rou­tine Posi­tions in Labor Cause Unnec­es­sary Birth Trauma
In vagi­nal births, 4.6% of term neonates suf­fer unex­plained brain bleeds and up to 10% suf­fer neona­tal encephalopa­thy. These injuries may be avoided by decreas­ing dis­tor­tion of fetal skulls, from pelvic con­tracure at deliv­ery. The pop­u­lar semi-recumbent posi­tion places the labor­ing woman squarely on her sacral apex. This closes her pelvic open­ing and cre­ates a undue stress and dif­fi­culty in the baby’s descent. Labor pos­ture. Gastaldo TD. Birth 1992 Dec;19(4):230

Oper­a­tive Devices: For­ceps and Vac­uum Extrac­tion:
Kine­matic Imbal­ance Due to Sub­oc­cip­i­tal Strain
A sig­nif­i­cantly high por­tion of babies suf­fered birthing injuries due to pro­longed labor and use of extrac­tion devices result­ing in Kine­matic Imbal­ances due to Sub­oc­cip­i­tal Strain. 135 chil­dren younger than 24 months were all treated by spe­cific “manip­u­la­tion” of sub­oc­cip­i­tal joints caused by: intrauter­ine malalign­ment, assisted births (extrac­tion side), pro­longed labor, mul­ti­ple fetuses, and higher trauma. Kine­matic Imbal­ance Due to Sub­oc­cip­i­tal Strain in New­borns. Bie­der­mann H; Manuelle Medi­zin 19926:151 – 6 Arti­cle on Sub Occip­i­tal Strain by Peter Fysh

For­ceps Com­bined with Rota­tion Causes Seri­ous Com­pli­ca­tions
High cer­vi­cal spinal cord injury in neonates resulted as a seri­ous com­pli­ca­tion of for­ceps rota­tions of 90 degrees or more. The com­mon fea­ture in all cases was a for­ceps cephalic deliv­ery, almost always a rota­tion of 90 degrees or more from the occip­i­to­pos­te­rior or occip­i­to­trans­verse posi­tion. High cer­vi­cal spinal cord injury in neonates is a spe­cific com­pli­ca­tion of for­ceps rota­tion. High cer­vi­cal spinal cord injury in neonates deliv­ered with for­ceps: report of 15 cases. Men­ticoglou SM, Perl­man M, Man­ning FA. Obstet Gynecol 1995 Oct;86(4 Pt 1):589 – 94

For­ceps Caus­ing Mul­ti­ple Trau­mas and Even Death
The neona­tal mor­tal­ity rate attrib­ut­able to use of the for­ceps was 34.9 per 1000. The inci­dences of delayed onset of res­pi­ra­tion (17.4%), birth trauma (15.1%), and abnor­mal neu­ro­log­i­cal behav­iour – namely, apa­thy or irri­tabil­ity or both – (23.3%) sig­nif­i­cantly exceeded those in a matched group of babies born spon­ta­neously. Fetal asphyxia played a major part in the aeti­ol­ogy of neona­tal com­pli­ca­tions. Babies on whom Kielland’s for­ceps were used, how­ever, had a sig­nif­i­cantly greater inci­dence of abnor­mal neu­ro­log­i­cal behav­iour even in the absence of fetal asphyxia (14.3%), and in all of these babies the abnor­mal behav­iour was tran­sient and did not neces­si­tate admis­sion to the special-care baby unit The results sug­gest the neona­tal com­pli­ca­tions are caused by the for­ceps and not related to the process of birth itself. Kielland’s for­ceps: asso­ci­a­tion with neona­tal mor­bid­ity and mortality.Chiswick ML, James DK. Br Med J 1979 Jan 6;1(6155):7 – 9 Related Arti­cles, Books, Link­Out

For­ceps Related to Facial Paral­y­sis
This study pub­lished in “Plas­tic Recon­struc­tive Surgery” ret­ro­spec­tively iden­ti­fies and char­ac­ter­izes patients with facial palsy related to birth trauma and describes the nat­ural his­tory of this dis­or­der. This ret­ro­spec­tive study revealed that 91% of all chil­dren who had suffesed with facial paral­y­sis were deliv­ered with for­ceps. The inci­dence of addi­tional birth injuries also was sub­stan­tially higher among affected sub­jects than among the gen­eral pop­u­la­tion of new­borns Facial nerve palsy in the new­born: inci­dence and out­come. Falco NA, Eriks­son E. Plast Recon­str Surg 1990 Jan;85(1):1 – 4

Fetal Skull Frac­tures from Vac­uum Extrac­tion Devices
The vac­uum extrac­tor is being increas­ingly advo­cated as the instru­ment of first choice for assisted vagi­nal deliv­ery. It is widely believed that the vac­uum cup will dis­lodge before caus­ing seri­ous fetal trauma. The vac­uum extrac­tor exerts con­sid­er­able trac­tion force. Fetal skull frac­ture can result, and its true inci­dence may be higher than expected, con­sid­er­ing that few neonates with nor­mal neu­ro­logic behav­ior undergo skull x-ray.

