Introduction to Birth Injury

Each year, a small but significant number of newborns experience a birth injury, an event that can transform a joyous occasion into a period of concern and specialized care. For every 1,000 live births in the United States, approximately 7 to 29 infants may sustain some form of birth injury, with scalp injuries being the most frequently reported (Cleveland Clinic, 2025; Cerebral Palsy Guide, 2024). As future nurses, understanding the nuances of each birth injury is paramount to providing effective and compassionate care.

A birth injury, also known as neonatal birth trauma, is defined as an impairment of the neonate’s body function or structure due to an adverse event that occurred during labor or delivery (StatPearls – Birth Trauma, 2023). It is crucial to differentiate a birth injury from a birth defect (congenital anomaly), which is a structural or functional abnormality present before birth, arising from genetic, environmental, or unknown factors. A birth injury, in contrast, is acquired during the birthing process itself.

While many instances of birth injury are minor and resolve with minimal or no intervention, some can lead to serious, long-term consequences, affecting the child’s physical and neurological development, and imposing significant emotional and financial burdens on families. The spectrum of a neonatal birth injury ranges from superficial bruises and minor fractures to severe nerve damage and intracranial hemorrhages.

For nursing students, a comprehensive understanding of birth injury – encompassing its assessment, management, and prevention – is critical. Nurses are often the first to identify subtle signs of a birth injury in a newborn. Their role involves meticulous assessment, implementation of appropriate care strategies, provision of vital support and education to families navigating a difficult period, and active participation in efforts to prevent the occurrence of a birth injury. This guide aims to provide a thorough overview of neonatal birth injury, equipping aspiring nurses with the knowledge and insights necessary for exemplary practice in maternal and child health. We will explore the types of birth injury, their causes, risk factors, diagnostic approaches, management strategies, long-term implications, and global efforts to mitigate this challenge.

Understanding Birth Injuries: Types and Etiology

A foundational knowledge of the various types of birth injury and their underlying causes is essential for nursing students. This understanding allows for prompt recognition, appropriate intervention, and effective communication with the healthcare team and the infant’s family. Each type of birth injury presents unique challenges and requires specific management approaches.

Types of Birth Injury

A birth injury can affect various parts of the newborn’s body, with differing degrees of severity. They are broadly categorized into nerve injuries, musculoskeletal injuries, head trauma, and soft tissue injuries.

Nerve Injuries

Nerve injuries are a significant category of birth injury, often resulting from stretching or compression during a difficult delivery.

• Brachial Plexus Palsy (BPP): This type of birth injury involves damage to the brachial plexus, a network of nerves (C5-T1) that controls movement and sensation in the shoulder, arm, and hand. It’s commonly associated with shoulder dystocia, macrosomia, or breech delivery (StatPearls – Birth Trauma, 2023).
  • Erb’s Palsy (Upper Plexus Injury, C5-C6, sometimes C7): The most common form of BPP.
    Pathophysiology: Stretching or tearing of the upper nerve roots.
    Clinical Features: Characterized by the “waiter’s tip” posture: the arm hangs limply by the side, adducted and internally rotated, with the elbow extended, forearm pronated, and wrist flexed. The Moro reflex is asymmetric, and spontaneous movement of the affected arm is decreased. Grasp reflex may be intact. The Narakas Classification (simplified for understanding) Group I typically involves C5-C6 roots (OrthoBullets – Obstetric Brachial Plexopathy).
  • Klumpke’s Palsy (Lower Plexus Injury, C8-T1): A rarer form of BPP.
    Pathophysiology: Stretching or tearing of the lower nerve roots, often due to hyperabduction of the arm during delivery (e.g., arm pulled overhead in a breech birth).
    Clinical Features: Results in a “claw hand” deformity due to paralysis of the intrinsic hand muscles (wrist flexed, fingers hyperextended at metacarpophalangeal joints and flexed at interphalangeal joints). The grasp reflex is typically absent. May be associated with Horner’s syndrome (ptosis, miosis, anhidrosis) if the T1 sympathetic fibers are involved (StatPearls – Klumpke Palsy, 2023).
  • Total Plexus Palsy (C5-T1): The entire arm is flaccid (limp), insensate (lacking sensation), and without reflexes. This is the most severe form of brachial plexus birth injury.
• Facial Nerve Palsy (Cranial Nerve VII Injury):
  Pathophysiology: Occurs due to compression of the facial nerve, often by obstetric forceps or pressure from the maternal sacral promontory during descent (Stanford Medicine Children’s Health – Birth Injuries).
  Clinical Features: Presents as facial asymmetry, most noticeable when the infant cries. The mouth draws to the unaffected side, the eye on the affected side may not close completely, the nasolabial fold may be absent, and the corner of the mouth may droop. It is usually unilateral.
• Phrenic Nerve Palsy (C3-C5 roots to diaphragm):
  Pathophysiology: Injury to the phrenic nerve, which controls the diaphragm. It is often associated with a brachial plexus birth injury due to extensive traction on the cervical nerve roots.
  Clinical Features: Leads to respiratory distress, including tachypnea (rapid breathing), cyanosis (bluish discoloration), and paradoxical chest movement (the abdomen rises while the chest falls during inspiration). Recurrent pneumonia can be a complication. Diagnosis is often confirmed by ultrasound showing an elevated hemidiaphragm on the affected side.
• Spinal Cord Injuries:
  Pathophysiology: A rare but devastating type of birth injury resulting from excessive traction, torsion, or hyperextension of the fetal spine, particularly during difficult breech deliveries or deliveries with significant fetal manipulation.
  Clinical Features: Symptoms vary depending on the level and severity of the spinal cord birth injury. They can include flaccid paralysis below the level of injury, respiratory failure if the high cervical cord is affected, and bladder/bowel dysfunction.

Musculoskeletal Injuries

• Fractures: These are among the more common types of neonatal birth injury.
  • Clavicle Fracture: The most common fracture in newborns.
    Pathophysiology: Typically occurs during a difficult delivery, especially with shoulder dystocia or during a breech extraction, due to direct pressure or traction.
    Clinical Features: Often detected by palpable crepitus (a grating sound or sensation), a visible lump or deformity over the clavicle, decreased or absent movement of the arm on the affected side, an asymmetric Moro reflex, and signs of pain on movement. A callus (new bone formation) becomes noticeable as a firm lump within 7-10 days, indicating healing (Stanford Medicine Children’s Health – Birth Injuries).
  • Humerus Fracture: Fracture of the upper arm bone.
    Pathophysiology: Similar mechanisms to clavicle fractures, involving traction or torsion during delivery. It is rarer than clavicle fractures.
    Clinical Features: Presents with pain, swelling, crepitus, and deformity of the upper arm. The infant will show limited arm movement and an asymmetric Moro reflex. Most are diaphyseal (shaft) fractures (Pediatric Orthopedics – Common Injuries).
  • Femur Fracture: Fracture of the thigh bone.
    Pathophysiology: A rare birth injury, usually associated with difficult breech deliveries or excessive manipulation of the lower limbs.
    Clinical Features: Obvious deformity, swelling, significant pain, and immobility of the affected leg.
  • Skull Fractures (Linear or Depressed):
    Pathophysiology: Can result from pressure against the maternal pelvis or the use of instruments like forceps.
    Clinical Features: Linear fractures are often asymptomatic and may go undetected unless imaging is performed for other reasons. Depressed fractures, sometimes called “ping-pong ball” fractures, present as a palpable indentation on the skull. There is a risk of underlying intracranial birth injury with any skull fracture.
• Joint Dislocations: These are rare forms of birth injury and can involve the hip, knee, or shoulder, usually resulting from significant manipulation during delivery.

Head Trauma

Head trauma is a critical area of concern in neonatal birth injury, encompassing a range of injuries from superficial scalp issues to serious intracranial bleeding.

