Types of Birth Injuries That Can Occur During Labor and Delivery

Birth injuries affect thousands of families every year, bringing with them questions, concerns, and the immediate need for clear information. These injuries represent a spectrum of conditions that can occur before, during, or shortly after delivery. While some resolve quickly with minimal intervention, others carry lifelong implications that require ongoing care and support.

Understanding what different birth injuries look like, how they happen, and what they mean for the future makes a meaningful difference when navigating medical appointments, asking the right questions, and planning for what comes next.

What Counts as a Birth Injury

The term “birth injury” encompasses any physical harm to a baby that occurs during the labor and delivery process. These injuries differ from birth defects, which develop during pregnancy due to genetic or environmental factors. Birth injuries specifically result from mechanical forces, oxygen deprivation, or complications during the actual birth.

Currently, birth injuries occur in approximately 6 to 7 out of every 1,000 live births in the United States. That translates to roughly 29,000 to 30,000 babies annually. The encouraging news is that rates have been declining. Between 2004 and 2012, birth injury rates dropped 27%, from 2.6 per 1,000 births down to 1.9 per 1,000 births.

Male infants experience birth injuries more frequently than females, with rates of 6.9 per 1,000 births compared to 5.1 per 1,000 for female babies. This difference primarily stems from male babies typically having larger average birth weights and sizes, which can complicate delivery.

Brain Injuries From Oxygen Loss

Among birth injuries, those affecting the brain through oxygen deprivation are particularly significant because of their potential for lasting impact. The brain requires a constant supply of oxygen-rich blood. When that supply gets interrupted during birth, even briefly, damage can occur.

When the Brain Doesn’t Get Enough Oxygen

Hypoxic-ischemic encephalopathy, usually shortened to HIE, represents the most common type of brain damage occurring during childbirth. The term breaks down into understandable parts: “hypoxic” means not enough oxygen, “ischemic” means not enough blood flow, and “encephalopathy” means brain dysfunction.

HIE happens when something interrupts the baby’s oxygen or blood supply long enough to cause cell death in the brain. This can occur before labor begins, during delivery, or in the hours immediately after birth. The interruption triggers a cascade of events. First, when blood flow drops too low, cells don’t receive the oxygen they need and begin to die. Then, even after normal blood flow resumes, a second wave of injury can unfold over days or weeks as damaged cells release harmful chemicals.

Several situations can lead to HIE. Maternal high blood pressure, particularly preeclampsia, can affect blood flow to the placenta. Labor that goes on for an extended period may compromise oxygen delivery. Problems with the umbilical cord, whether it wraps around the baby’s neck or gets compressed, can cut off the oxygen supply. Issues with the placenta separating too early or respiratory failure in the baby after birth also create risk.

The severity of HIE depends largely on how long the oxygen deprivation lasted. Some babies receive prompt medical intervention, particularly therapeutic hypothermia treatment where the baby’s body temperature is carefully lowered for 72 hours, and go on to recover with few lasting effects. Others face long-term challenges including cerebral palsy, epilepsy, developmental delays, or cognitive impairments.

Damage to the Brain’s White Matter

Periventricular leukomalacia, or PVL, involves damage to the white matter of the brain near the fluid-filled spaces called ventricles. White matter consists of nerve fibers that transmit information between different brain regions and down to the spinal cord. When this tissue doesn’t receive adequate blood and oxygen, it can soften and die.

This injury primarily affects premature babies, especially those born before 30 weeks of pregnancy. The area around the ventricles is particularly vulnerable in preterm infants, with the highest risk period being before 32 weeks gestation.

When PVL damages the nerve cells responsible for controlling movement, those nerves can become spastic, meaning tight and resistant to normal motion. This damage is a major contributor to cerebral palsy in premature infants. Beyond movement problems, PVL can also cause vision difficulties and developmental delays.

Risk factors include bleeding into the ventricles, premature rupture of the membranes surrounding the baby, infections, low birth weight under 5 pounds 8 ounces, and HIE itself.