Skull frac­ture caused by vac­uum extrac­tion. Hickey K, McKenna P. Obstet Gynecol 1996 Oct;88(4 Pt 2):671 – 3;db=PubMed&amp;list_uids=8841247&amp;dopt=Abstract In only 134 vac­uum extraction-assisted deliv­er­ies there were 28 infants with scalp trauma, includ­ing 17 super­fi­cial lac­er­a­tions, six large caputs, and 12 cephalo­he­matomata; one infant had sub­galeal, sub­dural, and sub­arach­noid hem­or­rhages. The pro­por­tion of injuries was greater for appli­ca­tions exceed­ing 10 min­utes (6 of 9) than for those 10 min­utes or shorter (22 of 121, P < .01). Cos­metic scalp trauma occurred in 21% of our new­borns deliv­ered by vac­uum extrac­tion and was more com­mon after longer vac­uum appli­ca­tions, longer sec­ond stages, and para­me­dian cup placement.

Vac­uum extrac­tion: does dura­tion pre­dict scalp injury? Teng FY, Sayre JW.Obstet Gynecol 1997 Feb;89(2):281 – 5;db=PubMed&amp;list_uids=9015036&amp;dopt=Abstract

Vac­uum Extrac­tion Increases Neu­ro­log­i­cal Deficits in Chil­dren.
A case of grow­ing skull frac­ture fol­low­ing birth trauma and caused by vac­uum extrac­tion is reported in order to empha­size the inci­dence of this pecu­liar head injury at the begin­ning of extrauter­ine life and to point out its rela­tion to pos­si­ble neu­ropsy­cho­log­i­cal dis­tur­bances that may appear later in child­hood. Deliv­ery by vac­uum extrac­tion increases the inci­dence of peri­na­tal injuries and con­se­quently the inci­dence of neu­ro­log­i­cal deficits in chil­dren. Neu­ro­sur­gi­cal repair is advo­cated as the appro­pri­ate treat­ment, with the aim not only of cos­met­i­cally cor­rect­ing the lesion’s typ­i­cal sub­galeal pro­tu­ber­ance with cran­io­plasty, but also of per­form­ing a water-tight clo­sure of the dura, enabling the cere­bral cor­tex to “fill in” the intrac­ere­bral lesion. The sur­gi­cal tech­nique and gross pathol­ogy of the lesion are described together with radi­o­log­i­cal find­ings before and after surgery. Reports by other authors are reviewed in an attempt to iden­tify the con­di­tion­ing fac­tors and patho­log­i­cal fea­tures of this trau­matic injury to skull and brain in neonates and infants. The lit­er­a­ture on cra­nial frac­tures asso­ci­ated with intrac­ere­bral lesions at this age shows a sig­nif­i­cant dif­fer­ence in recov­ery and out­come from that after sim­i­lar lesions in older chil­dren. Cran­io­cere­bral birth trauma caused by vac­uum extrac­tion: a case of grow­ing skull frac­ture as a peri­na­tal com­pli­ca­tion. Papaefthymiou G, Ober­bauer R, Pendl G. Childs Nerv Syst 1996 Feb;12(2):117 – 20;db=PubMed&amp;list_uids=8674080&amp;dopt=Abstract

Spinal Cord Injury Dur­ing Birth
Rec­og­nized causative fac­tors are trac­tion on the infant’s trunk dur­ing breech deliv­ery, rota­tional stresses applied to the spinal axis, trac­tion on the cord via the brachial plexus in shoul­der dys­to­cia, and hyper­ex­ten­sion of the fetal head in breech deliv­ery or trans­verse pre­sen­ta­tion. Recog­ni­tion of these fac­tors is the basis for pre­ven­tion of this ter­ri­ble accident.

Byers RK; Spinal-cord injuries dur­ing birth. Dev Med Child Neu­rol 197517(1):103 – 10 /Med­line ID75131672

Birth Trauma: A Mod­ern Epi­demic
“Birth today has become a tech­no­log­i­cal expe­ri­ence where a nat­ural process has been replaced with arti­fi­cial pro­ce­dures and sched­ules. With­out the nec­es­sary sup­port dur­ing preg­nancy, women enter the birth process with fear and are led to rely on drugs instead of their bod­ies’ own nat­ural strengths. These drugs weaken her body’s abil­ity to func­tion and lead to even fur­ther inter­ven­tions. The more inter­ven­tions used in birth, the greater the risk of injury to both the mother and baby.” Ref­er­ences: Kimin­ski HM, Stafl.A & Aiman J. The effect of epidural anes­the­sia on the fre­quency of instru­men­tal obstet­ric deliv­ery. Obstet Gynecol 198769 (5): 770 – 773 Benedetti T. “Birth Injury and Method of Deliv­ery” Edi­to­r­ial NEJM 1999 Vol 341, No. 23 Sakala C. Con­tent of care by inde­pen­dent mid­wives assis­tance with pain in labor & birth.Soc Sci Med 199826 (11): 1141115

