Spiritual cause of birth trauma. Birth injury. Symptoms of internal injuries

Birth injuries in newborns are quite common. They are understood as damage to the organs and tissues of the baby, resulting from the impact of mechanical forces in the process of delivery, which entail a number of violations in the compensatory-adaptive mechanisms of the child and the corresponding reaction of the body to these injuries.

We want to clarify that in medicine the concepts of "birth injury" and "birth injury" are not the same thing. Damage can be toxic, hypoxic, infectious or otherwise, which indicates a pathological process and the root cause of the development of pathology. Birth trauma, on the other hand, is a disease, a kind of response of the body, when other pathological processes occur after birth injuries.

Causes

It is conditionally possible to distinguish 3 groups of factors that affect the causes of injury: fetal pathology, anatomical features and diseases of the mother, the technique of conducting the birth itself.

The most common group is related to the condition of the fetus:

• prematurity;
• big weight;
• breech presentation, cord entanglement;
• incorrect cutting head;
• hypoxia or asphyxia;
• oligohydramnios or polyhydramnios;
• intrauterine pathology.

The imposition of obstetric forceps is fraught with birth injuries

• narrow pelvis;
• late gestosis;
• hypoplasia (underdevelopment) of the uterus;
• inflection of the uterus (hyperanteflexia);
• age less than 18 or more than 35 years;
• diseases of the endocrine, cardiovascular or gynecological system;
• bad habits (smoking, taking drugs, alcohol);
• inhalation of harmful substances at work.

And finally, childbirth itself can be traumatic. Difficulties are:

• rapid or prolonged labor;
• stimulation with oxytocin, prostaglandins, antiprogestogens, bladder puncture;
• use of obstetric aids: forceps, vacuum extraction,
• midwife's hand pressure on the bottom of the uterus in order to accelerate the progress of the fetus.

Classification

There are several types of birth trauma:

1. Cranial.
2. Trauma to internal organs.
3. Soft tissue injuries.
4. Skeletal damage.
5. Injuries of the central nervous system and peripheral nervous system.

Traumatic brain injury

Unfortunately, head injuries are considered one of the main causes leading to disability or even death in newborns. The situation can be aggravated by aspiration of amniotic fluid or prolonged hypoxia due to placental abruption.

Causes

As a result of the fact that the head forms the birth canal and is the largest part of the body in circumference, it takes on the maximum load during childbirth. Due to the ability to change the configuration due to the elasticity and elasticity associated with the presence of fontanelles, the bones of the skull overlap each other during birth, and the volume of the head decreases to withstand the pressure exerted on it. However, with pressure stronger than usual or for a long time, damage to brain structures can occur.

Symptoms and Diagnosis

The severity of damage is judged by assessing the behavioral state of the infant. Pathological manifestations can be:

• stupor - there are practically no reactions to external stimuli;
• lethargy - the child sleeps almost all the time, waking up in response to a strong pain stimulus;
• coma.

The localization of hemorrhages in the brain can be different, but it always poses a danger to the health and even the life of the baby.

Brain lesions can be in the form of hemorrhages under the meninges (subarachnoid, epidural, subdural), directly into the brain (then hematomas form) or into the ventricles.

Outwardly, it is not so easy to determine the presence of an injury, since healthy babies are also able to react sluggishly to light, their pupils wander, there are manifestations of strabismus - and these are normal variants.

Normally, the brain should not protrude above the bony edge of the fontanel, and when probing, a pulsation is felt. When compiling a clinical picture, they are guided by the presence (or absence) of a convulsive, hydrocephalic syndrome, increased excitability, and a decrease in the sucking and swallowing reflex.

The most informative diagnostic methods are neurosonography through the large fontanel, X-ray examination (allows you to assess damage to bone structures), as well as MRI.

Treatment

Newborns with craniocerebral injuries are treated in intensive care units, placed in special incubators. All manipulations related to care and feeding are performed in the crib.

Postpartum edema is usually simply observed, while large cephalohematomas (greater than 6 cm) require removal of the contents with two needles. After the procedure, a tight bandage is applied to the head. Abrasions are treated with a solution of brilliant green. If the scalp is affected, a course of antibiotic therapy is prescribed, stitches are applied.

Skull fractures are almost always associated with the use of obstetric aids. But, due to bone elasticity, not all of them need surgical correction. For example, depressed fractures may spontaneously heal.

The most severe treatment for birth brain injuries is associated with intracranial hemorrhages, since they are fraught with large blood loss and functional changes in the brain. Surgical treatment is carried out in 3 directions: puncture, staged and craniotomy.

Injuries of internal organs

Mechanical pressure on the fetus often leads to hemorrhages in the spleen, liver or adrenal glands. Symptoms are clearly visible after 4-5 days after birth. Due to the existing internal bleeding, muscle weakness, intestinal paresis, low blood pressure, bloating along with regurgitation and vomiting are observed. Reflexes are depressed.

The diagnosis is established by ultrasound and X-ray of the peritoneal organs, as well as ultrasound of the adrenal glands. Therapy is aimed at stopping bleeding, sometimes resorting to laparoscopic intervention or performing a laparotomy.

The consequences of a birth injury of this kind depend on the severity and extent of the lesion, as well as the speed of its detection and assistance.

Soft tissue injuries

This variety includes damage to the skin and subcutaneous tissue. They may look like scratches, abrasions, or have other manifestations. So, if the sternocleidomastoid muscle is damaged, not only a soft seal (tumor) is formed, but also torticollis develops. For treatment in this case, massage techniques, electrophoresis with potassium iodide are used, the position of the head is fixed with special orthopedic rollers.

This type of trauma can also include birth tumors and cephalohematomas. The tactics of their treatment are described above. However, it should be noted that cephalohematomas can be observed for 3-4 weeks, but if there are signs of suppuration, it must be removed immediately. Since cephalohematomas are often accompanied by intrauterine development of mycoplasmosis, PCR diagnostics are performed.

Traumatization of the skeletal system

This type of injury is considered exclusively an obstetric defect. More often than others, the clavicle and bones of the limbs are damaged. If the fracture of the clavicle is without displacement, it is diagnosed approximately on the 3rd day, when a bone callus forms in the form of swelling. In case of displacement in newborns, not only swelling appears, but the movements of the hand are limited, the child cries when trying to carry out any manipulations with the damaged limb.

Rarely, during childbirth, a displacement of the epiphysis of the upper or lower end of the shoulder or thigh can occur. In such cases, limb traction with temporary fixation is done. The regenerative abilities of the child's body are amazing, so the bones are completely restored over time.