• Scalp Injuries:
  • Caput Succedaneum:
    Pathophysiology: Edematous swelling of the soft tissues of the scalp, caused by pressure of the presenting part against the cervix during labor. It involves a collection of serosanguinous fluid above the periosteum.
    Clinical Features: Presents as a diffuse, boggy swelling that crosses suture lines and pits on pressure. Overlying bruising or petechiae may be present. It is typically evident at birth and resolves spontaneously within a few days (Stony Brook Medicine – Birth Injuries PDF).
  • Cephalohematoma:
    Pathophysiology: A subperiosteal collection of blood resulting from the rupture of blood vessels between the skull bone and its periosteum.
    Clinical Features: Appears as a firm, well-demarcated swelling that does NOT cross suture lines because it is limited by the attachment of the periosteum to a single cranial bone. It often appears several hours to a day after birth and resolves over weeks to months. There is an increased risk of hyperbilirubinemia as the blood breaks down. Initially, there is no overlying skin discoloration (Stanford Medicine Children’s Health – Birth Injuries).
  • Subgaleal Hemorrhage:
    Pathophysiology: Bleeding into the potential space between the epicranial aponeurosis (galea) and the periosteum. This serious birth injury occurs due to the shearing of emissary veins that connect the dural sinuses to the scalp veins, often from forceful vacuum extraction or difficult forceps delivery.
    Clinical Features: This is a potentially life-threatening neonatal birth injury. It presents as a diffuse, fluctuant, boggy swelling that crosses suture lines, can shift with movement, and can expand significantly to accommodate large volumes of blood. Bruising may extend to the neck and ears. Signs of hypovolemic shock (pallor, tachycardia, hypotension, increasing head circumference) are critical indicators (StatPearls – Birth Trauma, 2023). Any suspected subgaleal hemorrhage warrants immediate and intensive medical attention.
• Intracranial Hemorrhages (ICH): Bleeding within the skull.
  Pathophysiology Overview: Can result from trauma, hypoxia-ischemia, or prematurity. Our focus here is on traumatic birth injury.
  • Epidural Hemorrhage (EDH): Rare in neonates.
    Location: Between the dura mater and the inner table of the skull.
    Cause: Often associated with a linear skull fracture that tears a meningeal artery or venous sinus.
    Clinical Features: The infant may initially appear well (lucid interval), followed by signs of increased intracranial pressure (ICP) such as a bulging fontanelle, bradycardia, hypertension, irritability, seizures, and altered consciousness (StatPearls – Birth Trauma, 2023).
  • Subdural Hemorrhage (SDH): The most common type of traumatic ICH in neonates.
    Location: Between the dura mater and the arachnoid mater.
    Cause: Results from the tearing of bridging veins, often due to excessive cranial molding, rotational forces during delivery, or instrumental delivery. Commonly occurs over the cerebral convexities, tentorium, or in the posterior fossa.
    Clinical Features: Highly variable; can be asymptomatic if small. If symptoms are present, they may include seizures, a bulging fontanelle, irritability, lethargy, apnea, respiratory depression, or altered muscle tone (StatPearls – Birth Trauma, 2023).
  • Subarachnoid Hemorrhage (SAH): The second most common type of traumatic ICH.
    Location: Between the arachnoid mater and the pia mater.
    Cause: Typically due to the rupture of small bridging veins in the subarachnoid space as a result of trauma or hypoxia.
    Clinical Features: Often asymptomatic in term infants. If the hemorrhage is extensive, it may cause seizures or apnea. Blood in the cerebrospinal fluid (CSF) is a diagnostic indicator.
  • Intraventricular Hemorrhage (IVH): Primarily considered a lesion of prematurity (germinal matrix hemorrhage), but it can occur in term infants due to severe trauma or asphyxia.
    Location: Within the ventricular system of the brain.
    Cause (in term infants): Can result from the extension of other types of hemorrhages or severe direct trauma.
    Clinical Features: Severity varies (often graded I-IV, though this is more typical for preterm IVH, the concept of severity applies). Symptoms can range from asymptomatic to catastrophic, including seizures, apnea, and coma.
  • Intraparenchymal/Intracerebral Hemorrhage: Bleeding directly into the brain tissue itself. Less common purely from trauma in term infants, often linked to severe hypoxia-ischemia or as an extension of other hemorrhages. This type of birth injury can have severe neurological consequences.

Soft Tissue Injuries

• Bruising (Ecchymosis) and Petechiae: These are common findings, especially on the presenting part of the baby (e.g., face, scalp). They result from pressure during passage through the birth canal or from the application of instruments. Usually benign and resolve spontaneously within a few days. Petechiae are tiny, pinpoint hemorrhages.
• Lacerations and Abrasions: These can occur from scalpels during Cesarean sections, fetal scalp electrodes used for monitoring during labor, or from obstetric instruments. Most are superficial and heal without complications.
• Subconjunctival Hemorrhage: Presents as bright red patches on the sclera (the white part) of the baby’s eyes. Caused by the rupture of small blood vessels due to increased pressure during delivery. This birth injury is harmless and typically resolves within 1-2 weeks without treatment (Stanford Medicine Children’s Health – Birth Injuries).
• Fat Necrosis: Appears as firm, nodular lesions in the subcutaneous tissue. This birth injury can occur days to weeks after a difficult delivery involving prolonged pressure or trauma to fatty areas. These lesions typically resolve on their own over several months but can sometimes calcify.

Etiology (Causes) of Birth Injury

The causes of a birth injury are multifactorial, often involving a combination of fetal, maternal, and labor-related factors.

Fetal Factors

• Macrosomia: Defined as a birth weight over approximately 8 pounds, 13 ounces (4,000 grams) or, by some definitions, over 4,500 grams (Stanford Medicine Children’s Health – Birth Injuries). Larger babies are at increased risk for shoulder dystocia, which can lead to brachial plexus palsy or fractures, and generally more difficult passage through the birth canal, increasing the likelihood of a birth injury.
• Prematurity: Infants born before 37 weeks of gestation have more fragile tissues and underdeveloped vasculature. This makes them more susceptible to certain types of birth injury, particularly intracranial hemorrhages (like IVH related to the fragile germinal matrix) and physical trauma due to their delicate bodies (Stanford Medicine Children’s Health – Birth Injuries).
• Abnormal Fetal Presentation or Position: Presentations such as breech (buttocks or feet first), transverse lie (sideways), face, or brow presentation, or a persistent occiput posterior position can lead to a more difficult and prolonged labor. These situations may necessitate more complex obstetric maneuvers or instrumental delivery, increasing the risk of a specific birth injury. For example, breech deliveries are associated with higher rates of head trauma, spinal cord injury, and fractures.
• Fetal Anomalies: Certain congenital conditions, such as hydrocephalus (enlarged head due to fluid accumulation) or large fetal tumors, can complicate vaginal delivery and predispose to a birth injury.
• Multiple Gestation (Twins, Triplets, etc.): Pregnancies with multiple fetuses carry a higher risk of malpresentation of one or more babies, prematurity, and intrauterine growth restriction, all of which can contribute to a higher incidence of birth injury.

Maternal Factors

• Cephalopelvic Disproportion (CPD): This occurs when the size and shape of the mother’s pelvis are not adequate for the baby’s head to pass through vaginally (Stanford Medicine Children’s Health – Birth Injuries). CPD is a significant cause of obstructed labor and may necessitate instrumental delivery or Cesarean section, both of which carry risks for different types of birth injury.
• Maternal Pelvic Abnormalities: A small or abnormally shaped pelvis (e.g., android or platypelloid) can impede fetal descent and rotation, contributing to dystocia and the risk of birth injury.
• Primiparity (First Birth): Women giving birth for the first time may have longer labors and a higher likelihood of dystocia or requiring operative vaginal delivery, which can increase the risk of certain types of birth injury.
• Maternal Obesity: Obesity in pregnancy is associated with an increased risk of gestational diabetes, macrosomia, prolonged labor, and shoulder dystocia, thereby heightening the chance of a birth injury.
• Gestational Diabetes Mellitus (GDM): GDM often leads to fetal macrosomia, which is a primary risk factor for shoulder dystocia and other traumatic birth injury types (Birth Injury Help Center – Risk Factors).
• History of Previous Difficult Delivery or Birth Injury: Mothers who have previously experienced a difficult birth or whose prior infant sustained a birth injury may be at increased risk in subsequent pregnancies, depending on the cause of the previous event.

Labor and Delivery Factors (Intrapartum Events)

• Prolonged or Precipitous Labor: Both extremes of labor duration can increase stress on the fetus. Prolonged labor (dystocia) can lead to fetal exhaustion, hypoxia, and the need for interventions that carry risk of birth injury (Stanford Medicine Children’s Health – Birth Injuries). Precipitous (very rapid) labor can cause rapid, uncontrolled descent and expulsion, potentially leading to cranial trauma or other injuries.
• Dystocia (Difficult Labor): This encompasses various problems with the progress of labor.
  • Shoulder Dystocia: A critical obstetric emergency where, after delivery of the fetal head, the anterior shoulder becomes impacted behind the maternal pubic symphysis (or, less commonly, the posterior shoulder gets stuck on the sacral promontory). This situation can lead to severe brachial plexus birth injury, clavicle or humerus fractures, and hypoxic brain injury if not resolved promptly (Cerebral Palsy Guide – Shoulder Dystocia).
• Operative Vaginal Delivery: The use of instruments to assist delivery.
  • Forceps Delivery: Associated with an increased risk of facial nerve palsy, cephalohematoma, skull fractures, intracranial hemorrhage, and maternal perineal trauma (Stanford Medicine Children’s Health – Birth Injuries).
  • Vacuum Extraction (Ventouse): Associated with caput succedaneum, cephalohematoma, subgaleal hemorrhage, retinal hemorrhages, and scalp abrasions or lacerations (StatPearls – Birth Trauma, 2023 mentions subgaleal hemorrhage incidence 59/10000 vacuum-assisted deliveries).
• Uterine Rupture or Dehiscence: A rare but life-threatening event for both mother and baby, which can lead to severe fetal hypoxia and traumatic birth injury.
• Cord Accidents: While conditions like cord prolapse or a tight nuchal cord primarily lead to hypoxic-ischemic injury rather than direct mechanical birth injury, the ensuing fetal distress might necessitate rapid, forceful extraction, potentially increasing trauma risk.

Iatrogenic Factors/Medical Negligence (Briefly)

While many instances of birth injury occur despite optimal care, some can be attributed to iatrogenic factors or deviations from the standard of care. These can include:

• Improper or excessive force used during delivery maneuvers or with obstetric instruments.
• Excessive or inappropriate traction applied to the fetal head or neck.
• Failure to recognize and respond appropriately and timely to signs of fetal distress or obstructed labor.
• Inappropriate decision-making regarding the mode of delivery (e.g., persisting with vaginal delivery attempts when a Cesarean section is indicated).
• Failure to anticipate or manage known risk factors such as macrosomia or shoulder dystocia effectively (Cerebral Palsy Guide, 2024).

Understanding these varied causes is the first step towards effective prevention and management of any neonatal birth injury.