 Intracranial Hemorrhage and Bleeding Inside the Baby’s Skull

Intracranial hemorrhages are bleeding that occurs within the skull, and they come in several types depending on exactly where the bleeding happens. Each type has different implications and requires different responses.

Subdural hemorrhage is the most common form in newborns. This bleeding occurs between the brain and the dura, the tough outer membrane covering the brain. It typically results from tearing of veins that bridge this space or from tears in the tentorium, a membrane that separates parts of the brain.

Operative deliveries using forceps or vacuum extraction increase the risk for this type of hemorrhage. Signs that a subdural hemorrhage may be present include a soft spot that bulges outward, changes in consciousness, unusual irritability, difficulty breathing, slow heart rate, abnormal muscle tone, and seizures.

Sometimes subdural hemorrhages are discovered incidentally in babies who don’t show any symptoms. When symptoms do occur, treatment depends on the location and extent of bleeding. Extensive hemorrhages that increase pressure inside the skull may require surgical removal of the blood.

Epidural hemorrhage is rare in newborns, accounting for only 2% of intracranial bleeding. This type occurs between the skull bone and the dura. It typically happens alongside linear skull fractures, particularly in the parietal and temporal regions of the head, and associates with instrument-assisted deliveries.

Signs include a bulging soft spot, slow heart rate, low blood pressure, irritability, altered consciousness, decreased muscle tone, and seizures. On CT or MRI scans, epidural hemorrhages appear as a convex collection of blood in the epidural space. Because babies can deteriorate rapidly with this injury, prompt neurosurgical consultation is essential.

Subarachnoid hemorrhage is the second most common type of intracranial bleeding in newborns. This bleeding occurs in the space between the arachnoid membrane and the brain itself. It usually results from rupture of bridging veins in this space.

Operative vaginal deliveries with forceps or vacuum increase risk for subarachnoid hemorrhage. Most affected infants show no symptoms unless the bleeding is extensive. Treatment typically involves observation rather than intervention, though rarely, bleeding from a ruptured vascular malformation requires more aggressive treatment.

Intraventricular hemorrhage, or IVH, occurs most commonly in premature infants, particularly those born before 33 weeks. This bleeding happens when tiny vessels in an area called the germinal matrix rupture, causing blood to flow into the brain’s ventricles.

Among extremely premature infants weighing between 500 and 750 grams (about 1.1 to 1.7 pounds), IVH occurs in approximately 45% of cases. Fortunately, the incidence in very low birth weight infants overall has declined from 40-50% in the early 1980s to about 20% by the late 1980s.

IVH is graded on a scale from I to IV based on severity. Grade I means bleeding is limited to the germinal matrix area where it originated. Grade II indicates blood has entered the ventricles but hasn’t enlarged them. Grade III involves ventricles enlarged by accumulated blood. Grade IV represents the most serious form, with bleeding extending into the brain tissue surrounding the ventricles.

Grades I and II are most common and often resolve without further complications. Grades III and IV are more serious and may result in long-term brain injury. One particular concern with more severe IVH is hydrocephalus, a condition where fluid accumulates in the brain because the blood blocks normal drainage pathways.

Perinatal Stroke in Newborns During or After Birth

Perinatal arterial ischemic stroke, or PAIS, occurs when a blood vessel supplying the brain becomes blocked, cutting off oxygen to a specific brain region. This happens in approximately 1 out of every 4,000 live births.

About 70% of newborns with PAIS have focal clonic seizures, which means rhythmic jerking limited to one side of the body or one limb. These seizures typically appear within the first week after birth.

The causes of PAIS involve a complex mix of maternal, placental, and newborn factors. Maternal conditions that increase risk include preeclampsia, gestational diabetes, infertility treatment, being a first-time mother, and fever or infection of the amniotic sac. During labor and delivery, abnormal fetal heart rate patterns, vacuum or forceps use, and emergency cesarean section elevate risk. Newborn factors include poor growth in the womb, meconium staining, being male, and blood clotting disorders.

The blocked blood vessel is most commonly in the middle cerebral artery distribution, the area supplying much of the outer brain surface. When low blood pressure is also present, strokes may occur in “watershed” zones where blood supply from different arteries overlaps.