A fracture of the humerus, radius or femur is diagnosed by pain reaction, visual shortening of the limb, swelling, and of course, by x-ray. A pediatric traumatologist is necessarily involved in the treatment of fractures in newborns. In some cases, for example, with a fracture of the collarbone, a tight bandage is sufficient, while in others the limb is immobilized with a cast.

In case of a clavicle fracture, it is enough to fix the injured arm with a bandage bandage for a week

Cervical and spine injuries

During birth, the baby experiences colossal overloads: it is affected by forces that expel the fetus from the womb. And since most often the child has a head presentation, there are frequent injuries to the head and neck, which encounters resistance from the pelvic floor and muscles throughout the birth canal.

Causes

Birth trauma of the cervical spine occurs most often due to traction of the head and neck in newborns. Under such circumstances, the bodies of I-II vertebrae can be displaced, subluxation in the joints in the vertebrae of the cervical region, rotational subluxation of the atlas, and intervertebral discs may be damaged.

Symptoms and Diagnosis

There is no clear clinical picture that helps to establish the presence of a birth injury of the cervical spine or spinal cord. Pathology can be suspected by a decrease in reflexes (swallowing, sucking), a violation of muscle tone, more often in the direction of hypotension, a shortened or elongated neck, and the presence of torticollis. The muscles of the cervical-occipital region are often tense, and when probing the spinous processes and paravertebral points in the cervical region, the child begins to worry, cry, and changes facial expressions.

Children with suspected injuries of the cervical spine and spine are given x-rays in two projections. The study also uses neurosonography and dopplerography of the vessels of the spinal cord and brain - this way you can understand whether there are violations of vascular blood flow, in particular, blood circulation in the basin of the vertebral arteries or damage to the membranes of the spinal cord.

Treatment

If the clinic is mild, alarming symptoms may disappear on their own within a few days. However, in case of suspected serious damage, an integrated approach to treatment is necessary.

The main goal of therapy is to restore brain trophism. To do this, in some cases, it is necessary to temporarily (up to two weeks) immobilize the cervical region by applying special cotton-gauze collars (for example,). Later, the collar is replaced with an orthopedic pillow.

Massage performed by an experienced and qualified osteopath gives a good result in the treatment of birth injuries

The treatment regimen includes taking drugs aimed at improving the functioning of the central nervous system and ensuring the trophism of muscle tissues. Massages and electrophoresis with aminofillin, relaxing baths with pine needles and salt are effective. Therapeutic treatment may take about 6 months or more, and during the first year massage and electrophoresis courses are repeated. In any case, after the restoration of functions, the child is still under the supervision of doctors - a neurologist and an orthopedist.

Consequences with possible complications

The sooner the treatment of a birth injury begins, the less likely it is to develop complications. But the bones of the neck and spine in infants are very fragile, able to stretch, thereby disrupting the outflow of fluid and affecting blood circulation. If nothing is done, then the child may suffer from such diseases:

• headaches, digestive problems;
• vegetovascular dystonia, hypertension;
• diseases of the joints and spine (scoliosis, osteochondrosis), flat feet, clubfoot;
• physical and mental retardation in development;
• underdevelopment of fine motor skills ("clumsy fingers").

CNS and peripheral nervous system injuries

These include the considered spinal injuries, when the spinal cord is affected, and damage to the peripheral nervous system:

• paresis of the facial nerve - appears with prolonged childbirth and prolonged compression of the nerve; the face is asymmetrical, the lips move to the healthy side;
• Duchenne-Erb palsy - the brachial trunk of the nerve plexus is damaged, due to which the arm does not move;
• paresis of the diaphragm - occurs when using obstetric aids and fetal asphyxia;
• paralysis of Dejerine-Klumpke - partial paralysis of the branches of the brachial plexus leads to immobilization of the muscles of the hand, loss of their sensitivity.

To clarify the diagnosis, an x-ray or MRI of the spine is taken, and a lumbar puncture is taken. They are treated with massage, electrical stimulation, exercise therapy, as well as therapy aimed at eliminating circulatory disorders.

Are injuries possible during caesarean section?

There is an opinion that if a child is born by caesarean section, birth injuries can be avoided. Most often this happens, however, under the influence of various factors, damage is still possible:

1. Indications for caesarean section in history can cause trauma.
2. Technique for caesarean section. During the operation, an incision of 25 cm is made, and the circumference of the baby's shoulders is somewhat larger, about 35 cm. Therefore, removing the baby requires effort on the part of the midwife, hence damage to the cervical region is possible.
3. The lack of passage through the birth canal negatively affects the development of the baby's nervous system, because the restructuring of the cardiovascular and respiratory systems occurs in a completely different scenario. This is a kind of stress for the body.

A caesarean section is not an absolute guarantee that the birth will take place without injury.

Therefore, if there are no direct indications for a cesarean, you should not insist on an operation, thinking that in this way it will be possible to protect the child from all troubles. In addition, a caesarean section does not make it possible to endure the next pregnancy for 3-4 years.

Preventive actions

Is there any way to reduce the risk of birth trauma? Yes, if you follow some guidelines:

• plan pregnancy in advance with an examination of the reproductive system;
• treatment of diseases, especially chronic ones, without delay;
• a pregnant woman should avoid crowded places during the period of viral and respiratory diseases in order to reduce the risk of catching an infection;
• quality and balanced nutrition during pregnancy;
• timely observation by a gynecologist, delivery of all necessary tests;
• the future mother should lead a healthy lifestyle;
• during childbirth, listen to the midwife and push properly.

So, injuries in newborns during childbirth are common. Most of them do not pose a danger to the life of the baby, and the body recovers after a while without outside help. However, in difficult situations, it is necessary to trust specialists in the field of neurosurgery, neurology and traumatology. For her part, the expectant mother can do a lot to ensure that her child is born healthy.

Injuries that occur during childbirth are recorded in 5 to 10% of cases, which are accompanied not only by violations on the part of the child, but also by traumatism in the mother (ruptures of the vagina, uterus, formation of fistulas between the reproductive system and intestines). Today, they occur much less frequently than several decades ago, but nevertheless they can lead to serious complications, because injuries in newborns are a dangerous phenomenon.

The concept of the disease

Birth trauma is defined as damage to the baby of various localization and severity, which arise due to incorrect management tactics or pathology of labor. Violations can be triggered by mechanical (when squeezing or pulling the fetus) or hypoxic (when there is insufficient oxygen transport to the body of the unborn child) factors.

