There are a large number of different types of injury a baby can suffer during the birthing process. These include brachial plexus injury, cerebral palsy, Group B streptococcus infection, head trauma, facial nerve trauma, spinal cord trauma, intracranial hemorrhage, bone fractures, and other injuries.

Brachial Plexus Injury

Brachial plexus injury, often called brachial plexus palsy, is one of the most common birth injuries. It occurs when the baby is pulled in such a way as to stretch or tear some or all of the five nerves that emanate from the brachial plexus nerve bundle and control the shoulders, arms and hands. Symptoms may include a limp or paralyzed arm, lack of muscle control in the arm, hand, or wrist, and lack of feeling or sensation in the arm or hand. A child's disability depends on which nerves are injured and how severely they have been damaged. Brachial plexus injury is 10 to 20 times more common than spinal cord injury.

Most brachial plexus injuries occur at birth. Approximately one or two babies out of every 1,000 born are affected. There are four types of brachial plexus injuries: (1) avulsion, the most severe type, in which the nerve is torn from the spine; (2) rupture, in which the nerve is torn but not at the spinal attachment; (3) neuroma, in which the nerve has tried to heal itself but scar tissue has grown around the injury, putting pressure on the injured nerve and preventing the nerve from conducting signals to the muscles; and (4) neuropraxia or stretch, in which the nerve has been damaged but not torn. Neuropraxia is the most common type of brachial plexus injury.

Some brachial plexus injuries may heal on their own. Many children improve or recover by three to four months of age. Treatment for brachial plexus injuries includes physical therapy and, in some cases, surgery. The site and type of brachial plexus injury determine the prognosis. For avulsion and rupture injuries there is no potential for recovery unless surgical reconnection is made in a timely manner. For neuroma and neuropraxia injuries the potential for recovery varies. Most children with neuropraxia injuries recover spontaneously with a 90-100% return of function.

The upper trunk of the brachial plexus consists of the C5 and C6 nerve roots, which exit the spinal cord at the levels of the 5th and 6th cervical vertebra, respectively. The middle trunk consists of the C7 nerve root, which exits the spinal cord above the 7th cervical vertebra. The lower trunk consists of the C8 and T1 nerve roots, which exit below the 7th cervical and 1st thoracic vertebra, respectively. Erb's palsy refers to injuries of the upper trunk (and sometimes the middle trunk as well), affecting muscles around the shoulder and elbow, and Klumpke's palsy refers to injuries of the lower plexus, which affect muscles of the forearm and hand. Erb's palsy comprises approximately 60 percent, Klumpke's about 5 percent, and mixed (upper and lower trunk involvement) perhaps 35 percent of all brachial plexus injuries.

Cerebral Palsy

Cerebral palsy is a term used broadly to describe a number of movement disorders resulting from prenatal developmental abnormalities or brain damage occurring during birth or before age five. It results from faulty development of, or damage to, the "motor" areas of the brain, which are responsible for controlling movement.

Approximately 500,000 people in the United States have been diagnosed with cerebral palsy. More than 5,000 children (between 0.1% and 0.2% of all children), the vast majority of whom are babies or infants, are diagnosed with cerebral palsy each year. Premature infants are at a much higher risk for developing cerebral palsy than full-term babies, and the risk increases as the birth weight decreases. Between five and eight percent of infants weighing less than 1500 grams (3 pounds) at birth develop cerebral palsy, and infants weighing less than 1500 grams are 25 times more likely to develop cerebral palsy than infants who are born at full term weighing more than 2500 grams.

Cerebral palsy can result from a multitude of causes. Birth trauma and lack of oxygen during the birthing process may cause 15% of the cases. Trauma to the baby's head due to improper use of forceps or a vacuum extractor at the time of delivery can cause bleeding in the brain, resulting in cerebral palsy. Other possible causes include Rh incompatibility and rubella (German measles).

Early signs of cerebral palsy usually appear before three years of age. Infants with cerebral palsy are frequently slow to reach developmental milestones such as learning to roll over, sit, crawl, smile, or walk.

Types of Cerebral Palsy

Cerebral palsy syndromes are grouped into four main categories: spastic, athetoid, ataxic, and mixed forms. Spastic syndromes occur in about 70% of cases. The spasticity is due to upper motor neuron involvement and may mildly or severely affect motor function. The syndrome may produce hemiplegia (paralysis on one side of the body), paraplegia (paralysis of both legs), quadriplegia (paralysis of both legs and both arms), or diplegia (paralysis of both arms). Affected limbs usually are underdeveloped and show increased deep tendon reflexes and muscular hypertonicity, weakness, and a tendency toward contractures.

Athetoid or dyskinetic syndromes occur in about 20% of cases and result from basal ganglia involvement. Slow, writhing, involuntary movements may affect the extremities (athetoid) or the proximal parts of the limbs and the trunk (dystonic); abrupt, jerky, distal movements also may occur. The movements increase with emotional tension and disappear during sleep. Dysarthria occurs and is often severe.