Risk Factors and Prevention Strategies for Birth Injury

Preventing a neonatal birth injury where possible is a primary goal of obstetric and neonatal care. This involves identifying pregnancies and deliveries at higher risk and implementing evidence-based prevention strategies throughout the antenatal and intrapartum periods. A significant proportion of birth injury events may be avoidable with careful planning and management.

Identifying High-Risk Pregnancies and Deliveries

Early identification of risk factors allows healthcare providers to anticipate potential complications and plan accordingly, which may involve more intensive monitoring, specialist consultation, or planning for a specific mode of delivery.

• Comprehensive Antenatal Assessment:
  • A detailed maternal history is crucial. This includes previous obstetric history (e.g., prior shoulder dystocia, previous macrosomic infant, previous birth injury), existing maternal medical conditions (e.g., diabetes, hypertension, obesity), and parity (Goldberg & Schulkin – Risk Factors).
  • Regular fetal growth monitoring using clinical measurements (fundal height) and ultrasound is essential, especially if macrosomia is suspected. Serial ultrasounds can help estimate fetal weight, although these estimates have a margin of error.
  • Assessment of fetal presentation and position as term approaches. Malpresentations like breech or transverse lie significantly increase the risk of a difficult delivery and potential birth injury.
  • Clinical or imaging-based pelvimetry may be considered in select cases to assess for cephalopelvic disproportion (CPD), though routine use is not standard.
  • Screening for and management of gestational diabetes is vital, as poorly controlled GDM is a major cause of macrosomia (Birth Injury Help Center – Gestational Diabetes).
• Recognizing Intrapartum Risk Factors:
  • Continuous and careful monitoring of labor progress using tools like a partograph helps identify deviations from normal, such as prolonged stages of labor or arrest of descent.
  • Electronic fetal heart rate monitoring (EFM) in high-risk situations or when fetal distress is suspected can provide early warning signs. However, interpretation must be accurate to avoid unnecessary interventions.
  • Early identification of developing macrosomia (if not previously diagnosed), malpresentation diagnosed during labor, or signs of labor dystocia (e.g., failure to progress despite adequate contractions).
  • Recognizing maternal exhaustion or inadequate pushing efforts, which might necessitate assisted delivery.

Prevention Strategies

Preventive measures for a birth injury span the continuum of care from preconception through the postpartum period.

Antenatal Care

• Optimize Maternal Health: Preconception counseling and management of pre-existing conditions. For example, achieving good glycemic control in women with diabetes before and during pregnancy can reduce the risk of macrosomia and associated birth injury (ABC Law Centers – Prenatal Care).
• Appropriate Nutritional Counseling and Weight Management: Advising on healthy weight gain during pregnancy can reduce risks associated with maternal obesity and fetal macrosomia.
• Patient Education: Educating expectant parents about the signs of labor, when to seek care, and realistic expectations for labor and delivery can improve preparedness. Discussing birth plans and preferences while also acknowledging potential deviations is important.

Intrapartum Management

• Skilled Birth Attendants: Ensuring that all births are attended by healthcare professionals (doctors, midwives) trained and competent in routine delivery, recognition and management of obstetric emergencies (Emergency Obstetric Care – EmOC), and neonatal resuscitation (Neonatal Resuscitation Program – NRP) is fundamental.
• Appropriate Fetal Monitoring: As mentioned, early detection of fetal distress through intermittent auscultation or continuous EFM (when indicated) is vital. Prompt intervention based on concerning patterns can prevent adverse outcomes, including certain types of birth injury related to hypoxia.
• Judicious Use of Labor Augmentation and Induction: Labor should be induced or augmented only for clear medical indications, following established protocols. Overuse or improper use of oxytocin can lead to uterine hyperstimulation, fetal distress, and potentially traumatic delivery.
• Active Management of Labor and Prevention of Prolonged Labor: Adherence to guidelines for managing labor progress can help prevent prolonged labor, which is a risk factor for both maternal and fetal complications, including some forms of birth injury. Timely intervention, which may include Cesarean section, is crucial if labor is not progressing appropriately.
• Management of Malpresentations: For a breech presentation near term, options like External Cephalic Version (ECV) may be offered under specific criteria to turn the baby to a cephalic presentation. If ECV is unsuccessful or contraindicated, a planned Cesarean section is often the safest mode of delivery to prevent birth injury associated with vaginal breech birth.
• Management of Shoulder Dystocia: This is a critical area for birth injury prevention.
  • Anticipation and Preparation: Identifying risk factors (macrosomia, diabetes, history of shoulder dystocia) allows the team to be prepared. However, many cases occur without identifiable risk factors.
  • Maneuvers: A sequence of evidence-based maneuvers should be employed systematically. McRoberts maneuver (hyperflexing maternal thighs onto abdomen) and suprapubic pressure are often first-line.
  • HELPERR Mnemonic: This protocol, often taught in courses like Advanced Life Support in Obstetrics (ALSO), provides a structured approach (HELPERR Mnemonic discussion; Cleveland Clinic – Shoulder Dystocia):
    • Help: Call for additional experienced staff (obstetrician, anesthesiologist, neonatologist).
    • Evaluate for Episiotomy: Consider if it will facilitate internal maneuvers (though episiotomy itself doesn’t relieve bony obstruction).
    • Legs: McRoberts maneuver.
    • Pressure: Suprapubic pressure (not fundal pressure, which is contraindicated).
    • Enter maneuvers: Internal rotational maneuvers (e.g., Rubin II, Woods’ screw).
    • Remove the posterior arm.
    • Roll the patient: Gaskin maneuver (mother on all fours).
• Appropriate Use of Operative Vaginal Delivery: Forceps or vacuum should be used only by trained operators, for clear indications, with an awareness of prerequisites (e.g., fully dilated cervix, engaged head, known position) and contraindications. The number of pulls with a vacuum and the duration of application should be limited. If progress is not made, the attempt should be abandoned in favor of a Cesarean section to avoid escalating risk of neonatal birth injury.
• Timely Decision for Cesarean Section: When the risks of vaginal delivery are deemed to outweigh the benefits (e.g., confirmed cephalopelvic disproportion, persistent fetal distress unresponsive to conservative measures, failed operative vaginal delivery, certain malpresentations), a timely Cesarean section can be the most effective way to prevent a severe birth injury. (ABC Law Centers – C-Section).

Neonatal Resuscitation

• Prompt and effective neonatal resuscitation by a skilled team can mitigate the consequences of perinatal hypoxia-ischemia, which can often co-occur with or predispose to a traumatic birth injury. Ensuring adequate oxygenation and perfusion can protect the brain and other organs.

Teamwork and Communication

• Clear, effective communication and collaboration among all members of the obstetric, midwifery, pediatric, and anesthesia teams are essential for safe maternal and neonatal care. Regular team briefings, debriefings, and simulation training for obstetric emergencies (like shoulder dystocia or eclampsia) can significantly improve team performance and reduce the likelihood of errors contributing to a birth injury.

Patient Education and Shared Decision-Making

• Involving expectant mothers and their families in discussions about potential risks, benefits of different delivery modes, and management plans (especially when risk factors for a neonatal birth injury are present) promotes shared decision-making and can lead to more informed choices. Providing clear information about what constitutes a birth injury and how it differs from unavoidable outcomes is also part of comprehensive care.

By focusing on these multifaceted prevention strategies, healthcare systems and individual providers can work towards reducing the incidence of preventable birth injury and improving outcomes for newborns.

Assessment and Diagnosis of Birth Injury

Prompt and accurate assessment and diagnosis are fundamental to managing any neonatal birth injury effectively. This process begins immediately after birth with the initial newborn examination and continues with specific diagnostic approaches tailored to the suspected type of birth injury.

Initial Newborn Assessment (The Golden Hour and Beyond)

A thorough and systematic head-to-toe examination of the newborn is crucial for detecting any immediate signs of a birth injury. This assessment often starts in the delivery room and is repeated within the first 24 hours of life.

Systematic Observation and Palpation:

• General Appearance: Note the infant’s posture at rest (e.g., “waiter’s tip” of Erb’s palsy), activity level, and any signs of distress.
• Head and Face:
  • Inspect and palpate the scalp for swellings like caput succedaneum, cephalohematoma, or a subgaleal hemorrhage. Note whether the swelling crosses suture lines, its consistency, and any associated bruising.
  • Palpate skull bones for depressions (depressed fracture) or crepitus.
  • Examine the face for symmetry, especially during crying, to detect facial nerve palsy. Note eye closure and nasolabial folds.
  • Inspect eyes for subconjunctival hemorrhages.
• Neck and Clavicles: Palpate clavicles for crepitus, deformity, or tenderness indicative of a fracture. Observe neck movement and for any masses.
• Chest and Abdomen: Auscultate breath sounds and heart sounds. Observe for symmetrical chest rise. Palpate abdomen for distension or masses (rarely, a birth injury can involve abdominal organs).
• Extremities:
  • Observe for symmetry of movement and muscle tone. Compare active and passive range of motion in all limbs.
  • Palpate long bones (humerus, femur) for swelling, deformity, or crepitus.
  • Note any abnormal positioning (e.g., persistent internal rotation of an arm).
• Spine: Inspect and palpate along the spine for deformities or tenderness (spinal cord birth injury is rare but severe).
• Skin: Document any bruising, petechiae, lacerations, or abrasions. Note their location and extent.

The Apgar score, assigned at 1 and 5 minutes (and sometimes later if scores are low), provides a quick summary of the infant’s physiological status but is not specifically designed to detect a birth injury. However, a low Apgar score might prompt a more detailed search for underlying problems, including potential injury secondary to a difficult birth.