Damage during childbirth can be of a different nature, but it is this period of life that plays an important role in the further physical and mental development of the child. Distinguish:

Soft tissue injuries:

• skin - abrasions on the scalp and other parts of the body when using instruments during childbirth;
• subcutaneous fat;
• muscles;
• cephalohematoma - hemorrhage into the subperiosteum (a thin layer of connective tissue that covers the outside of the bone);
• head compression - the bones of the child's skull have properties for displacement, but during natural childbirth under high vaginal pressure, deformation may occur.

Injuries to the bones and joints of the newborn:

• clavicle fracture or fissure;
• fracture of the humerus or femur;
• subluxations of the first and second cervical vertebrae;
• damage to the cranial bones;
• fractures of the bones of the skull due to depression with forceps during childbirth.

Birth injuries of the peripheral nervous system:

• facial nerve - a very common birth injury that occurs when the head is presented and the nerve is pressed against the sacral promontory, own shoulder or uterine fibromyoma;
• brachial plexus - occurs due to stretching of the neck and extraction of the fetus over the shoulder with a gluteal or pronounced extension of the neck in head presentation. There are two types of plexus injury: superior or Erb's palsy, which affects the muscles around the shoulder and elbow joints; lower or Klumpke's paralysis, in which there is weakness of the muscles of the forearm and wrist joint;
• phrenic nerve - occurs in parallel with damage to the brachial plexus due to traction behind the head and neck (extraction of the fetus from the birth canal).

Damage to the central nervous system:

Spinal cord injury occurs as a result of overstretching of the cervical spine with breech presentation, difficulty in removing the head, tilting the handle.

There are two types of brain damage:

• hypoxic - in which the inhibition of the function of the central nervous system occurs due to insufficient oxygen levels in the child's body;
• hemorrhagic - bleeding in or around the brain tissue.

Bleeding during childbirth can occur in different structures of the central nervous system and be of the following types:

• epidural - accumulation of blood between the skull and the dura mater;
• subdural - hematoma under the dura mater;
• intraventricular - hemorrhage into the internal formations of the brain - the ventricles;
• subarachnoid - between the subarachnoid and pia mater;
• parenchymal - hemorrhage in the soft tissues of the brain.

Injuries of internal organs:

An abnormal course of labor leads to hemorrhage in:

• spleen;
• adrenal glands;
• liver.

Causes and risk factors

The immediate cause of injury is the use of physical stimulation during labor, for example:

• the use of obstetric forceps or a vacuum extractor;
• turning the fetus by the leg;
• incorrect caesarean section.

It exacerbates fetal damage and oxygen deficiency (hypoxia), which in some cases leads to hemorrhage even without vascular injury.

The provoking factors of this pathology are:

Mismatch between the size of the fetus and the pelvis of the mother

• large fruit;
• narrow pelvis;
• anomalies in the development of the pelvis in the mother;
• hypoplasia of the uterus (underdevelopment).

Pathology of labor activity

• breech presentation;
• exacerbation of chronic diseases of the cardiovascular, respiratory or endocrine system in the mother;
• rapid or prolonged labor;
• uncoordinated labor activity;
• delayed pregnancy.

Symptoms of the disease

Clinical manifestations - table

Symptoms of birth injuries - photo gallery

Manifestation of Erb's palsy and atrophy of the muscles of the hand of the upper limb Klumpke's palsy is manifested by a lack of sensitivity of the upper limb Damage to the facial nerve is manifested by smoothing of the facial muscles Hemorrhage leads to hydrocephalus Cephalhematoma - occurs due to hemorrhage

Diagnosis of pathology

Frequent asymptomatic or atypical course of birth trauma complicates timely diagnosis and provision of specialized care. The main goal of the study is an early assessment of changes in damaged organs and their functional state. To do this, newborns use those methods that do not require violation of the integrity of the skin (non-invasive), and also do not cause even more harm when exposed.

To study the bones of the skull, its cavity and brain tissue, the following are used:

• ultrasonography - a method for diagnosing brain structures, which works on the principle of ultrasound and shows the condition and volume of the ventricles, gray matter, large vessels, the presence of hematomas, the area of ​​ischemia;
• computed tomography or magnetic resonance therapy - examines and determines the usefulness of the cranium, localization of hemorrhages, the presence of cysts, vascular pathologies, and is also performed in case of damage to the spinal cord;
• electroencephalography - shows the functional state of the brain, recording biopotentials from the cortex;
• Ophthalmoscopy is a mandatory method of examination in newborns. The position of the internal fundus corresponds to the degree of damage to the brain tissue: edema of the optic disc, vein dilation, retinal hemorrhages are determined;
• lumbar and ventricular puncture are invasive examination options in which a puncture of the spinal canal or ventricles is performed to obtain cerebrospinal fluid (cerebral fluid). Use it in case of high intracranial pressure, hydrocephalus, intraventricular or epidural hemorrhage.

For fractures of the limbs:

• radiograph - the location of the fracture and its type are determined.

To diagnose plexus or nerve damage:

• radiography of the cervical spine - allows you to find out the causes of violation of the integrity of the nerve fibers (fracture of the humerus, dislocations, collarbones, subluxations of the cervical vertebrae);
• magnetic resonance imaging - shows damage to the roots, nerve fibers and plexuses.

With hemorrhages in internal organs:

• ultrasound examination of the abdominal cavity and adrenal glands - determines the size of the hematoma and the degree of bleeding.

Birth trauma treatment

In the acute period, the child is carried out the restoration and stabilization of the vital functions of the body. Measures that are aimed at eliminating the pathological mechanisms of brain damage:

• resumption of airway patency and adequate ventilation of the lungs;
• elimination of hypovolemia (low volume of circulating blood);
• maintaining adequate blood supply to the brain;
• prevention of hypothermia, overheating, infection;
• systematic delivery of energy to the brain in the form of a glucose solution;
• correction of pathological metabolic processes of the child.

The baby is placed in an incubator and oxygen therapy is performed.

Of the drugs used:

• drugs to stop bleeding - Vikasol, Etamzilat;
• to reduce cerebral edema - Magnesium sulfate, Furosemide, Ethacrynic acid;
• in the event of seizures - Phenobarbital, Seduxen, Sodium hydroxybutyrate;
• with trauma to the spinal cord and to improve neuromuscular conduction - Dibazol and Prozerin;
• to improve microcirculation - Papaverine, Trental.