One expert med­ical researcher on spinal cord and brain stem injury tells us, ‘the birth process, even under opti­mal, con­trolled con­di­tions is a trau­matic poten­tially crip­pling event for the fetus.’” Tow­bin A. Latent spinal cord and brain stem injuries in new­born infants. Develop Med Child Neu­rol. 19691154 – 68

‘Spinal cord and brain stem injuries often occur dur­ing the process of birth but fre­quently escape diag­no­sis. Res­pi­ra­tory depres­sion in the neonate is a car­di­nal sign of much injury. In infants, there may be last­ing neu­ro­log­i­cal defects reflect­ing the pri­mary injury.’” Tow­bin A. Latent spinal cord and brain stem injuries in new­born infants. Develop Med Child Neu­rol. 19691154 – 68

Rou­tine pro­ce­dures such as induc­ing labor, pain med­ica­tions 9 and restricted mater­nal posi­tions are known to cause greater dif­fi­culty in labor and lead to fur­ther inter­ven­tions.” Satin AJ& Han­k­ins, GD. Induc­tion of labor in post­date fetuses. Clin Obste Gynecol 198932 (2): 269 – 277 Arulku­maran S et al. Obstet­ric out­come of patients with a pre­vi­ous episode of spu­ri­ous labor. Am J Obstet Gynecol 1987157 (1): 17 – 20 Chest­nut DH et al. The influ­ence of con­tin­u­ous epidural bupi­va­caine anal­ge­sia on the sec­ond stage of labor and method of deliv­ery in nul­li­parous women. Anes­the­si­ol­ogy 198766774 – 780. Gar­dosi J, Hus­ton N & B-Lynch. C-Randomized con­trolled trial of squat­ting in the sec­ond stage of labour. Lancet 19892 (8654): 74 – 77.

Med­ical research on birth trauma tells us , ‘Force­ful pulling on the baby’s neck par­tic­u­larly when com­bined with stretch­ing of the spine– has been con­sid­ered the most impor­tant cause of infant spinal and brain stem injury.’ Tow­bin A. “Brain Dam­age in the New­born and its Neu­ro­log­i­cal Sequels” 1998 Chap­ter 1138. Adams C, et al. “Spinal cord birth injury: value of com­puted tomo­graphic myel­og­ra­phy,” 1998 Depts of pedi­atric neu­rol­ogy and radi­ol­ogy: Uni­ver­sity of Toronto Rossitch E, Oakes J. Peri­na­tal spinal cord injury: clin­i­cal, radi­ographic and patho­log­i­cal fea­tures. Pedi­atr Neu­ro­surg 199218149 – 152

A recent study pub­lished in the New Eng­land Jour­nal of Med­i­cine revealed star­tling data. It reports: dif­fi­cult labor itself and the method of deliv­ery may lead to brain injuries and deaths in babies. Brain injuries were found in: one out of every 664 infants deliv­ered with for­ceps; one out of every 860 deliv­er­ies by vac­uum extrac­tion and one out of every 907 infants deliv­ered by c-section.

Towner D et al.. Effect of Mode of Deliv­ery in Nul­li­parous Women on Neona­tal Intracra­nial Injury. NEJM1999; Vol. 341, No. 23 Another pub­lished med­ical study reports: “mechan­i­cal stress imposed by obstet­ric manipulation-even the appli­ca­tion of stan­dard ortho­dox pro­ce­dures may prove intol­er­a­ble to the fetus. Dif­fi­cult breath­ing in the new­born is a clas­sic indi­ca­tion of such injury” It fur­ther states ‚” Sur­vival of the new­born is gov­erned mainly by the integrity and func­tion of the vital cen­ters in the brain stem. Yet para­dox­i­cally, the impor­tance of injury at birth to the brain stem and spinal cord are mat­ters which have gen­er­ally escaped last­ing atten­tion.” Tow­bin A. Latent spinal cord and brain stem injury in new­born infants. Develp Med Child Neo­rol 196911:54 – 68 Birth trauma causes spinal injury. The effect is life­long impair­ment Got­tlieb MS. Neglected spinal cord, brain stem and mus­cu­loskele­tal injuries stem­ming from birth trauma. J Manip­u­la­tive Phys­iol ther 1993 Oct; 16(8): 537 – 43. (The above excerpts are taken from the video script, “Birth Trauma: A Mod­ern Epi­demic” by Dr. Jeanne Ohm)