One could adapt the **ALPPPS** mnemonic (Attitude, Lie, Presentation, Presenting part, Position, Station), typically used for fetal assessment during labor, to consider how these intrapartum factors might have predisposed the infant to specific types of birth injury that are then observed during the postnatal assessment (Nursing.com – ALPPPS Mnemonic). For example, a breech presentation (Presentation) might alert the nurse to look for hip issues or specific types of head/neck birth injury.

Specific Diagnostic Approaches for Common Birth Injuries

While clinical examination by a skilled nurse or physician is often primary, imaging and other studies are frequently needed to confirm a diagnosis of birth injury and assess its extent.

• Brachial Plexus Palsy (BPP):
  • Clinical Examination: The diagnosis is primarily clinical, based on the characteristic posture and weakness of the affected arm.
  • Imaging: A chest X-ray is often performed to rule out an associated clavicle fracture or phrenic nerve palsy (which would show an elevated hemidiaphragm). Specialists may later use MRI or CT myelography if nerve root avulsion is suspected and surgical intervention is being considered (Cleveland Clinic – Erb’s Palsy).
  • Electromyography (EMG) and Nerve Conduction Studies (NCS): These tests are typically performed after a few weeks (3-4 weeks post-birth injury) if recovery is not evident. They help assess the extent of nerve damage (neuropraxia, axonotmesis, neurotmesis) and can aid in predicting prognosis and guiding decisions about surgery.
• Fractures (Clavicle, Humerus, Femur, Skull):
  • X-ray: This is the gold standard for confirming suspected fractures. Anteroposterior (AP) and sometimes lateral views are taken of the affected bone(s). (Stanford Medicine Children’s Health – Fractures).
  • Ultrasound: Can be useful for diagnosing clavicle fractures, especially if X-ray is inconclusive or if clinicians wish to avoid radiation. It can also show callus formation.
• Head Trauma / Intracranial Hemorrhage (ICH):
  • Scalp Injuries (Caput, Cephalohematoma): Diagnosis is usually clinical, based on palpation and appearance (see table below).
  • Subgaleal Hemorrhage: Primarily a clinical diagnosis based on the characteristic rapidly expanding, diffuse, fluctuant scalp swelling that crosses suture lines, often accompanied by signs of hypovolemia. Serial head circumference measurements and hematocrit monitoring are key. Ultrasound can help delineate the extent of the bleed.
  • Suspected Skull Fracture or Intracranial Hemorrhage:
    • Cranial Ultrasound (CUS): This is often the initial imaging modality of choice for suspected ICH in neonates, especially preterm infants. It is readily available at the bedside, portable, non-invasive, and does not involve ionizing radiation. It is good for detecting intraventricular hemorrhage (IVH), larger parenchymal bleeds, and hydrocephalus. However, it is less sensitive for detecting subdural, epidural, or small subarachnoid hemorrhages, or posterior fossa lesions.
    • Computed Tomography (CT) Scan: CT is more sensitive than ultrasound for detecting acute blood in the epidural, subdural, and subarachnoid spaces, as well as for identifying skull fractures. It is generally faster to perform than MRI. The main disadvantage is exposure to ionizing radiation (StatPearls – Birth Trauma, 2023 regarding EDH/SDH diagnosis).
    • Magnetic Resonance Imaging (MRI): MRI provides the most detailed images of the brain and is superior for delineating the extent of brain birth injury, ischemia, and for providing prognostic information. It does not involve ionizing radiation. However, MRI scans take longer and may require the infant to be sedated to ensure good image quality, making it less suitable for unstable infants or for rapid initial assessment needed in an emergency.
• Facial Nerve Palsy: Diagnosis is clinical, based on observation of asymmetric facial movements, particularly when crying. No specific imaging is usually required unless other pathology is suspected.

Differentiating Birth Injuries from Congenital Anomalies

It is essential for nurses to distinguish a neonatal birth injury (acquired during birth) from a congenital anomaly (present before birth).

• Timing of Onset: A birth injury manifests at or shortly after birth. Congenital anomalies are present from fetal development, though some may only become apparent after birth.
• History:
  • Maternal History: Review for risk factors for specific types of birth injury (e.g., difficult labor, instrumental delivery, macrosomia).
  • Family History: A family history of genetic conditions or specific anomalies may point towards a congenital issue.
  • Prenatal Ultrasounds and Screening: Review prenatal records for any anomalies detected during pregnancy.
• Physical Examination Findings:
  • A birth injury often has localized signs consistent with trauma (e.g., bruising over a cephalohematoma, crepitus with a fracture).
  • Congenital anomalies may have a more syndromic pattern, involving multiple body systems, or specific dysmorphic features not directly attributable to the birth process. For example, asymmetric crying facies due to congenital hypoplasia of the depressor anguli oris muscle must be differentiated from traumatic facial nerve palsy (StatPearls – Birth Trauma, 2023).
• Imaging and Other Tests: Specific imaging can confirm trauma (e.g., X-ray for fracture). If a congenital anomaly is suspected, further investigations like genetic testing, chromosomal analysis, or more detailed organ-specific imaging may be warranted.

Accurate differentiation is critical because the management, prognosis, and counseling for a neonatal birth injury versus a congenital anomaly are often very different.

Management and Nursing Interventions for Common Birth Injuries

The management of a neonatal birth injury is multifaceted, involving careful assessment, targeted interventions, and strong family support. The nurse’s role is central to coordinating care, monitoring the infant’s progress, educating parents, and preventing complications. The specific approach varies significantly depending on the type and severity of the birth injury.

General Principles of Nursing Care for Neonatal Birth Injury

Regardless of the specific birth injury, several core nursing principles apply:

• Comprehensive and Frequent Assessments: Continuous monitoring of vital signs, neurological status (level of consciousness, reflexes, fontanelle, seizures), pain levels using appropriate neonatal scales (e.g., NIPS, PIPP), and specific assessment of the injured site (e.g., swelling, bruising, range of motion, neurovascular status).
• Thermoregulation: Maintaining a neutral thermal environment is crucial, as neonates, especially those stressed by a birth injury, are prone to hypothermia. Use radiant warmers, incubators, and swaddling as appropriate.
• Nutritional Support: Ensure adequate caloric and fluid intake to support healing and growth. Assist with breastfeeding or bottle-feeding. Some types of birth injury (e.g., facial palsy, severe ICH) may complicate oral feeding, necessitating alternative methods like gavage feeding or parenteral nutrition.
• Pain Management: Pain associated with a birth injury (e.g., fractures, surgical sites) must be anticipated and managed.
  • Non-pharmacological: Swaddling, gentle positioning, non-nutritive sucking (pacifier), skin-to-skin contact, minimizing painful stimuli.
  • Pharmacological: Administer analgesics (e.g., acetaminophen, morphine in severe cases) as prescribed by the physician, carefully monitoring for effectiveness and side effects.
• Skin Integrity: Prevent skin breakdown, especially if the infant requires immobilization (splints, casts) or has an edematous birth injury. Frequent repositioning (if permissible), keeping skin clean and dry, and using protective barriers are important.
• Infection Prevention: Strict adherence to hand hygiene and aseptic techniques for any procedures (e.g., IV line care, wound care) is paramount, as infants with a birth injury may be more vulnerable to infection.
• Safety: Handle the infant gently, always supporting the injured area. Implement seizure precautions if the infant is at risk (e.g., significant ICH). Ensure a safe sleep environment.
• Parental Support and Education: This is a cornerstone of nursing care for any neonatal birth injury.
  • Provide clear, accurate, and honest information about the birth injury, planned investigations, treatment, and expected prognosis, using language parents can understand.
  • Teach parents specific care techniques relevant to their infant’s birth injury (e.g., how to handle an infant with a clavicle fracture, eye care for facial palsy, range-of-motion exercises for BPP). Allow for return demonstration.
  • Acknowledge and validate parental emotions (anxiety, fear, guilt, sadness). Provide emotional support and create a trusting environment.
  • Facilitate bonding and parent-infant interaction, adapting as needed due to the birth injury.
  • Refer families to social workers, chaplains, psychologists, and parent support groups as needed.
• Interprofessional Collaboration: Effective management of a neonatal birth injury requires working closely with physicians (neonatologists, neurologists, orthopedic surgeons, neurosurgeons, physiatrists), physical therapists (PT), occupational therapists (OT), speech-language pathologists (SLP), lactation consultants, and social workers. Nurses often coordinate this care.

Management of Brachial Plexus Palsy (Erb’s Palsy / Klumpke’s Palsy)

Management of this common nerve-related birth injury aims to restore function and prevent long-term disability.