Conservative therapy - photo gallery

Furosemide is used to reduce cerebral edema
Seduxen - a drug used for convulsions in a child
Vikasol is used to stop bleeding Prozerin - improves neuromuscular conduction
Trental improves the microcirculation of the newborn

When diagnosing fractures, the limb of the newborn is immobilized with a plaster or elastic bandage.

Surgical intervention is performed if it is necessary to remove large hematomas or intracerebral hemorrhages, to eliminate the accumulation of blood. This method of treatment is also performed to restore the outflow of cerebrospinal fluid from the brain.

If a birth injury leads to the formation of jaundice in a baby, then a physiotherapeutic method is used to eliminate it - phototherapy, which stimulates the breakdown of bilirubin.

With Erb's or Klumpke's paralysis, the limb is first immobilized so as not to additionally damage the nerve plexuses and prevent the development of muscle contracture (spasm), and after a month, therapeutic massage and gymnastics, electrical stimulation of the muscles of the upper limbs and reflexology are recommended.

Complications of birth trauma

1. Damage to the facial nerve, soft tissues and cephalohematoma do not need specific treatment and does not lead to consequences for the health of the baby.
2. Hemorrhage in the adrenal glands leads to chronic adrenal insufficiency.
3. Injuries of the brain and spinal cord are the most dangerous for the physical and mental health of the child: psychomotor retardation, mental retardation, convulsions, paralysis, epilepsy, coma.
4. A lethal outcome occurs with hemorrhage in the respiratory center and uncontrolled intracranial pressure.

Injury prevention

Proper pregnancy management and management of chronic diseases prevents the occurrence of injuries during childbirth. An important element of prevention is the avoidance of bad habits, occupational hazards, rational nutrition of the mother and regular visits to the antenatal clinic.

Hello! I am a doctor who knows how and loves to write medical articles. Copyright interested me 2 years ago. Creating interesting and informative texts helps not only to earn money, but also to constantly improve oneself in the field of medicine.

The birth process is quite unpredictable and can result in complications for both the mother and the baby. One such complication is birth trauma.

What is this?

Birth injuries of newborns are called pathological conditions that occur during childbirth, in which tissues or organs are damaged in a newborn, as a result of which their functions are impaired.

With prenatal trauma in a newborn, the work of the main body systems is disrupted.

Types of injury

All injuries during childbirth are divided into:

1. Mechanical. These are bone fractures, head injuries, birth tumors, various hemorrhages, spinal cord and central nervous system injuries, cephalohematomas, cervical spine injuries, nerve damage, traumatic brain injury and other pathologies.
2. hypoxic. They are represented by damage to the internal organs and tissues of the brain, which leads to hypoxia and asphyxia during the birth process.

Cardiotocography is one of the methods for early diagnosis of intrauterine fetal hypoxia

Depending on the location of the lesion, injuries are distinguished:

• Bones.
• Soft tissues.
• nervous system.
• Internal organs.

Common Causes

To the appearance of mechanical birth injuries cite various obstacles in the advancement of the fetus through the female birth canal.

Cause of hypoxic injury is the complete or partial cessation of oxygen access to the child.

CNS damage or traumatic brain injury of the baby is one of the most common problems during childbirth.

Predisposing factors for which the risk of child injury during childbirth increases, include:

• Large fruit weight.
• Prematurity of the child.
• Narrow pelvis of a pregnant woman.
• Maternal pelvic injury.
• Wrong presentation.
• Mom's old age.
• The rapidity of the birth process.
• Prolongation of the birth process.
• Stimulation of childbirth.
• C-section.
• Use of midwifery aids and devices.
• Postmaturity.
• Chronic fetal hypoxia.
• Problems with the umbilical cord (entanglement, short length).

For a detailed explanation of how prenatal injuries occur in a baby, see the video:

Symptoms

• The most common birth injuries are swelling of the soft tissues of the child's head, which is called a birth tumor. It looks like a small swelling on the head of a newborn. With such edema, babies can also experience hemorrhages in the skin in the form of small dots.
• Cephalhematoma is manifested by hemorrhage in the baby's head. It occurs due to displacement of the skin and rupture of blood vessels, as a result of which blood collects under the periosteum of the cranial bones. The tumor appears immediately after childbirth and in the first two or three days its size increases.
• Bleeding into the muscles often appears in the neck(in the sternocleidomastoid muscles) and looks like a moderately dense formation of a small size (for example, the size of a nut or the size of a plum).
• Among bone fractures, the clavicle (often right) is most often damaged without displacement. With such an injury, when feeling the body of a newborn at the site of a broken collarbone, swelling, crunching and soreness are detected. Fractures of the femur or humerus are much less common. With them, movements in the limbs are impossible, their lethargy and soreness are noted.

Hematoma on the head of a newborn

• Nerves can be damaged due to both hypoxia and mechanical trauma. The most common nerve problem is damage to the facial nerve. Often there are also injuries of the brachial plexus.
• Traumatic brain injury may vary in severity. In severe cases, the baby may die in the first days or even hours after birth. Also, in severe trauma, organic changes in the tissues of the nervous system are possible, manifested by paralysis, paresis, and the development of mental retardation. Immediately after childbirth, the baby may develop convulsions, inhibition of the sucking reflex, breathing problems, severe crying, tremors of the arms and legs, insomnia, and other symptoms of CNS excitation. Further, the baby becomes lethargic, his cry and muscle tone weakens, the skin turns pale, the child sleeps a lot, sucks badly, burps a lot.
• Injuries of internal organs are less common than other types of injuries and usually do not appear in the first time after childbirth. The baby may have damage to the adrenal glands, spleen, or liver. The condition of the baby worsens from the third to fifth day of life, when the hematoma in the damaged organ ruptures, which leads to internal bleeding and anemia.

Consequences

The prognosis for birth injuries is affected by the severity of the injury, the timeliness of treatment, and the correctness of the selected therapy. If the child was correctly diagnosed in time and treated immediately, in 70-80% of cases he fully recovers.

The least dangerous damage to soft tissues and bones. The birth tumor usually disappears in one or two days without any consequences for the child's body. A small cephalohematoma resolves by 3-7 weeks of life without treatment. Due to a hemorrhage in the muscles of the neck, the child develops torticollis, in which the head of the crumbs leans towards the formation, and the chin is directed in the opposite direction. This condition is corrected by a special massage.

The magnitude of the hematoma affects the consequences of damage to internal organs. No less important is the extent to which the function of the affected organ has been preserved. For example, a large hemorrhage in the adrenal glands in many children leads to the development of chronic insufficiency of these glands.