Because recurrence is rare and the risk factors typically relate to the pregnancy itself rather than ongoing conditions, anticoagulation or antiplatelet medications are usually not recommended. While most newborns with PAIS don’t develop epilepsy, long-term motor, cognitive, and behavioral challenges can follow. Early recognition and therapy initiation make a difference in outcomes.

Scalp and Skull Injuries That Happen During Delivery

The baby’s head bears the brunt of mechanical forces during delivery. Several different types of injuries can affect the scalp and skull, ranging from minor swelling that resolves quickly to serious conditions requiring immediate attention.

Cephalohematoma

A cephalohematoma is a collection of blood between the baby’s skull bone and the periosteum, the membrane that covers the bone. Unlike other types of swelling, this develops gradually as small blood vessels crossing the thin tissues rupture. Signs may not become clear until hours or even days after birth.

Pressure during childbirth causes cephalohematomas, particularly when assisted delivery devices like forceps or vacuum extractors are used. The defining characteristic of a cephalohematoma is that it doesn’t cross suture lines, the fibrous joints between skull bones. This happens because the periosteum attaches firmly at the sutures, confining the blood collection to the area above a single bone.

A cephalohematoma feels firm rather than soft, and pressing on it won’t leave an indentation. It appears as a raised lump or bulge on the baby’s head. Unlike some scalp swellings that resolve quickly, cephalohematomas typically take weeks to months to fully disappear as the body gradually reabsorbs the collected blood.

The main complication to watch for is jaundice. As the collected blood breaks down, it releases bilirubin, which can cause yellowing of the skin and eyes. In rare cases, the blood collection can become infected, or there may be an underlying skull fracture that requires evaluation.

Caput Succedaneum

Caput succedaneum refers to swelling in the soft tissues of the scalp itself, above the periosteum. This swelling results from pressure on the baby’s head, particularly during prolonged vaginal delivery or when assisted delivery devices are used. Fluid accumulates in the scalp tissues, creating noticeable puffiness.

Unlike cephalohematoma, caput succedaneum crosses suture lines freely because the swelling is in the scalp tissue rather than under the periosteum. When you press on this type of swelling, it feels soft and may hold an indentation briefly. The swelling extends over the midline of the head rather than staying confined to one area.

Caput succedaneum typically resolves within a few days without any treatment, making it more benign than other birth injuries. However, if significant fluid has accumulated, the breakdown of red blood cells in that fluid can contribute to jaundice.

Subgaleal Hemorrhage

Subgaleal hemorrhage represents one of the most serious scalp injuries that can occur during birth. This bleeding happens in a potential space between two layers of the scalp: the epicranial aponeurosis below and the periosteum closer to the skull.

What makes this space particularly dangerous is its size. It extends forward to the margins around the eyes, backward to the ridge at the base of the skull, and sideways to the temporal fascia above the ears. In a full-term infant, this space can hold 40 to 260 milliliters of blood, which represents a significant portion of a newborn’s total blood volume.

Subgaleal hemorrhage occurs in approximately 0.04% of spontaneous vaginal deliveries but rises to 0.59% of vacuum-assisted deliveries. Forceps deliveries also carry increased risk. The injury occurs when shearing forces applied to the scalp during delivery rupture the emissary veins that bridge this space.

The mortality rate for subgaleal hemorrhage is concerning at 22.8%. Death typically results from hypovolemic shock, meaning the baby loses so much blood volume that the circulatory system can’t maintain adequate blood pressure and organ perfusion. Newborns can lose 50-70% of their circulating blood volume into this space.

Warning signs of subgaleal hemorrhage include swelling of the scalp that feels fluctuant, meaning it moves like fluid when touched. The swelling crosses suture lines and may extend over the entire head and in front of the ears, with pitting edema where finger pressure leaves an indentation. When the infant is repositioned, the fluid may visibly shift. Signs of blood loss include pallor, low blood pressure, and rapid heart rate.

The average time to diagnosis is 1 to 6 hours after birth, making careful observation during this period crucial. Babies who survive may face lasting neurological conditions including seizure disorders, developmental delays, and cerebral palsy.