• Medical/Surgical Management:
  • Conservative Management: The majority (80-90%) of infants with BPP, especially Erb’s palsy, experience spontaneous recovery or significant improvement with conservative measures, often within the first 3-12 months (Cleveland Clinic – Erb’s Palsy).
  • Physical Therapy (PT) and Occupational Therapy (OT): Initiated early, often within the first 1-3 weeks of life. Therapists guide parents in performing gentle passive range-of-motion (ROM) exercises multiple times a day to maintain joint mobility, prevent contractures, and provide sensory input. Positioning techniques and, occasionally, splinting (e.g., wrist or elbow splints) may be used.
  • Botulinum Toxin Injections: In some cases, injections into overactive, unopposed muscles can help address muscle imbalances and improve function or positioning.
  • Surgical Intervention: Considered if there is no significant recovery of key muscle functions (e.g., biceps function for elbow flexion, shoulder abduction/external rotation) by 3-9 months of age. Surgical options, performed by specialized pediatric brachial plexus surgeons, include:
    • Nerve Repair/Grafting: Excising damaged nerve segments (neuromas) and bridging the gap with nerve grafts (often from the sural nerve in the leg).
    • Nerve Transfers (Neurotization): Using a nearby healthy, less critical nerve (or part of it) to reinnervate the paralyzed muscles.
    • Neurolysis: Freeing the nerve from scar tissue.
  • Secondary Surgeries: May be needed later in childhood for residual deficits, such as tendon transfers, muscle releases, or osteotomies (bone reshaping) to improve arm position and function.
• Nursing Assessments and Monitoring:
  • Regularly assess the affected arm for: spontaneous movement, active and passive ROM in all joints (shoulder, elbow, wrist, fingers), muscle tone, and strength (e.g., ability to bring hand to mouth, quality of grasp).
  • Look for signs of pain or discomfort during movement or handling.
  • Inspect skin integrity, especially in the axilla and around any splints, for signs of irritation or pressure.
  • Observe for signs of Horner’s syndrome (ptosis, miosis, anhidrosis on one side of the face) if Klumpke’s palsy is suspected, as this indicates T1 root involvement.
  • Document and monitor for improvement or lack of improvement over time, which is crucial for decisions regarding surgical referral.
• Key Nursing Interventions:

  Mnemonic for Brachial Plexus Palsy Care: A.R.M.S.

  • Assess: Regularly assess movement, sensation, and signs of recovery or complications.
  • Range of Motion: Gently perform and teach parents prescribed exercises to prevent contractures.
  • Minimize Stress/Traction: Careful handling and positioning to protect the injured plexus.
  • Support and Educate: Provide comprehensive education and emotional support to the family.
  • Gentle Handling: Crucial to prevent further injury. Avoid pulling or traction on the affected arm and shoulder. Always support the arm during lifting, carrying, dressing, and bathing.
  • Positioning: Position the arm in a neutral or functional position to prevent contractures and overstretching of denervated muscles. This often involves keeping the shoulder adducted and neutrally rotated, with the elbow flexed (specifics depend on the type of palsy and therapist recommendations). Avoid prolonged periods with the arm pinned tightly against the body or hanging unsupported.
  • Exercise Implementation: Reinforce and assist parents with the gentle passive ROM exercises prescribed by the PT/OT. Emphasize the importance of performing these exercises correctly, gently, and consistently (usually several times a day during diaper changes or quiet play). Examples include gentle shoulder abduction/adduction, external/internal rotation, elbow flexion/extension, forearm supination/pronation, and wrist/finger movements.
  • Splinting Care: If splints are used (less common in the acute phase unless specifically indicated), monitor the skin for any signs of pressure, redness, or breakdown. Ensure parents understand correct application, removal, and cleaning of the splint.
  • Dressing and Bathing: Teach parents techniques to dress and undress the infant that minimize stress on the affected arm. Generally, dress the affected arm first and undress it last. Support the arm during bathing.
  • Feeding Support: Help the mother find comfortable positions for breastfeeding or bottle-feeding that support the infant’s affected arm and head.
  • Pain Management: While BPP itself may not always be painful initially (unless there’s an associated fracture), later development of stiffness or contractures can cause discomfort. Post-operative pain management is critical.
  • Post-Operative Care (if surgery is performed):
    • The affected arm is typically immobilized in a sling (e.g., Velpeau-type sling made of stockinette or a specialized orthosis) or a cast for several weeks (often 3-6 weeks) to protect the nerve repairs/grafts (UPMC Children’s – Post-Operative Sling).
    • Meticulous pain management using prescribed analgesics.
    • Careful wound care and monitoring for signs of infection at incision sites.
    • Regular neurovascular checks of the affected extremity (color, temperature, capillary refill, sensation if possible to assess).
    • Parental education on sling/cast care, activity restrictions, and signs of complications.
    • Gradual reintroduction of PT/OT and specific exercises as per the surgeon’s and therapist’s protocol once immobilization is discontinued. Nerve regeneration is slow (approx. 1 mm/day), so recovery is a lengthy process.
• Parental Support and Education:
  • Thoroughly explain this type of neonatal birth injury, its potential causes (without assigning blame), the expected course of recovery, and treatment options.
  • Provide detailed hands-on instruction and opportunities for return demonstration for all home care aspects (exercises, handling, positioning, splint care).
  • Emphasize the importance of long-term follow-up with a multidisciplinary brachial plexus team (pediatric neurologist, orthopedic/plastic surgeon specializing in nerve surgery, PT, OT).
  • Offer emotional support and acknowledge the challenges parents face. Connect them with BPP support groups and reliable online resources.

Management of Fractures (Clavicle, Humerus)

Fractures are a common traumatic birth injury, typically with good outcomes.

• Clavicle Fracture:
  • Medical Management: Generally conservative. The primary goal is comfort. Immobilization is achieved by gently pinning the infant’s sleeve on the affected side to the front of their shirt or using a soft shoulder immobilizer (figure-of-eight bandages are rarely used in neonates due to risk of axillary компромисс). Analgesia (e.g., acetaminophen) may be given if the infant appears to be in pain. Healing occurs rapidly, typically within 2-4 weeks, with robust callus formation (Nationwide Children’s – Clavicle Fractures).
  • Nursing Assessments: Monitor for signs of pain (increased crying with movement), swelling, visible deformity, or crepitus over the clavicle. Assess arm movement on the affected side (often decreased or absent initially) and symmetry of the Moro reflex. Observe for callus formation (a palpable, firm lump over the fracture site, which is a normal sign of healing) around 7-10 days.
  • Nursing Interventions:
    • Gentle Handling: Be extremely careful when lifting, dressing, and diapering the infant to minimize movement of the affected shoulder and arm. Support the back and neck.
    • Immobilization Techniques: Teach parents how to correctly and safely pin the infant’s sleeve to their shirt (across the chest) or apply any prescribed soft immobilization device. Ensure it is snug but not too tight to avoid compromising circulation or causing skin irritation. An example includes: “When dressing the baby, put the affected arm into the sleeve first. When undressing, take the unaffected arm out first. Use a safety pin to attach the sleeve of the affected arm to the front of the baby’s shirt near their side, keeping the elbow bent.” Always ensure safety pins are closed and covered if possible to prevent accidental opening.
    • Pain Relief: Careful positioning to keep the affected side comfortable. Limiting movement of the affected arm. Administer prescribed analgesia if needed.
    • Parental Education: Reassure parents that this type of birth injury usually heals quickly and completely with no long-term problems. Explain the normal healing process, including callus formation. Instruct on care of the immobilization method and signs of rare complications (e.g., worsening swelling, skin breakdown, refusal to feed due to pain).
• Humerus Fracture:
  • Medical Management: Immobilization using a splint (e.g., coaptation splint) or by swaddling the arm to the chest for 2-4 weeks. Analgesia as needed. Orthopedic consultation is common.
  • Nursing Assessments: Similar to clavicle fracture assessment (pain, swelling, deformity, crepitus, limited arm movement, Moro reflex). Also, specifically assess for signs of radial nerve injury (wrist drop), although this is rare with neonatal humeral shaft fractures. Check distal pulses and capillary refill.
  • Nursing Interventions:
    • Gentle Handling and support of the fractured arm.
    • Splint Care: If a splint is applied, monitor for correct fit, skin irritation or pressure sores (especially in the axilla and around the elbow), and neurovascular status of the hand (warmth, color, capillary refill). Keep the splint clean and dry.
    • Pain Management using prescribed analgesics and comfort measures.
    • Parental Education: Instructions on splint care, signs of neurovascular compromise (e.g., cool, pale, or blue fingers; increased swelling below the splint), importance of follow-up appointments. Reassurance about good healing potential.
• Femur Fracture (Rare birth injury):
  • Medical Management: Typically requires orthopedic consultation. Management often involves immobilization in a Pavlik harness or a spica cast for several weeks.
  • Nursing Interventions: This care is highly specialized. Focus on meticulous cast or harness care, regular neurovascular checks of the toes, pain management, maintaining hygiene (challenging with spica casts), managing feeding and positioning challenges, and preventing complications like skin breakdown or constipation. Extensive parental education and support are vital.

Management of Head Trauma (Scalp Injuries, Skull Fractures & Intracranial Hemorrhages)

Head trauma is a significant category of neonatal birth injury, requiring careful assessment and differentiated management.

Scalp Injuries

• Caput Succedaneum:
  • Nursing Interventions: No specific medical treatment is generally required for this benign birth injury. The primary nursing role is to reassure parents that the swelling is common, temporary, and will resolve spontaneously within a few days without any long-term effects. Observe the area for size reduction and ensure skin integrity.
• Cephalohematoma:
  • Nursing Interventions: Observe the cephalohematoma for any increase in size and for resolution over time (typically weeks to months).
    A key nursing responsibility is to monitor the infant for jaundice (hyperbilirubinemia) (Stanford Medicine Children’s Health – Cephalohematoma). As the collected blood breaks down, bilirubin is released, which can lead to jaundice. Assess skin and sclera for yellowing, and monitor bilirubin levels as ordered.
    Reassure parents that this birth injury usually resolves without intervention, although it takes longer than a caput. Explain that temporary calcification of the hematoma can sometimes occur, feeling like a firm lump, before it is fully resorbed.
    Aspiration of a cephalohematoma is generally avoided due to the risk of infection unless infection is suspected (which is rare). Maintain good scalp hygiene.

• Subgaleal Hemorrhage (SGH) – NURSING EMERGENCY!

  This is a rare but potentially life-threatening neonatal birth injury requiring immediate recognition and intensive management.