The consequences of hypoxic injuries depend on the duration of the period when the child experienced a lack of oxygen. If such a period was long, a severe degree of delay in intellectual and physical development is possible, caused by the death of nerve cells in the brain. Children may develop cerebral palsy, hydrocephalus, seizures, nerve damage, encephalopathy and other pathologies. With an average degree of hypoxia in older children, increased fatigue, headaches, dizziness, and posture problems may occur.

For information on what hypoxia is and how to avoid it, see the following story:

Therapy

In most cases birth injuries are diagnosed in the maternity hospital, where the child is immediately prescribed the right treatment. In case of fractures, the damaged area is immobilized. In a serious condition of the baby, he is fed through a tube with colostrum, which the mother expresses.

With a severe degree of hypoxia, the treatment of the baby is carried out in the conditions of resuscitation of newborns.

In the treatment of injuries, depending on the type of damage, agents for blood vessels and the heart, drugs that affect the central nervous system, hemostatic agents, oxygen therapy, the introduction of vitamins and glucose are used.

Some types of injuries require surgical treatment. For example, with a rapidly growing cephalohematoma, a child is punctured. Surgical treatment is also indicated for hematomas of internal organs.

The term "birth trauma" combines violations of the integrity (and hence the dysfunction) of the tissues and organs of the child that occurred during childbirth. Perinatal hypoxia and during childbirth often accompany birth injuries, but can also be one of the pathogenetic links in their occurrence.

The frequency of birth injuries has not been established, because it significantly depends on diagnostic approaches and examination capabilities, as well as on the art and skill of obstetricians, the frequency of caesarean sections, etc. However, birth trauma as a cause of death is currently extremely rare and, according to M.E. Wegmag (1994), is 3.7 per 100,000 live births.

Etiology

Birth injury- a much broader concept than obstetric trauma; obstetric benefits in childbirth - one of the causes of birth trauma. The traumatic nature of obstetric benefits is determined not only by the skills of the obstetrician, but also by how the fetus enters labor. Prolonged intrauterine hypoxia, severe intranatal increase the likelihood of birth trauma even in the normal course of childbirth.

Predisposing factors for the development of birth trauma are:

Breech and other abnormal presentations;

Macrosomia, large size of the fetal head;

Prolonged and excessively fast (rapid) childbirth;

Deep prematurity;

Oligohydroamnion;

Anomalies in the development of the fetus;

Size reduction (infantilism, consequences, etc.) and increased rigidity of the birth canal (elderly primiparous, excess vitamin D during pregnancy);

Obstetric aids - turns on the leg, the imposition of abdominal or output obstetric forceps, vacuum extractor, etc.

Examples of purely obstetric injuries are fractures of the skull, limbs, and clavicles.

Clinical picture

Soft tissue injuries. Petechiae and ecchymosis, abrasions in various parts of the body are the most common manifestation of birth injuries. They can be at the site of the presenting part of the fetus during childbirth, applying forceps or electrodes during intrauterine monitoring, taking blood from the fetal head. Birth trauma can occur as a result of resuscitation, gripping the obstetrician's hand during intrauterine benefits. Small abrasions and cuts require only local antiseptic measures - treatment with alcohol solutions of aniline dyes, dressing, etc. Petechiae and ecchymosis resolve on their own within a few days - 1 week of life.

Adiponecrosis is possible at the site of compression by the hand of an obstetrician or neonatologist.

Injuries and hemorrhages in the sternocleidomastoid muscle occur when forceps are applied, manual aids, especially during childbirth in the breech presentation. A muscle tear usually occurs in the lower third (sternal). In the area of ​​damage and hematoma, a small, moderately dense or doughy consistency tumor is palpated. Sometimes for the first time it is diagnosed by the middle - the end of the first week of life, when torticollis develops - the child's head is tilted towards the damaged muscle, and the chin is turned in the opposite direction. Often, hemorrhage into the muscle is combined with a spinal injury.

It is necessary to differentiate the hematoma of the sternocleidomastoid muscle with congenital muscular torticollis, the pathogenesis of which is not clear. In some cases, fibrous degeneration of the muscle before delivery is associated with an anomaly in the position of the fetus, a small amount of amniotic fluid and pressure on the muscle of the bone part of the mother's pelvis, and sometimes it is a manifestation of multiple lesions of the musculoskeletal system (spine, skull bones, etc.), probably hereditary genesis.

The diagnosis is made on the basis of the detection of the above position of the head, asymmetry of the face and a shortened dense sternocleidomastoid muscle, smaller sizes of the auricle on the side of the lesion. With a bilateral process, the head is tilted forward, the cervical lordosis is increased, and the mobility of the spine in the cervical region is limited.

The treatment consists in creating a corrective position of the head (rollers that help eliminate the pathological tilt of the head and turning the face), the use of dry heat, physiotherapy (electrophoresis with potassium iodide), and a little later - massage. In case of inefficiency, surgical correction is required, which is carried out in the first half of life.

birth tumor

Swelling of the soft tissues of the head during cephalic presentation or at the site of the application of a vacuum extractor; it is often cyanotic, with many petechiae or ecchymosis, and may be the cause of hyperbilirubinemia. It does not require treatment, it passes on its own in 1-3 days; differentiate with cephalohematoma (see below), hemorrhage under the aponeurosis.

Hemorrhage under the aponeurosis

It is manifested by test-like swelling, swelling of the parietal and occipital parts of the head. Unlike cephalohematoma, swelling is not limited to one bone, but from a birth tumor, it can increase in intensity after birth. Risk factors are: vacuum extractor and other obstetric aids in childbirth. It is often the cause of posthemorrhagic anemia in the first days of life, because it can contain up to 260 ml of blood (Plauche W.C., 1980), and then hyperbilirubinemia. Possible infection. With large hemorrhages, it is necessary to exclude hereditary hemorrhagic diseases. An x-ray of the skull is needed to rule out fractures. Often combined with signs of intracranial birth trauma. According to W.C. Plauche (1980), mortality reaches 25%. The hemorrhage is resorbed in 2-3 weeks.

cephalohematoma

External cephalohematoma- hemorrhage under the periosteum of any bone of the cranial vault; may appear clearly only a few hours after childbirth (more often in the region of one or both parietal and less often in the region of the occipital bone); observed in 0.4-2.5% of newborns (Mangurten N. N., 2002).