Skull Fractures That Can Occur During Difficult Deliveries

While skull fractures are rare in connection with birth, they do occasionally occur, most commonly with instrument-assisted delivery or cesarean section when the baby’s head is wedged deeply into the maternal pelvis. Three types can occur during birth.

Linear fractures are cracks in the skull bone that don’t create a depression. They most commonly involve the parietal bone on the side of the head or the frontal bone forming the forehead. A cephalohematoma may overlie the fracture site. These fractures typically don’t cause symptoms and heal within 2 to 6 months. If the fracture creates a depression, often from forceps, there may be bleeding inside the skull that requires monitoring.

Ping-pong ball deformation isn’t actually a fracture because the bone maintains its continuity. Instead, the outer table of the skull becomes depressed inward, creating a concavity usually in the parietal bone and less commonly in the frontal bone. This most often happens with forceps deliveries. The depression usually elevates spontaneously within three months unless it exceeds 2 centimeters in depth.

Occipital osteodiastasis is uncommon but severe. This injury involves separation of the cartilaginous joint between different portions of the occipital bone at the base of the skull. It occurs especially with hyperextension of the baby’s head, pressure against the maternal pubic bone, forceps use, and breech positioning.

The mechanism involves the front portion of the occipital bone being pushed forward and upward, tearing bridging veins and potentially causing subdural hemorrhage, cerebellar injury, or compression of the brainstem region. The mortality rate is very high with this injury.

Nerve Injuries That Affect Movement After Birth

Nerves can be stretched, compressed, or torn during delivery, particularly when difficult births require significant manipulation to deliver the baby. These injuries affect the baby’s ability to move certain body parts and, depending on severity, may or may not fully resolve.

Brachial Plexus Injuries and Erb’s Palsy Affecting the Arm

The brachial plexus is a network of nerves originating from the spinal cord in the neck and traveling down the arm, controlling movement and sensation in the shoulder, arm, and hand. Brachial plexus injuries affect approximately 2.6 out of every 1,000 full-term live births, or about 1 in 385.

The classic obstetric brachial plexus injury is Erb’s palsy, which is more common than Klumpke’s palsy or facial nerve injury. The injury occurs when excessive widening of the angle between the head and shoulder stretches or tears the nerve roots. When upper roots of the plexus are damaged, it causes Erb’s palsy. When lower roots are affected through abduction and backward rotation, it causes Klumpke’s palsy. In rare cases, the entire plexus from C5 to T1 can be injured, resulting in total arm paralysis.

Nerve injuries range in severity. Neuropraxia involves bruising or compression of the nerve without structural damage. Axonotmesis means the nerve fibers are damaged but the nerve sheath remains intact. The most severe injuries involve root avulsion, where the nerve root tears completely away from the spinal cord.

Shoulder dystocia and vaginal breech delivery strongly associate with brachial plexus injuries. Other risk factors include babies weighing over 8 pounds 13 ounces (macrosomia), mothers who have had multiple previous pregnancies, having previously delivered a baby with brachial plexus injury, vacuum and forceps use, excessive maternal weight gain during pregnancy, maternal diabetes, and maternal obesity.

Common symptoms include lack of muscle control in the elbow, wrist, or hand on the affected side. The baby may have less sensation in that limb and show paralysis or weakness, often holding the arm in a characteristic position against the body.

If the nerve was only bruised, movement typically returns within a few months. Tearing of the nerve may result in permanent damage. During healing, special exercises help maintain range of motion and prevent the joints from becoming stiff. Research indicates that approximately 80% to 96% of babies with Erb’s palsy achieve significant recovery, though this depends on the severity of the initial injury.

Facial Nerve Palsy and Facial Weakness After Forceps Delivery

The facial nerve, the seventh cranial nerve, controls movement of the facial muscles. Facial nerve palsy occurs when this nerve is injured due to pressure during delivery, particularly from forceps pressing against the nerve as it exits the skull.