  • Medical Management: Immediate admission to a Neonatal Intensive Care Unit (NICU) is essential. Treatment focuses on:
    • Aggressive volume resuscitation with crystalloids (Normal Saline), colloids (albumin), packed red blood cells (PRBCs), and fresh frozen plasma (FFP) to correct hypovolemia, anemia, and coagulopathy.
    • Supportive care including oxygen therapy, mechanical ventilation if respiratory failure occurs, and maintenance of electrolyte balance.
    • Continuous, intensive monitoring of vital signs, hematocrit, coagulation profile, and head circumference.
    • Investigation for underlying bleeding disorders may be considered (StatPearls – Birth Trauma, Subgaleal Hemorrhage).
  • Nursing Assessments (Critical and Frequent):
    • Vital Signs: Monitor heart rate, respiratory rate, blood pressure (often requiring an arterial line), and temperature continuously or very frequently (e.g., every 15-30 minutes initially). Watch for tachycardia, hypotension (late sign of shock), tachypnea, and temperature instability.
    • Head Circumference: Serial measurements (e.g., hourly or as indicated) are crucial to detect ongoing bleeding and expansion of the hematoma. Mark the measuring tape position for consistency.
    • Scalp Assessment: Observe the characteristics of the swelling – is it boggy, diffuse, fluctuant? Does it shift with movement (classic sign)? Note color (pallor, bruising), and tenseness.
    • Signs of Shock: Vigilantly assess for pallor (especially of mucous membranes), cool extremities, delayed capillary refill (>3 seconds), altered mental status (lethargy, irritability, poor response to stimuli), decreased urine output (<1 ml/kg/hr).
    • Laboratory Values: Closely monitor serial hematocrit/hemoglobin levels, platelet counts, and coagulation studies (PT, PTT, fibrinogen).
    • Neurological Status: Assess for irritability, lethargy, seizures. A bulging fontanelle can also occur.
  • Nursing Interventions:
    • IMMEDIATELY alert the physician/neonatal team if SGH is suspected or if there is any deterioration.
    • Assist with establishing secure intravenous access (often multiple large-bore peripheral IVs or central venous access will be needed).
    • Administer IV fluids, blood products, and medications (e.g., vitamin K, coagulation factors) as ordered, ensuring compatibility, correct rates, and meticulous documentation. Use blood warmers for transfusions.
    • Maintain a patent airway; provide oxygen as needed. Be prepared to assist with intubation and mechanical ventilation.
    • Minimize handling and stress to the infant to prevent further dislodgement of clots or increased bleeding. Cluster care.
    • Keep the infant warm using radiant warmers or incubators to prevent hypothermia, which can worsen coagulopathy.
    • Maintain accurate intake and output records. Insert an indwelling urinary catheter if ordered to monitor urine output closely.
    • Provide strong emotional support to parents during this highly critical period. Keep them informed about their infant’s condition and the interventions being performed.

Skull Fractures

• Linear Skull Fractures: If isolated (no underlying intracranial birth injury) and the infant is asymptomatic, these often require no specific treatment other than observation.
• Depressed Skull Fractures (“Ping-Pong” Fractures): These may require neurosurgical consultation. Elevation of the depressed segment might be considered, especially if the depression is significant, associated with neurological signs, or if there’s an underlying dural tear or hematoma. Some minor depressions may resolve spontaneously.
• Nursing Interventions for Skull Fractures:
  • Perform regular neurological assessments (level of consciousness, pupil response, fontanelle, presence of seizures).
  • Monitor for signs of increased intracranial pressure (ICP) or cerebrospinal fluid (CSF) leakage (e.g., from the nose or ear if there’s a basal skull fracture, though this is very rare from a typical neonatal birth injury).
  • Provide pain management as needed.
  • If there’s an associated scalp laceration, provide wound care as ordered to prevent infection.
  • Prepare the infant and family for diagnostic imaging (CT or MRI) and potential surgical intervention if indicated.
  • Educate parents about the specific type of skull birth injury, the treatment plan, and follow-up care.

Intracranial Hemorrhages (ICH)

Management of ICH, a serious form of neonatal birth injury, depends on the type, location, and severity of the bleed.

• Medical Management Principles:
  • Largely supportive care, aiming to maintain physiological stability (blood pressure, oxygenation, glucose levels, electrolytes).
  • Treatment of seizures with anticonvulsant medications (e.g., phenobarbital, levetiracetam).
  • Correction of any coagulopathies (e.g., Vitamin K administration, FFP, platelet transfusions if indicated).
  • Neurosurgical consultation is essential for all significant ICH. Surgical intervention (e.g., evacuation of a hematoma) may be considered for large epidural or subdural hematomas causing significant mass effect or neurological deterioration. Management of post-hemorrhagic hydrocephalus (common after severe IVH) may involve serial lumbar punctures, placement of a ventricular reservoir, or a ventriculoperitoneal (VP) shunt.
• Nursing Assessments (Frequent and Detailed) are paramount for any infant with suspected or confirmed ICH, a critical neonatal birth injury:
  • Neurological Status: Level of consciousness/alertness (use neonatal assessment tools like the Neonatal Infant Pain Scale or modified Glasgow Coma Scale if appropriate for context), pupil size and reactivity, fontanelle tension (bulging is a key sign of increased ICP), quality of cry (high-pitched, weak), muscle tone (hypotonia, hypertonia, asymmetry), abnormal movements or posturing, and seizure activity. Neonatal seizures can be subtle (e.g., lip smacking, chewing motions, rhythmic eye movements, bicycling or pedaling movements of legs, apnea).
  • Vital Signs: Continuously monitor heart rate, respiratory rate, blood pressure, and temperature. Watch for Cushing’s triad (hypertension, bradycardia, irregular respirations), which is a late and ominous sign of severely increased ICP and brainstem compression. Temperature instability can also occur.
  • Respiratory Status: Assess for apnea, irregular breathing patterns, or increased work of breathing. The infant may require respiratory support ranging from supplemental oxygen to mechanical ventilation.
  • Head Circumference: Measure daily, or more frequently if there is concern for an expanding hematoma or developing hydrocephalus. Consistent measurement technique is vital.
  • Feeding Tolerance: Observe for vomiting (which can be a sign of increased ICP), poor suck, or abdominal distension.
• Nursing Interventions for ICH:

  Minimizing Intracranial Pressure (ICP) is a Priority

  • Maintain a quiet, low-stimulus environment (dim lights, reduce noise levels, limit visitors).
  • Cluster nursing care activities to allow for periods of undisturbed rest.
  • Handle the infant gently, avoiding sudden movements, jarring, or procedures that cause pain or distress (which can elevate ICP). Avoid Valsalva-like maneuvers (e.g., from straining during defecation or excessive crying).
  • Positioning: Elevate the head of the bed slightly (15-30 degrees) unless contraindicated (e.g., shock). Keep the infant’s head in a midline position to promote optimal venous drainage from the brain and prevent jugular vein compression. Avoid neck flexion or extreme rotation.
  • Airway Management: Ensure a patent airway. Suction only as needed (PRN) and gently to avoid stimulating coughing or increasing ICP. Hyperoxygenate before and after suctioning if indicated.
  • Seizure Precautions and Management: Implement seizure precautions (e.g., padded cot sides, ensuring emergency resuscitation equipment and suction are readily available). Administer anticonvulsant medications as prescribed by the physician. Monitor for seizure activity, duration, characteristics, and the infant’s response to treatment. Monitor for side effects of anticonvulsants.
  • Fluid and Electrolyte Balance: Maintain strict intake and output records. Administer IV fluids as ordered, often with careful fluid restriction to prevent cerebral edema. Monitor serum electrolytes, glucose, and osmolality regularly. Watch for signs of Syndrome of Inappropriate Antidiuretic Hormone (SIADH) or Diabetes Insipidus (DI), which can occur with certain types of brain birth injury.
  • Nutritional Support: If the infant is unable to feed orally due to neurological impairment or risk of aspiration, they may require nasogastric (NG) or orogastric (OG) tube feedings, or parenteral nutrition (PN). Initiate feeds cautiously and advance as tolerated.
  • Thermoregulation: Maintain normothermia. Both hypothermia and hyperthermia can adversely affect neurological outcome.
  • Medication Administration: Accurately administer prescribed medications such as Vitamin K (if not already given at birth), anticonvulsants, analgesics, sedatives, diuretics (e.g., mannitol or furosemide for ICP management, if ordered), and antibiotics (if infection is a concern).
  • Support During Diagnostic Procedures: Prepare and support the infant and family during cranial ultrasound, CT, or MRI scans. Ensure stability during transport and the procedure.

Management of Facial Nerve Palsy

This specific nerve birth injury usually has a good prognosis but requires careful supportive care.