The tumor initially has an elastic consistency, never passes to the adjacent bone, does not pulsate, is painless, with careful palpation, fluctuation is detected and, as it were, a roller along the periphery. The surface of the skin over the cephalohematoma is not changed, although sometimes there are petechiae. In the first days of life, cephalohematoma may increase, often due to increased extravascular production of bilirubin. At the 2-3rd week of life, the size of the cephalohematoma decreases, and complete resorption occurs by the 6-8th week. In some cases, calcification is possible, rarely - suppuration.

Cause of subperiosteal hemorrhage- detachment of the periosteum during movements of the head at the time of its eruption, less often - cracks in the skull (5-25%).

As a result, all children with large cephalohematomas (diameter greater than 6 cm) should have a skull x-ray to rule out a crack.

Very rarely, cephalohematoma is the first manifestation of hereditary coagulopathy. In preterm infants, cephalohematoma may be associated with generalized intrauterine mycoplasma.

Differential diagnosis is carried out with a birth tumor (passes through the sutures, disappears after 2-3 days), hemorrhage under the aponeurosis (flat, doughy consistency, passes over the sutures, fluctuates), cerebral hernias (protrusion of the meninges and brain substance through the fontanel and bone defects; they pulsate, reflecting respiratory movements, are located more often in the forehead; a bone defect is visible on the x-ray of the skull).

Treatment

For the first 3-4 days of life, feed expressed breast milk from a bottle, and then, if the condition is stable, attach the baby to the breast. Vitamin K (if not introduced at birth) once intramuscularly. Despite the fact that sometimes cephalohematomas become infected, calcified, and after resorption of large (more than 8 cm in diameter) hemorrhages, the underlying bone plate can sharply become thinner or bone cystic growths form, neonatologists have refused any surgical intervention for many years. Currently, tactics are changing somewhat: it is customary to puncture cephalohematomas larger than 6-8 cm in diameter at the end of the first week of life. Linear cracks in the skull do not require any specific treatment.

Paralysis of the facial nerve

Occurs when the peripheral part of the nerve and its branches are damaged by the imposed output obstetric forceps. It is characterized by the drooping and immobility of the corner of the mouth, its swelling, the absence of the nasolabial fold, the superciliary reflex, the loose closure of the eyelids on the side of the lesion, the asymmetry of the mouth when crying, and lacrimation. Differentiate with Mobius syndrome (absence of the nerve nucleus), intracranial hemorrhages. Treatment is carried out in consultation with a neurologist.

Birth injury of the spinal cord and brachial plexus.

There are two approaches to the interpretation of "obstetric paralysis of the shoulder" and "congenital paralysis of the shoulder", described for the first time in the 19th century. Erb and Duchenne and named after the original writers: a consequence of a brachial plexus injury and a consequence of a spinal cord injury. In Russia, among neonatologists, the point of view of Alexander Yuryevich Ratner and his school is more popular: in most cases, Duchenne-Erb palsy is caused by lesions of the spine and spinal cord. Foreign experts and a number of Russian neurologists consider this pathology to be the result of a lesion of the brachial plexus.

According to A.Yu.Ratner and his school, spinal injury develops 2-3 times more often than intracranial. In 40-85% of dead newborns, special studies reveal spinal cord injury, but only in 20% of cases it is regarded as the cause of death. With a thorough neurological examination, A.Yu. Ratner and his staff diagnose the so-called obstetric paralysis of the hands in 2-2.5% of newborns. At the same time, congenital paralysis of the hands is diagnosed much less frequently abroad: for example, in England and Ireland - 0.42 per 1000 live births (Evans-Jones G. et al., 2003), and in no country in the world, according to these authors , does not exceed 2.0 per 1000. Whether this is due to more advanced obstetric tactics and a higher frequency of caesarean sections abroad or with overdiagnosis is not clear in our country. It seems to us that the point of view of A.Yu.

Etiology

The cause of spinal cord lesions is a forced increase in the distance between the shoulders and the base of the skull, which is observed when pulling the head with fixed shoulders and pulling the shoulders with a fixed head (with breech presentation), excessive rotation (with face presentation in 25%). At the time of delivery, these children often used forceps, a vacuum extractor, and various manual aids.

Pathogenesis

Various factors may be relevant:

1. Defects of the spine: subluxation in the joints of the I and II cervical vertebrae, blocking of the atlanto-axial and intervertebral joints by a capsule strangulated in them, displacement of the vertebral bodies (dislocation of the I-II vertebrae), fracture of the cervical vertebrae and their transverse process, anomalies in the development of the vertebrae (nonfusion arches, underdevelopment of the arch of the I cervical vertebra, its absence in the back).

2. Hemorrhages in the spinal cord and its membranes, epidural tissue due to vascular tears or increased permeability.

3. Ischemia in the basin of the vertebral arteries due to stenosis, spasm or occlusion, compression of the Adamkevich artery, spinal cord edema.

4. Damage to the intervertebral discs.

In the mechanism of traumatic injury of the spinal cord, according to A.Yu. Vascular disorders occur with a sharp flexion, traction or torsion of the cervical spine of the fetus during childbirth. During childbirth in the breech presentation, the greatest load falls not only on the cervical, but also on the thoracic and lumbar spinal cord. Traction behind the trunk of a newborn with a fixed head can lead to spinal stretch up to 4-5 cm, and the spinal cord - up to 0.5-0.6 cm, so spinal injury is less common than spinal cord injury.

N.G. Palenova and A. Yu. Ratner note that in severe intrauterine hypoxia, there is a lesion of the motor neurons of the anterior internal group of cells of the anterior horn, i.e. spinal cord injuries can develop antenatal, resulting in childbirth.

The pathogenesis of damage to the cervical roots and brachial plexus is still actively discussed. Along with mechanical factors (tension of the nerve trunks, pressure from the clavicle or rotated shoulder) during obstetric manipulations, prolapse of the handles, they indicate the possible role of intrauterine changes in the brachial plexus, disorders of the segmental circulation of the spinal cord, including spinal injuries.

The clinical picture depends on the location and type of damage. In the presence of an injury to the cervical spine, as a rule, there is a pain symptom (changes in the position of the child, taking him in his arms, and especially the study of Robinson's symptom cause sharp crying). In addition, there may be a fixed torticollis, a shortened or elongated neck, tension in the cervico-occipital muscles, bruising and hardening of the soft tissues of the neck, lack of sweat, and dry skin over the site of the lesion.