This injury occurs in approximately 1.8 out of every 1,000 births. Notably, 91% of facial nerve palsies are associated with forceps delivery, even though forceps are used in only about 19% of all deliveries. Other risk factors include babies weighing 3,500 grams (about 7 pounds 11 ounces) or more and first-time mothers.

The lower part of the facial nerve is most commonly affected. The hallmark sign is asymmetric crying facies, where the mouth doesn’t pull down the same way on both sides when the baby cries. On the affected side, there’s no movement, creating an uneven appearance. The baby may be unable to close the eyelid completely on that side, which requires eye lubrication to prevent corneal damage.

The prognosis for facial nerve palsy is generally good, with 89% of patients achieving complete recovery. Most cases resolve spontaneously as the nerve heals, though recovery time varies from days to months. If the nerve was torn rather than bruised, surgery may be needed to repair it.

Broken Bones and Fractures During Birth

Bones can fracture during birth, particularly when the baby is large or when difficult deliveries require significant force or manipulation. The most commonly fractured bone is the clavicle.

Broken Collarbone (Clavicle Fractures) During Delivery

The clavicle, or collarbone, is the most frequently broken bone during birth, with fractures occurring in approximately 2.0 out of every 1,000 full-term live births, or about 1 in 495 babies. Reported rates across different studies range from 0.2% to 4.4%.

The exact mechanism isn’t completely understood, but fractures are thought to occur when the baby’s shoulder compresses against the mother’s pubic bone during delivery or when maneuvers to relieve shoulder dystocia apply force to the clavicle.

Risk factors identified through statistical analysis include spontaneous vaginal delivery (interestingly, cesarean deliveries have lower rates), prolonged second stage of labor, head-first presentation, vitamin D deficiency in mothers, higher birth weight, and macrosomia.

The main symptom is that the baby won’t move the arm on the affected side, instead holding it still against the body. Lifting the baby under the arms causes pain, and the baby may cry when that arm is moved.

The long-term outlook is very good. Clavicle fractures heal without complications in the vast majority of cases. Treatment typically involves no intervention other than gentle handling to minimize discomfort. Sometimes the arm on the affected side is pinned gently to the baby’s clothing to reduce movement. Within a few weeks, a hard lump develops at the fracture site where healing bone forms a callus. This lump may be the only lasting sign that a fracture occurred, though it typically becomes less prominent over time.

Most neonatal clavicle fractures are considered unavoidable complications of labor rather than evidence of negligence, with overall excellent prognosis.

Birth Complications When Delivery Becomes Difficult

Sometimes the physical realities of delivering a baby through the birth canal create situations where injury becomes more likely. Understanding these complicating factors helps explain why certain injuries occur.

Shoulder Dystocia

Shoulder dystocia is defined as a delivery requiring additional obstetric maneuvers to release the baby’s shoulders after gentle downward traction has failed. In other words, the baby’s head delivers, but the shoulders get stuck behind the mother’s pubic bone, and standard delivery techniques aren’t enough to complete the birth.

This complication occurs in 0.3% to 3% of all vaginal deliveries. The underlying problem is that the baby’s shoulders enter the pelvic inlet in an anterior-posterior position, aligned with the long axis of the pelvis, rather than rotating to fit through the narrowest diameter. Sometimes both shoulders try to enter the pelvis simultaneously rather than one at a time.

An important warning sign is the “turtle sign.” If the baby’s head retracts back toward the birth canal after it delivers, this indicates the shoulders are lodged and unable to follow.

Risk factors include maternal diabetes, having experienced shoulder dystocia in a previous delivery, and fetal macrosomia. Maternal diabetes causes elevated glucose levels in the baby, stimulating excess insulin production. This can result in large for gestational age infants who have disproportionately larger shoulders and increased abdominal-to-head circumference ratios compared to babies of similar weight born to mothers without diabetes.

Despite these known risk factors, the majority of shoulder dystocia cases occur in mothers without diabetes delivering average-size babies, making prediction difficult.

Shoulder dystocia creates urgency because the baby’s body remains in the birth canal while the delivered head compresses the umbilical cord against the pelvis. This cuts off oxygen supply, and the longer the dystocia lasts, the greater the risk of hypoxic brain injury.