Ataxic syndromes occur in about 10% of cases and result from involvement of the cerebellum or its pathways. Weakness, lack of coordination, and intention tremor produce unsteadiness, a wide-based gait, and difficulty with rapid or fine movements.

Mixed forms are common--most often, spasticity and athetosis; less often, ataxia and athetosis.

Convulsive seizures occur in about 25% of patients, most often in those with spasticity. Children with spastic hemiplegia or paraplegia frequently have normal intelligence; spastic quadriplegia and mixed forms often are associated with disabling mental retardation. Short attention span and hyperactivity are common.

The brain damage which causes cerebral palsy remains permanent from the time of injury. There is no cure for cerebral palsy, and it is not contagious. The goal is for patients to develop maximal independence within the limits of their motor and associated handicaps. With proper management, many patients, especially those with spastic paraplegia or hemiplegia, can lead near-normal lives. Complete social independence is not realistic for others, who will require varying degrees of lifelong supervision and assistance.

Group B Streptococcus

Group B streptococcus (GBS) infection is a common bacterial infection that is rarely serious in adults, but can be life-threatening to newborns. GBS affects about 1 in every 2,000 babies born in the United States, and nearly 400 die each year. Group B streptococcus should not be confused with Group A streptococcus, which commonly causes strep throat and, rarely, a potentially deadly flesh-destroying infection.

Between 10 and 30 percent of pregnant women carry the GBS bacterium in their vaginal or rectal area, but few babies of these women actually develop an infection. Doctors believe that babies who become sick with GBS infection have taken the bacterium into their bodies--for example, by ingesting GBS-laden vaginal fluids during labor and delivery.

There are two forms of GBS infection in infants, early- and late-onset. Babies with an early-onset infection develop symptoms within seven days of birth, most commonly within the first six hours of life. Babies with a late-onset infection develop symptoms at between seven days and three months of age.

About 80 percent of all GBS infections in newborns are early onset. Early-onset infections almost always are transmitted from mother to baby around the time of delivery. Late-onset infections can be contracted at delivery or acquired after birth.

Babies with an early-onset infection suffer from one or more of the following: pneumonia, sepsis (blood infection), and meningitis (infection of the membranes surrounding the brain). Babies with a late-onset infection usually have sepsis or meningitis.

In spite of treatment with antibiotics, about 5 percent of babies with GBS die. Preterm babies are more likely to die from the illness than are full-term babies. Most babies who survive GBS go on to develop normally. However, among those who develop meningitis, between 15 and 30 percent suffer lasting neurologic damage in the form of cerebral palsy, sight and hearing loss, or mental retardation.

Two approaches can prevent most early-onset GBS infections in the newborn. Both involve testing pregnant women and then treating those infected or at risk of infection with intravenous antibiotics during labor and delivery. Thanks to guidelines for preventing the infection, the number of babies who developed early-onset GBS dropped 70 percent between 1993 and 2000.

Other Birth Trauma Injuries

Head Trauma: Mild trauma may cause caput succedaneum--edema of the presenting portion of the scalp--as this area is forced against the cervix. Greater trauma may cause subgaleal hemorrhage, which is characterized by a boggy feeling over the entire scalp.

Depressed skull fractures are uncommon. Most result from forceps pressure; rarely, they are caused by the head's resting on a bony prominence in the uterus. Depressed skull fractures or other head trauma may be associated with subdural bleeding, subarachnoid hemorrhage, or contusion or laceration of the brain itself.

Facial Nerve Trauma: Although frequently attributed to forceps pressure, most trauma probably results from pressure on the nerve in utero, which may be due to fetal positioning or to pressure against the nerve by the sacral promontory or a uterine fibroid.

Spinal Cord Trauma: Spinal cord trauma is rare and may cause variable cord disruption, often with hemorrhage. Complete disruption of the cord is very rare. Trauma usually occurs in breech deliveries after excess longitudinal traction to the spine. It can also follow hyperextension of the fetal neck in utero. Injury usually affects the lower cervical region (C5-C7). When the injury is higher, the lesions are generally fatal because respiration is compromised.

Intracranial Hemorrhage: Hemorrhage in or around the brain can be life-threatening in newborns, especially those born prematurely. Hypoxia-ischemia, variations in blood pressure, and pressures exerted on the head during labor are major causes of intracranial hemorrhage. Hemorrhage can occur in several spaces. About 20% of premature infants weighing less than 1500 grams (three pounds) have intracranial hemorrhage.

Fractures: Midclavicular fracture, the most common fracture during birth, usually occurs with shoulder dystocia (difficulty in delivering the fetal shoulders after delivery of the head). Most clavicular fractures heal rapidly and uneventfully. The major significance of clavicular fractures is their tendency to cause brachial plexus injury or pneumothorax from perforation of the apical pleura. The humerus and the femur may be fractured during difficult deliveries.