In case of damage to the upper cervical segments (Q-Cy), a picture of spinal shock is observed: lethargy, adynamia, diffuse muscle hypotension, a tendency to hypothermia, arterial hypotension, hypo- or areflexia; tendon and pain reflexes are sharply reduced or absent; complete paralysis of voluntary movements distal to the site of injury or spastic tetraparesis. From the moment of birth, a syndrome of respiratory disorders has been noted (breathing is difficult, tachypnea or respiratory arrhythmia, intercostal spaces are smoothed or sunken, the stomach is swollen). Typical is the increase in respiratory disorders with a change in the position of the patient, up to (Kucherov A.P., 1993).

Urinary retention (neurogenic bladder) or intermittent urinary incontinence is characteristic. When examining a child, you can find a “frog pose”. Often the head is turned to one side (often spastic torticollis is found on the same side). Focal symptoms of damage to the III, VI, VII, IX, X pairs of cranial nerves and the vestibular portion of the VIII pair can also be detected. The combination of symptoms of damage to the brain stem, dysfunction of the pelvic organs and movement disorders of the myotonic type indicates ischemia in the vertebrobasilar basin. The cause of death of newborns are respiratory disorders and bouts of asphyxia after birth, shock.

Paresis of the diaphragm (Cofferat's syndrome) develops with an injury to the brachial plexus (n. frenicus), the spinal cord at the level of C-C^. It can be isolated or in 75% of children combined with upper paresis or total paralysis of the arm. Damage to the phrenic nerve is more common in left-sided Duchenne-Erb paresis.

The leading symptom in the clinic of paresis of the diaphragm is a syndrome of respiratory disorders: shortness of breath, aggravated by a change in position, arrhythmic breathing, bouts of cyanosis. When examining a newborn, asymmetry of the chest, a lag in the act of breathing of the affected half, paradoxical breathing (retraction of the abdominal wall on inhalation and its protrusion on exhalation) are revealed; during auscultation on the side of the paresis, weakened breathing and often crepitant wheezing are heard. In patients with paresis of the diaphragm, due to a decrease in pressure in the pleural cavity and insufficient ventilation, it may develop, a feature of which is an extremely severe and protracted course. Possible swelling in the neck on the side of the paresis (venous outflow is difficult). The X-ray picture is characteristic: on the side of the lesion, the dome of the diaphragm is high, deep rib-diaphragmatic sinuses, and on the healthy side, the dome of the diaphragm is somewhat flattened due to compensatory emphysema. There may be a shift of the mediastinal organs in the opposite direction, which is often accompanied by signs of heart failure (tachycardia, deep

host of heart sounds, systolic murmur, liver enlargement). Sometimes paresis of the diaphragm does not give a clear clinical picture, but is detected only radiographically and, conversely, mild forms of paresis of the diaphragm can be X-ray negative. Cofferat's syndrome is detected immediately after the birth of a child or when his condition worsens. With mild forms of paresis of the diaphragm, spontaneous recovery is possible. In severe paresis, in most cases, diaphragm function is fully or partially restored within 6-8 weeks. The prognosis worsens when paralysis of the diaphragm is combined with total paralysis of the upper limb.

Paresis and paralysis of Duchenne-Erb

develop with damage to the spinal cord at the level of GACyi or the brachial plexus. The clinical picture of Duchenne-Erb palsy is quite typical: the affected limb is brought to the body, extended at the elbow joint, turned inward, rotated at the shoulder joint, pronated in the forearm, the hand is in palmar flexion and turned back and outward. The head is often tilted and turned. The neck seems short, with a large number of transverse folds, sometimes with stubborn wetting. The rotation of the head is due to the presence of spastic or traumatic torticollis. Muscle tone is reduced in the proximal sections, as a result of which it is difficult to abduct the shoulder, turn it outward, raise it to a horizontal level, flex at the elbow joint and supinate the forearm.

When the child is placed face down in the palm of the hand, the paretic limb hangs down, and the healthy arm is separated from the body by a deep longitudinal fold (symptom of Novik's "doll's hand"), in the armpit there is sometimes an abundance of folds in the form of an island ("axillary island") and a skin constriction in the proximal department of the paretic shoulder (in the presence of it, it is necessary to exclude a fracture of the shoulder). Passive movements in the paretic limb are painless (!), Moro, Babkin and grasping reflexes are reduced, there is no tendon reflex of the biceps muscle. With passive movements of the paretic arm in the shoulder joint, a “clicking” symptom (Fink’s symptom) can be detected, subluxation or dislocation of the head of the humerus is possible due to a decrease in the tone of the muscles that fix the shoulder joint (confirmed radiographically). Pathological positioning of the shoulder and forearm leads to the formation of intrarotatory contracture of the shoulder and pronator contracture of the forearm (Volkmann's contracture). In severe lesions of Su and Cvi, pyramidal tracts may be involved in the process, which causes the appearance of a symptom of pyramidal insufficiency in the leg on the side of the lesion (increased knee and Achilles reflexes, less often an increase in muscle tone in the adductor muscles of the thigh). Proximal Duchenne-Erb palsy often occurs on the right, may be bilateral, combined with damage to the phrenic nerve and cerebral symptoms. Often a positive symptom of tension of the nerve trunks.

Lower distal paralysis of Dejerine-Klumpke occurs with spinal cord injury at the level of Suc-T | or middle and lower bundles of the brachial plexus. There is a gross violation of the function of the hand in the distal section: the function of the flexors of the hand and fingers, the interosseous and vermiform muscles of the hand, thenar and hypothenar muscles is sharply reduced or absent. Muscle tone in the distal parts of the arm is reduced, there are no movements in the elbow joint

Tave, the hand has the shape of a "seal's foot" (if the lesion of the radial nerve predominates) or a "clawed foot" (with a predominant lesion of the ulnar nerve). On examination, the hand is pale, with a cyanotic tinge (symptom of "ischemic glove"), cold to the touch, the muscles atrophy, the hand flattens. The movements in the shoulder joint are preserved, the Moro reflex is reduced, the Babkin reflexes and grasping reflexes are absent. Damage to the cervical sympathetic fibers is characterized by the appearance of the Bernard-Horner syndrome (ptosis, miosis, enophthalmos) on the affected side.

Total paralysis of the upper limb (Kerer's palsy)

observed when Su-T is damaged | segments of the spinal cord or brachial plexus, often unilateral. It is clinically characterized by the absence of active movements, severe muscle hypotension (may be a “scarf” symptom), the absence of congenital and tendon reflexes, and trophic disorders. As a rule, Bernard-Horner syndrome is noted.