Complications that can result from shoulder dystocia include brachial plexus injuries, clavicle fractures, facial nerve injuries, and brain damage from oxygen deprivation. The first therapeutic maneuver should be the McRoberts maneuver, where assistants flex the mother’s thighs up toward her chest, which changes the angle of the pelvis and often allows the shoulders to release.

Injuries From Vacuum Extraction and Forceps Assisted Delivery

Approximately 5% of deliveries are operative vaginal deliveries using vacuum extraction or forceps. These tools help complete delivery when labor isn’t progressing, when the mother can’t push effectively, or when the baby needs to be delivered quickly due to distress.

The rate of birth trauma with these methods is 2.45 per 1,000 births for significant injuries and 25.85 per 1,000 births when all trauma codes are included. These rates are higher than for spontaneous vaginal delivery but lower than for some specific injury types that occur more commonly with cesarean delivery.

Vacuum extraction uses a soft cup attached to the baby’s head with suction. Gentle traction during contractions helps guide the baby through the birth canal. Complications can include brain bleeds (intracranial hemorrhage), cephalohematoma, subgaleal hemorrhage (which occurs in 0.59% of vacuum-assisted deliveries), retinal injuries, brachial plexus injuries, scalp lacerations, and skull fractures.

Forceps are curved metal instruments that fit around the baby’s head, allowing the provider to guide the baby through the birth canal with traction. Forceps complications include facial palsy from pressure on the facial nerve, brain damage if excessive force is applied, skull fractures, scarring where the forceps blades pressed against the skin, bleeding inside the skull, and brachial plexus injuries.

Risk factors that increase complications with assisted delivery include the baby’s head being too high in the birth canal when instruments are applied, bleeding disorders or bone problems in the baby, early labor before 34 weeks when the skull is softer and more vulnerable, unclear head position making proper instrument placement difficult, and large baby size.

When used appropriately by experienced providers, vacuum extraction and forceps are valuable tools that can prevent the need for cesarean delivery or expedite birth when time is critical. However, proper monitoring, accurate diagnosis of the situation, and prompt treatment of any complications are essential to reduce the risk of lasting injuries.

Umbilical Cord Problems That Can Cause Birth Injuries

The umbilical cord is the baby’s lifeline, supplying oxygen and nutrients throughout pregnancy and during labor. When something goes wrong with the cord during delivery, the consequences can be serious.

Nuchal Cord

A nuchal cord occurs when the umbilical cord wraps one or more times around the baby’s neck. This is relatively common, happening in 15-34% of pregnancies. Most nuchal cords are loose and cause no problems during delivery.

Tightly wrapped nuchal cords are concerning because they can compress against themselves or against the baby’s neck, potentially cutting off oxygen supply. The cord can also get stretched or torn during delivery if it’s wrapped too tightly, disrupting blood flow.

In many instances, the cord is loose enough to allow normal delivery, or the provider can unwrap it once the head delivers. Sometimes the cord can be clamped and cut before the shoulders deliver if it’s too tight to unwrap safely.

Umbilical Cord Prolapse

Prolapsed umbilical cords occur in about 1 in 300 to 1 in 1,000 births. This represents a true medical emergency. A cord prolapse happens when the cord comes through the cervix before the baby, often when membranes rupture and a gush of fluid carries the cord downward.

Once prolapsed, the cord gets compressed by the baby’s body as the baby descends during delivery. This compression cuts off oxygen supply, leading to fetal hypoxia and bradycardia (slow heart rate), which can result in death or permanent disability if not immediately addressed.

Over half of cord prolapses occur within five minutes after membranes rupture. Up to 70% occur within one hour of water breaking, making this early period particularly critical for monitoring.

Complications from umbilical cord prolapse include neonatal encephalopathy (brain dysfunction) and cerebral palsy secondary to lack of oxygen. When a cord prolapse is diagnosed, emergent obstetric consultation and immediate delivery, typically via emergency cesarean section, are necessary. Every minute counts in preventing lasting harm.