• Medical Management: Most cases of traumatic facial nerve palsy resolve spontaneously within a few weeks to a few months if the injury is due to nerve bruising or compression (neuropraxia). If the nerve is torn (neurotmesis, which is rare in neonatal birth injury), surgical repair by specialists (e.g., facial plastic surgeon, neurosurgeon) might be considered, but this is uncommon. Specialist consultation (neurology, ophthalmology) may be sought.
• Nursing Assessments:
  • Observe and document the degree of facial asymmetry at rest and especially when the infant cries.
  • Assess the ability to close the eyelid completely on the affected side (lagophthalmos). Incomplete closure poses a risk for corneal injury.
  • Evaluate the symmetry of sucking and ability to form a seal around the nipple or bottle; note any leakage of milk from the affected side of the mouth.
  • Check for tearing (lacrimation) on the affected side, though this is often difficult to assess accurately in neonates.
• Nursing Interventions:
  • Eye Care: This is the most critical nursing intervention if eyelid closure is incomplete. The cornea can become dry, ulcerated, or infected.
    • Instill artificial tears (preservative-free lubricating eye drops) or ophthalmic lubricant ointment into the affected eye as prescribed by the physician (often every few hours).
    • Teach parents how to gently tape the eyelid closed during sleep, using hypoallergenic tape, if recommended by the physician or ophthalmologist. Ensure the tape does not abrade the delicate skin.
  • Feeding Support:
    • Assist the mother with positioning for breastfeeding or help with bottle-feeding techniques. The infant may have difficulty latching or sucking effectively due to weakness of the facial muscles on one side.
    • Supporting the cheek on the affected side during feeding may help improve the seal and reduce leakage of milk.
    • Small, frequent feeds may be better tolerated if feeding is inefficient.
    • Monitor for adequate intake, weight gain, and signs of dehydration. Refer to a lactation consultant if breastfeeding difficulties persist.
  • Parental Education and Reassurance:
    • Reassure parents that the majority of cases of this type of birth injury resolve spontaneously and completely. Provide a realistic timeframe (weeks to a few months).
    • Thoroughly teach parents how to perform eye care and any special feeding techniques. Have them demonstrate the procedures.
    • Explain signs of improvement to watch for (e.g., more symmetrical smile, better eye closure).
    • Emphasize the importance of follow-up appointments with the pediatrician and any specialists involved.
    • Provide emotional support, as any visible difference in their newborn can be distressing for parents.

Long-Term Outcomes and Support for Infants and Families

The long-term consequences of a neonatal birth injury can vary dramatically, from complete recovery to lifelong disability. Understanding these potential outcomes and the importance of ongoing support is crucial for nurses counseling and caring for affected families.

Prognosis and Potential Complications of Birth Injury

The prognosis after a birth injury is highly dependent on the specific type of birth injury, its severity, the location of the damage, and the timeliness and effectiveness of medical and rehabilitative interventions.

• Brachial Plexus Palsy (BPP):
  • Good Prognosis Overall: Approximately 80-90% of infants with BPP, particularly those with Erb’s palsy (upper plexus lesions involving C5-C6) due to neuropraxia (nerve stretching without tearing) or axonotmesis (axon damage with intact nerve sheath), make a full or near-full recovery. Significant improvement often occurs within the first 3-6 months, with continued recovery possible up to 12-18 months (Cleveland Clinic – Erb’s Palsy).
  • Potential Long-Term Complications: In cases of severe nerve damage (neurotmesis, nerve root avulsion) or incomplete recovery, infants may experience persistent weakness, muscle atrophy, limb length discrepancy, joint contractures (especially at the shoulder, elbow, and wrist), impaired arm and hand function (e.g., difficulty with activities of daily living), and abnormal bone growth or joint incongruity around the shoulder (e.g., glenohumeral dysplasia). Some children may require ongoing physical and occupational therapy, and further surgical procedures later in childhood (StatPearls – Birth Trauma).
• Fractures (Clavicle, Humerus, Femur):
  • Excellent prognosis for most neonatal fractures resulting from a birth injury. These bones have remarkable healing and remodeling capacity in newborns. Clavicle and humerus fractures typically heal well within 2-4 weeks, and femur fractures within 4-6 weeks, usually without any long-term functional impairment or significant residual deformity.
• Scalp Injuries:
  • Caput Succedaneum and Cephalohematoma: Prognosis is excellent. Caput resolves within days. Cephalohematomas resolve over weeks to months; temporary calcification of a cephalohematoma may occur but usually remodels without issue. The primary acute concern with cephalohematoma is hyperbilirubinemia.
• Subgaleal Hemorrhage (SGH):
  • Prognosis is variable. If the SGH is mild, recognized early, and treated promptly and effectively with volume resuscitation, the outcome can be good.
  • However, severe SGH with significant hypovolemic shock, prolonged hypoxia, or coagulopathy carries a risk of neurodevelopmental impairment (e.g., cognitive deficits, motor delays), end-organ damage (e.g., kidneys, brain), and even death. Mortality rates in severe cases can range from 10% to 20% or higher if diagnosis and treatment are delayed (StatPearls – Birth Trauma, Subgaleal Hemorrhage).
• Intracranial Hemorrhages (ICH): This type of neonatal birth injury has a widely variable prognosis.
  • Small, asymptomatic hemorrhages (e.g., tiny subdural or subarachnoid bleeds) detected incidentally may resolve completely with no long-term neurological sequelae.
  • Severe ICH (e.g., large volume bleeds, those involving brain parenchyma, causing significant increased intracranial pressure, or leading to post-hemorrhagic hydrocephalus) can result in significant long-term complications:
    • Cerebral Palsy (CP): A group of permanent disorders affecting movement, muscle tone, and posture. The type and severity of CP depend on the location and extent of brain damage from the birth injury (Childbirth Injuries – ICH and CP).
    • Seizure Disorders (Epilepsy): Chronic seizures may develop as a consequence of brain scarring from the hemorrhage.
    • Hydrocephalus: Abnormal accumulation of cerebrospinal fluid within the brain, often requiring surgical placement of a ventriculoperitoneal (VP) shunt. Shunts themselves can have complications (infection, malfunction).
    • Developmental Delays: Including cognitive impairments (intellectual disability), motor skill delays, and speech/language disorders.
    • Learning Disabilities, Attention Deficit Hyperactivity Disorder (ADHD).
    • Visual Impairments (e.g., cortical visual impairment, strabismus) or Hearing Impairments.
    • Behavioral and Emotional Problems.
    The severity of disability often correlates with the grade or extent of the initial intracranial birth injury (PMC – Long-Term Outcome IVH).
• Facial Nerve Palsy:
  • Generally, a good prognosis for this birth injury. Most cases (over 90%) related to compression or bruising resolve spontaneously and completely within a few weeks to months. Persistent, permanent facial paralysis is rare.
• Spinal Cord Injury:
  • The prognosis for functional recovery below the level of a significant spinal cord birth injury is generally poor. Infants may face lifelong disabilities including paralysis (quadriplegia or paraplegia), sensory loss, chronic pain, bowel and bladder dysfunction, respiratory compromise (requiring long-term ventilation if high cervical), and orthopedic complications like scoliosis and hip dysplasia (PMC – Spinal Cord Injury at Birth). Mortality is high with upper cervical cord injuries.

Role of Early Intervention and Rehabilitation

Early intervention services are crucial for optimizing the developmental outcomes of infants who have sustained a significant neonatal birth injury, particularly those involving nerve damage or intracranial hemorrhage.

• Multidisciplinary Team Approach: Comprehensive care typically involves a team of specialists:
  • Developmental Pediatricians: Oversee growth and development, coordinate care.
  • Pediatric Neurologists: Diagnose and manage neurological conditions like seizures, CP.
  • Physiatrists (Rehabilitation Physicians): Specialize in physical medicine and rehabilitation.
  • Physical Therapists (PT): Focus on gross motor skills (e.g., rolling, sitting, walking), strength, balance, coordination, and mobility. They provide exercises, positioning advice, and may recommend assistive devices.
  • Occupational Therapists (OT): Focus on fine motor skills (e.g., grasping, hand-eye coordination), activities of daily living (feeding, dressing), sensory processing and integration, and the use of adaptive equipment or splints.
  • Speech-Language Pathologists (SLP): Address feeding and swallowing difficulties (dysphagia), and assess and treat communication delays or disorders.
  • Pediatric Psychologists/Neuropsychologists: Assess cognitive and behavioral development, provide support for behavioral challenges, and assist families with coping.
• Specific Therapies:
  • Physical Therapy (PT) for BPP: Gentle ROM exercises, strengthening, developmental activities, kinesiotaping, constraint-induced movement therapy (CIMT) for the unaffected arm to encourage use of the affected arm (later in infancy).
  • Occupational Therapy (OT) for BPP and Hand Function Issues: Splinting, fine motor skill development, bimanual activities, sensory stimulation.
  • Neurodevelopmental Therapy (NDT) / Bobath Approach: Often used for infants with cerebral palsy or other motor impairments to improve posture, movement patterns, and functional abilities.
  • Feeding Therapy: For infants with sucking, swallowing, or oral motor difficulties resulting from a birth injury.
• Early Intervention Programs (EIP): In many countries, publicly funded EIPs (e.g., “Birth to Three” services in the US) provide comprehensive developmental support and therapies for infants and toddlers with developmental delays or disabilities, including those resulting from a neonatal birth injury. These programs are family-centered and often deliver services in the child’s natural environment (e.g., home, daycare).

The earlier appropriate therapies are initiated, the better the chances of maximizing the child’s developmental potential and minimizing long-term functional limitations from their birth injury.

Family-Centered Care and Psychosocial Support

The diagnosis of a neonatal birth injury, especially a severe one, can be a profoundly traumatic and stressful experience for parents and families. It can evoke a range of emotions, including shock, disbelief, anxiety, grief, guilt, anger, and fear for the future.