Duchenne-Erb palsy and Kehrer's palsy if they are combined with a violation of the integrity of the spine (dislocation, fracture, etc.), they can be complicated Unterharnscheidt's syndrome: with a sharp turn of the head, a spasm of the vertebral artery occurs, ischemia of the reticular formation develops, a clinic of spinal shock occurs, which can cause death; in milder cases, there is diffuse muscular hypotension, acrocyanosis, coldness of the hands, feet, paresis of the upper extremities, bulbar disorders. When the condition improves, neurological symptoms regress.

Thoracic spinal cord injury (Tj-T/n) clinically manifested by respiratory disorders as a result of dysfunction of the respiratory muscles of the chest: the intercostal spaces sink at the moment when the diaphragm inhales. Involvement of the spinal cord segments at the T3-T6 level is clinically manifested by spastic lower paraparesis.

Injury to the lower thoracic segments of the spinal cord is manifested by the symptom of a "flattened abdomen" due to weakness of the muscles of the abdominal wall. The cry in such children is weak, but with pressure on the abdominal wall it becomes louder.

Spinal cord injury in the lumbosacral region is manifested by lower flaccid paraparesis while maintaining normal motor activity of the upper limbs. The muscle tone of the lower extremities is reduced, active movements are sharply limited or absent. On examination: the lower limbs are in the “frog position”, when the child is placed in a vertical position, his legs hang down like whips, there are no support reflexes, automatic gait and Bauer reflexes, knee and Achilles reflexes are depressed, a symptom of “puppet leg” is observed. As a result of a violation of the synergism of individual muscle groups in children, paralytic clubfoot occurs, in which, unlike congenital, one can passively bring the foot into the correct position. Often, subluxations and dislocations of the hips are formed for the second time. When the sacral segments are involved in the process, the anal reflex disappears, gaping of the anus, urinary incontinence (urination in frequent drops outside the act of urination) and feces can be observed. In the subsequent progress

trophic disorders are caused: gluteal muscles (“punctured ball” symptom), smoothness of the folds on the thighs, atrophy of the muscles of the lower extremities, development of contractures in the ankle joints.

Local symptoms in injuries of the thoracic and lumbar spine: tension of the paravertebral muscle ridges, deformities like kyphosis or kyphoscoliosis, protrusion of the "spinous process" of the damaged vertebra, ecchymosis over the site of the lesion.

The most severe type of natal spinal cord injury is a partial or complete rupture of the spinal cord (mainly in the cervical and upper thoracic regions). Characteristic signs are flaccid paresis (paralysis) at the level of the lesion and spastic paralysis below the level of the lesion, dysfunction of the pelvic organs (involuntary urination and defecation or constipation) with the addition of a urinary tract infection. With an injury with a rupture of the spinal cord in the first hours and days of life, neurological symptoms may be the same as with hemorrhages, cerebral edema, shock, and the child may die within a few hours even before the appearance of "spinal" neurological symptoms.

Diagnosis and differential diagnosis

The diagnosis of natal spinal cord injury is based on a thorough history and typical clinical presentation. To confirm the diagnosis, an X-ray of the spine is necessary (identification of traumatic injuries), X-ray of the chest (for the diagnosis of paralysis of the diaphragm).

X-ray of the spine is carried out in two projections. To detect subluxation of the atlas, a direct x-ray is taken with the child's head slightly thrown back (by 20-25 °), and the x-ray beam is centered on the region of the upper lip.

Craniography and examination by an ophthalmologist are indicated for suspected concomitant trauma to the brain and spinal cord, especially if the upper cervical segments are damaged.

Electromyography reveals preganglionic (presence of denervation potentials) and postganglionic (electromyogram without pathology) disorders in paralysis.

It should be remembered that with flaccid paresis of spinal origin, unlike central paralysis, there are no tendon reflexes and there are trophic disorders.

Differential diagnosis of paralysis of the upper limbs should be carried out with:

Fracture of the collarbone;

epiphysiolysis;

Osteomyelitis of the shoulder (in this case, there is swelling of the joint, crepitus, pain during passive movements in the area of ​​the shoulder joint; X-ray examination is necessary, in which by the 7-10th day of life an expansion of the joint space is detected, and subsequently - bone changes; in addition, there are symptoms, in the blood - neutrophilic leukocytosis with a shift to the left; sometimes a joint puncture is performed for diagnostic purposes);

Congenital hemihypoplasia (there is a craniofacial asymmetry with underdevelopment of half of the body and the same limbs).

In addition, traumatic injuries of the spinal cord must be differentiated from malformations of the spinal cord (lack of positive dynamics against the background of complex treatment); Marines-cou-Segren's syndrome (neurosonography or computed tomography is indicated to detect cerebellar atrophy and examination by an ophthalmologist in dynamics to detect cataracts); with congenital myopathies (minimal positive dynamics during treatment, electromyography and histological examination of biopsied muscles are decisive in the diagnosis); arthrogryposis, infantile myofibromatosis.

Treatment

If a birth injury of the spinal column and spinal cord is suspected, the first measure is the immobilization of the head and neck. This can be done with a cotton-gauze collar of the Shants type, and with an objective detection of fractures of the cervical vertebrae, subluxations and dislocations, by traction with a mask with a load of 150-330 g until the pain syndrome disappears (Fig. 10.2). A simple and effective method of immobilization, proposed by O.M. Yukhnova et al., has gained particular popularity. (1988), using an annular cotton-gauze bandage of the pelota type: measure the circumference of the child's head with a centimeter tape, make an annular cotton-gauze bandage (Fig. 10.3) so that its inner diameter is 2-3 cm less than the circumference of the head child. The head of the child is placed in this bandage, the neck is given a functionally advantageous position and the child is swaddled along with the bandage. This procedure is optimally done already in the delivery room. The term of immobilization is 10-14 days. Immobilization is also possible with the help of a vacuum mattress.

In order to relieve pain syndrome, 0.1 mg / kg 2-3 times a day is prescribed, and for severe pain - fentanyl 2-10 mcg / kg every 2-3 hours, morphine or promedol in the same dose as ( 0.1 mg/kg, although it can be increased to 0.2 mg/kg).

Vikasol is administered intramuscularly (if vitamin K was not administered at birth).

Gentle care is important, careful swaddling with the obligatory support of the head and neck of the child by the mother or nurse; feeding - from a bottle or through a probe until the pain syndrome is relieved and the child's condition stabilizes.

In the subacute period, treatment is prescribed aimed at normalizing the function of the central nervous system (nootropil,), improving trophic processes in muscle tissue (ATP, vitamins Bb Bl and from the end of the 2nd week - vitamin B)