A Medicolegal Perspective on Birth Injuries Involving Nerve Damage and Scarring

A birth injury is defined as any structural damage and/or functional deterioration that occurs in a newborn infant as a direct result of a traumatic event during labour, delivery or both. Such injuries occur most frequently during the second stage of labour, during which the foetus descends through the birth canal, and may result in nerve damage or scarring. Although birth injuries are relatively rare, occurring in fewer than 1% of live births, their consequences can be devastating and can even lead to the death of the infant. 

The likelihood of a birth injury occurring is influenced by many factors, which can be broadly classified into three groups: foetal factors, delivery mechanisms and maternal factors. Foetal factors include large size, prematurity, breech or other abnormal presentation, and rapid labour. Delivery procedures, such as forceps delivery or vacuum extraction, that aim to ease the infant’s descent can also cause injuries, as can the use of foetal scalp electrodes, intrapartum heart rate monitors and other monitoring equipment. Birth injuries are also more common in the infants of mothers who are either very young or older than average, of short stature and giving birth to their first child. Maternal pelvic abnormalities can also increase the risk. 

One of the more common neurological birth injuries involves stretching or tearing of the nerves that make up the brachial plexus. This often occurs in association with shoulder dystocia – when the baby’s shoulder gets stuck on the pelvic brim. The severity of this condition can vary considerably, from a slight asymmetry in upper limb movement and placement, that fully resolves, to severe nerve damage that that essentially renders the limb paralysed. 

Facial nerve trauma, resulting in facial palsy, is particularly associated with the use of forceps during delivery. The condition is thought to arise from the pressure of the forceps blade on the facial nerve as it leaves the stylomastoid foramen or crosses the ramus of the mandible. The most noticeable sign is an inability to close the eye on the affected side, although in severe cases movement of the entire side of the face is affected. While most infants make a good recovery within the first few weeks of life, very rarely some may remain affected into childhood and beyond. Facial paralysis can have a significant impact on the child’s quality of life and psychological wellbeing. 

The prognosis for nerve injuries is generally good, but it can be influenced by the quality of initial treatment. It is therefore vital that these injuries are identified as soon as possible, as the resulting asymmetries may become more marked as the child grows. Initially, clinical examination alone may suffice, as the presence of many nerve injuries is usually obvious due to marked asymmetry in the range of movement or appearance of the affected area. However, determining the severity of the injury is more problematic and can necessitate a more thorough examination with the use of imaging techniques such as magnetic resonance imaging or ultrasound. The impact on sensory function can also be difficult to characterise. As many nerve injuries resolve spontaneously over time, conservative treatment is often sufficient, but if there is inadequate functional recovery within the first 9 months of life, surgical repair of the damaged never may be required. 

Birth trauma is also the underlying cause for the majority of intracranial haemorrhages. In prolonged deliveries, especially those in which forceps are used, excessive moulding of the baby’s head may cause a rupture of the tentorium and subsequent subdural haemorrhage. The clinical presentation is dependent on the extent of the bleeding. Significant bleeding can lead to a tense or bulging fontanelle, with an increased head circumference. This is associated with an increased likelihood of central sleep apnoea, bradycardia and seizures, or even stillbirth in extreme cases. Infants with less significant trauma may only show vague signs and it is likely that many mild cases of intracranial haemorrhage go undiagnosed. 

As well as nerve injuries, birth trauma can result in scarring of one form or another. Following instrument-assisted deliveries, the scalp may be swollen and haematomas are often present. If these become infected, permanent scarring and alopecia may develop and this could have significant consequences for the child’s appearance, social acceptance and self-esteem. The skin of newborn infants differs from that of older children, as it is physiologically more fragile and therefore more susceptible to pressure injuries. 

Although injuries following birth trauma are rare, they can have significant consequences. Therefore, whenever possible, such injuries should be prevented. However, this is not always easy as some factors that contribute to the likelihood of injury, such as maternal age or foetal presentation, cannot be controlled. Instead, importance should be placed on minimising the factors that can be changed, such as ensuring optimal technique for the use of instruments in assisted deliveries. Early identification of birth injuries will ensure that treatment is timely and appropriate, thus giving the best possible outcome for the infant and reducing the risk of subsequent litigation. 

Further reading:

de Bengy AF, Lamartine J, Sigaudo-Roussel D, Fromy B. Newborn and elderly skin: two fragile skins at higher risk of pressure injury. Biol Rev Camb Philos Soc. 2022 Jun;97(3):874-895. 

Ojumah N, Ramdhan RC, Wilson C, Loukas M, Oskouian RJ, Tubbs RS. Neurological Neonatal Birth Injuries: A Literature Review. Cureus. 2017 Dec 12;9(12): e1938.