True Knots in the Umbilical Cord During Pregnancy

True knots in the umbilical cord form from the baby’s natural movement and repositioning within the womb. The baby somersaults through the cord loop, creating an actual knot. Risk factors include excess amniotic fluid (polyhydramnios), gestational diabetes, and unusually long umbilical cords.

A true knot can tighten during labor as the baby descends, compressing the blood vessels within the cord. This compromises the baby’s supply of blood, oxygen, and nutrients. Depending on when and how severely the knot tightens, consequences can include poor fetal development, fetal distress during labor, and brain damage from oxygen deprivation.

Most true knots are discovered only after delivery when the cord is examined. They can’t be reliably detected before birth and are generally considered unpreventable.

Birth Injuries Caused by Lack of Oxygen

Several specific conditions result from interruption of oxygen supply to the baby. These conditions are distinct from HIE but share the common feature of hypoxia affecting the baby’s body systems.

Birth Asphyxia

Birth asphyxia occurs when blood flow or gas exchange to or from the baby is disrupted immediately before, during, or after birth. This affects approximately 2 out of every 1,000 newborns in developed countries, with rates ten times higher in developing countries where access to emergency obstetric care is limited.

Up to 20% of birth asphyxia cases are fatal, and 25% of newborns who survive experience permanent neurological damage. These statistics underscore why prevention and rapid treatment are so critical.

Birth asphyxia generally results from interruption of placental blood flow, leading to fetal hypoxia (low oxygen), hypercarbia (too much carbon dioxide), and acidosis (increased acidity in the blood). The injury unfolds in two stages. The first happens within minutes if blood flow drops and cells don’t receive enough oxygen. The second stage, called reperfusion injury, can last for days or weeks. During this phase, damaged cells release harmful chemicals even after blood and oxygen levels return to normal, causing additional injury.

Numerous situations can cause birth asphyxia: placental abruption where the placenta separates from the uterine wall prematurely, problems with the umbilical cord including compression or prolapse, uterine rupture, maternal oxygen deprivation from respiratory or cardiac problems, hemorrhaging during birth, prolonged or difficult delivery, and the baby getting stuck during delivery.

Currently, whole-body cooling, known as therapeutic hypothermia, is the only treatment proven to improve outcomes for babies born after 35 weeks’ gestation who have moderate or severe HIE. This treatment involves carefully controlling the baby’s body temperature at about 33.5°C (92.3°F) for 72 hours, starting within six hours of birth. Cooling slows down the secondary phase of injury, giving the brain time to recover.

Meconium Aspiration Syndrome

Meconium is the thick, dark first stool that babies produce, consisting of materials ingested in the womb. Normally, babies pass meconium after birth. However, when babies experience stress in the womb, particularly from low oxygen levels, they may pass meconium before birth. The amniotic fluid becomes stained green or brown.

If the baby gasps or takes breaths before delivery or immediately after while the airway still contains meconium-stained fluid, the thick substance can be aspirated into the lungs. This happens in 4-9% of infants born through meconium-stained amniotic fluid, a condition called meconium aspiration syndrome or MAS.

Affected infants are frequently small for gestational age or post-term, born beyond 41 weeks. Passage of meconium typically indicates the baby has experienced stress or low oxygen at some point.

When aspirated, meconium affects the lungs through three mechanisms. First, it causes airway obstruction. Complete blockage results in collapse of the lung area beyond the obstruction, a condition called atelectasis. Partial blockage creates a ball-valve effect where air can enter on inspiration but can’t fully exit on expiration, leading to hyperinflation and possibly air leaks with pneumothorax (collapsed lung) or pneumomediastinum (air in the chest cavity). On chest X-rays, this creates a characteristic “salt and pepper” appearance with areas of hyperinflation surrounded by atelectasis.

Second, meconium causes inflammation and chemical pneumonitis. The substances in meconium trigger an inflammatory response in the delicate lung tissue. Third, meconium interferes with surfactant, the substance that keeps air sacs open. Without functioning surfactant, breathing becomes much more difficult.