• Nursing Role in Psychosocial Support:
  • Empathetic Communication: Listen actively to parents’ concerns and feelings. Provide information honestly but compassionately. Use clear, understandable language, avoiding overly technical jargon.
  • Information and Involvement: Keep parents fully informed about their infant’s condition, progress, and treatment plan. Involve them in care planning and decision-making to the extent they desire, fostering a sense of partnership and control.
  • Facilitate Bonding and Attachment: Encourage skin-to-skin contact, cuddling, talking to, and participating in the care of their infant, adapting activities as needed due to the birth injury or medical interventions.
  • Assess Family Coping and Support Systems: Identify the family’s strengths, existing support networks (family, friends, community), and coping mechanisms. Recognize signs of parental distress, anxiety, or depression.
  • Referrals to Support Services:
    • Social Workers: Can provide counseling, assist with navigating healthcare systems, connect families with financial resources or community services, and help with discharge planning.
    • Psychological Counseling/Therapy: For parents struggling with emotional distress, anxiety, depression, or post-traumatic stress related to the birth experience and their child’s birth injury.
    • Parent Support Groups: Connecting with other families who have experienced similar challenges can provide invaluable emotional support, shared experiences, and practical advice. Nurses can provide information on local or national support organizations specific to the type of birth injury (e.g., United Brachial Plexus Network, cerebral palsy organizations).
    • Chaplaincy Services: For spiritual support, if desired by the family.
  • Help Families Navigate the Healthcare System: The journey can be complex, involving multiple specialists, appointments, and therapies. Nurses can help coordinate care and advocate for the family’s needs.
• Life Care Planning: For children who sustain a severe neonatal birth injury resulting in lifelong disabilities (e.g., severe cerebral palsy, spinal cord injury), a comprehensive life care plan may be developed. This document, often created by a certified life care planner (who may be a nurse or therapist), outlines the child’s anticipated future medical, therapeutic, educational, assistive technology, home care, and vocational needs, along with their associated costs over the child’s lifetime. This can be crucial for families seeking legal recourse or planning for long-term financial security (Birth Injury Help Center – Life Care Plan).

Providing holistic, family-centered care and robust psychosocial support is as important as the medical management of the neonatal birth injury itself for achieving the best possible long-term outcomes for both the child and the family.

Global Best Practices in Preventing and Managing Birth Injury

Efforts to reduce the incidence of neonatal birth injury and improve outcomes for affected infants are a global health priority. Adopting best practices from around the world can significantly enhance the quality and safety of maternity and newborn care.

• Emphasis on Quality Antenatal Care (ANC):
  • Universal access to comprehensive and high-quality ANC is fundamental. This includes early initiation of care, regular visits, and adherence to evidence-based guidelines like those from the World Health Organization (WHO) for a positive pregnancy experience (WHO – Antenatal Care Effectiveness).
  • diligent screening, early identification, and effective management of maternal risk factors such as gestational diabetes, hypertension, infections, and malnutrition.
  • Accurate assessment of fetal growth and well-being, including appropriate use of ultrasound to detect macrosomia or intrauterine growth restriction, which are risk factors for different types of birth injury.
• Skilled Attendance at Every Birth:
  • Ensuring that all births are attended by trained and competent health professionals (doctors, midwives, nurses) is a cornerstone of safe childbirth. These professionals must be skilled in routine delivery practices, early recognition of complications, emergency obstetric care (EmOC), and neonatal resuscitation (NRP). (StatPearls – Birth Trauma, Interprofessional Team highlights the role of a team).
• Standardized Protocols, Checklists, and Guidelines:
  • Implementation and adherence to evidence-based clinical guidelines and standardized protocols for managing labor, delivery, and obstetric emergencies (e.g., shoulder dystocia, fetal distress, postpartum hemorrhage which can be associated with traumatic births).
  • Use of safety checklists, such as surgical safety checklists for Cesarean sections and specific checklists for high-risk deliveries, can help reduce errors and improve adherence to critical safety steps.
  • Initiatives like the UK’s “Better Births” program emphasize personalized care pathways and prompt specialist referrals, guided by evidence (ScienceDirect – Better Births Guideline Review).
• Continuous Professional Development, Training, and Simulation:
  • Regular, ongoing training, competency assessments, and simulation-based drills for obstetric and neonatal teams on managing common birth complications (e.g., shoulder dystocia maneuvers, neonatal resuscitation, management of postpartum hemorrhage).
  • Focus on improving teamwork, communication skills (e.g., SBAR – Situation, Background, Assessment, Recommendation), and decision-making in high-stress situations. Interprofessional training is particularly valuable.
• Reduction of Unnecessary Medical Interventions:
  • Promoting physiological (natural) birth processes when appropriate and avoiding routine or unnecessary interventions (e.g., elective inductions without medical indication, routine episiotomy, instrumental deliveries without clear criteria).
  • Judicious use of labor induction/augmentation, operative vaginal delivery, and Cesarean sections, ensuring they are performed based on clear, evidence-based indications to minimize the risk of iatrogenic birth injury.
• Chart: Distribution of Birth Injury Types (Illustrative Example)

  Note: The chart above illustrates a hypothetical distribution based on general data indicating scalp injuries are common. Actual distributions can vary. Data sourced conceptually from Cleveland Clinic (2025) which states approx. 23 of 29 birth injuries per 1000 are scalp injuries.

• Data Collection, Audits, and Quality Improvement Cycles:
  • Systematic collection and analysis of data on the incidence, types, and risk factors for neonatal birth injury at local, regional, and national levels.
  • Regular perinatal mortality and morbidity reviews, including confidential enquiries into cases of severe birth injury, to identify preventable factors, learn from adverse events, and implement targeted quality improvement initiatives.
• Trauma-Informed Care in Maternity Settings:
  • Recognizing that the birth experience itself can be physically and emotionally traumatic for mothers, which can impact postnatal well-being and the mother-infant relationship.
  • Providing respectful maternity care, ensuring informed consent and shared decision-making, offering choices where possible, and providing psychological support or debriefing opportunities after difficult or traumatic births. This approach, highlighted in guidelines reviewed by ScienceDirect’s review of birth-related trauma guidelines, can improve the overall birth environment.
• Multidisciplinary Team Approach to Complex Cases:
  • Establishing clear referral pathways and access to specialized multidisciplinary centers or teams for infants who sustain a severe or complex neonatal birth injury requiring specialized management (e.g., neurosurgery for ICH, dedicated brachial plexus clinics, comprehensive rehabilitation services).
• Investment in Maternal and Newborn Health Systems:
  • Strengthening overall health infrastructure, ensuring the availability of essential equipment (e.g., for monitoring, resuscitation, diagnostics), medications, and supplies in all facilities providing maternity care. This includes adequate staffing levels of skilled professionals.
• Fostering a Culture of Patient Safety:
  • Promoting a healthcare environment where patient safety is prioritized, and errors or near misses can be openly reported, analyzed, and learned from without a culture of blame. This encourages continuous improvement in practices to prevent future instances of birth injury.

By embracing these global best practices, healthcare systems worldwide can make significant strides in preventing avoidable neonatal birth injury and ensuring that infants who do sustain an injury receive timely, effective, and compassionate care to optimize their long-term health and well-being.

Conclusion: The Evolving Role of Nurses in Mitigating Birth Injury

The occurrence of a neonatal birth injury, while often an unintended consequence of the complex birthing process, carries profound implications for the infant, their family, and the healthcare system. This comprehensive guide has underscored the multifaceted nature of birth injury, spanning a spectrum from minor, self-limiting conditions to severe, life-altering trauma. Throughout this continuum, nurses play an indispensable and evolving role – one that demands clinical excellence, critical thinking, compassionate care, and a steadfast commitment to patient advocacy.

Nurses serve as vigilant assessors, often being the first to detect subtle signs of a birth injury through meticulous antenatal screening, intrapartum monitoring, and detailed newborn examinations. Their ability to recognize deviations from normal, interpret clinical data accurately, and communicate effectively with the interprofessional team is crucial for early diagnosis and timely intervention. In the management of a diagnosed neonatal birth injury, nurses are skilled interveners, providing specialized care that ranges from gentle handling and positioning for musculoskeletal injuries to intensive monitoring and life support for critical conditions like subgaleal hemorrhage or severe intracranial bleeds. They are the primary providers of comfort, pain management, nutritional support, and surveillance for complications.

Beyond the technical aspects of care, nurses are crucial educators and compassionate supporters for families navigating the emotional turmoil that often accompanies a birth injury. They bridge the information gap, translating complex medical information into understandable terms, teaching parents essential care skills, and empowering them to participate in their child’s recovery. The ability to provide empathetic support, acknowledge parental distress, and facilitate connections to resources is a hallmark of quality nursing care in these challenging situations.

Furthermore, nurses are pivotal in the prevention of birth injury. Through comprehensive antenatal education, advocacy for adherence to best practices during labor and delivery, promotion of a patient safety culture, and participation in quality improvement initiatives, nurses contribute significantly to creating safer birth experiences. Their role extends to advocating for policies and systems that support optimal maternal and newborn health.

For nursing students embarking on their careers, a deep and nuanced understanding of neonatal birth injury is not merely academic; it is a professional imperative. The knowledge gained about the types, etiology, risk factors, assessment, diagnosis, and management of each potential birth injury will form the bedrock of safe and effective practice. As healthcare evolves, so too will the strategies for preventing and managing birth injury. Therefore, a commitment to continuous learning, embracing evidence-based practice, and honing critical thinking skills are essential for every nurse dedicated to improving outcomes for newborns and their families affected by any form of birth injury.

Ultimately, the journey of an infant who sustains a neonatal birth injury can be significantly shaped by the quality of nursing care they receive. Knowledgeable, skilled, and compassionate nurses make a profound difference, not only in mitigating the physical impact of the birth injury but also in fostering resilience, hope, and well-being for the entire family unit. This dedication is at the heart of the nursing profession’s evolving role in the intricate field of perinatal health.