Clinical features of MAS include rapid breathing, flaring of the nostrils, retractions where the skin pulls in between ribs or above the collarbone with each breath, blue discoloration or low oxygen saturation, and abnormal lung sounds. Greenish-yellow staining of the umbilical cord, nail beds, or skin indicates the baby was exposed to meconium for an extended period before birth.

Treatment consists primarily of respiratory support. Some babies require mechanical ventilation. Those with the most severe cases may need extracorporeal membrane oxygenation, or ECMO, where the baby’s blood is circulated through an external machine that adds oxygen and removes carbon dioxide, essentially doing the work of the lungs until they recover.

Bacterial Infections That Can Cause Birth Injuries

Infections around the time of birth can lead to serious complications, particularly when bacteria reach the bloodstream or nervous system.

Neonatal Meningitis and Sepsis Infections in Newborns

Neonatal bacterial meningitis occurs in approximately 3 per 10,000 full-term infants and 1 per 1,000 low-birth-weight neonates. The risk is greater in babies who have sepsis, a bloodstream infection. The incidence has declined substantially due to prevention strategies for early-onset group B streptococcal disease, primarily through screening pregnant women and giving antibiotics during labor when indicated.

Group B streptococcus remains the most common cause of neonatal meningitis, responsible for more than 40% of all early-onset infections. Escherichia coli (E. coli) is the second most common cause, followed by Listeria monocytogenes.

The immature immune system of newborns, especially those born prematurely, creates high susceptibility to bacterial infections. Despite advances in preventive care and treatment, bacterial meningitis continues to have an adverse outcome rate of 20-60% among survivors. There’s a 50% rate of neurodevelopmental disabilities after meningitis caused by E. coli and Streptococcus agalactiae, rising to 79% after meningitis caused by other Gram-negative bacteria.

Signs of meningitis include those of sepsis (temperature instability, poor feeding, lethargy, irritability), central nervous system irritation (seizures, vomiting, extreme sleepiness), and cranial nerve problems. Physical findings may include a stiff neck, bulging fontanelle (the soft spot on the head), and abnormal muscle tone.

Diagnosis requires lumbar puncture to examine the cerebrospinal fluid surrounding the brain and spinal cord. Treatment is with intravenous antibiotics, typically starting with broad-spectrum coverage before specific bacteria are identified, then adjusting based on culture results.

Delayed treatment can cause cerebral palsy, blindness, deafness, seizure disorders, and learning disabilities. Early-onset neonatal sepsis is associated with approximately double the risk of childhood epilepsy compared to infants without sepsis.

Metabolic Problems That Can Cause Brain Damage in Newborns

Certain metabolic imbalances in newborns can lead to injury if not promptly identified and treated.

Kernicterus Brain Damage From Severe Jaundice

Kernicterus, also called bilirubin encephalopathy, is brain damage caused by very high levels of unconjugated bilirubin in the blood. This occurs when bilirubin levels rise above 25 mg/dL, though damage can occur at lower levels in premature infants or those with other risk factors.

Bilirubin is a yellow pigment produced when red blood cells break down. Normally, the liver processes bilirubin and excretes it. Newborns often have mild jaundice as their livers mature and learn to process bilirubin efficiently. However, when levels rise too high, unconjugated bilirubin, which is fat-soluble, can cross the blood-brain barrier and deposit in brain tissue.

The regions most commonly affected include the basal ganglia deep within the brain, the hippocampus involved in memory, geniculate bodies in the sensory pathways, brainstem nuclei controlling eye movement and balance, and the cerebellum coordinating movement.

Kernicterus develops when serum bilirubin concentration is markedly elevated, serum albumin concentration is markedly low (albumin normally binds bilirubin in the blood), or when certain medications or substances displace bilirubin from albumin, allowing more to cross into the brain.

While rare in developed countries due to routine bilirubin screening and treatment, kernicterus can result in intellectual disability, choreoathetoid cerebral palsy characterized by involuntary movements, sensorineural hearing loss, and paralysis of upward gaze later in childhood.

The condition progresses through stages. Early symptoms include lethargy, poor feeding, vomiting, absent startle reflex, and extreme sleepiness. The middle stage brings high-pitched cry, irritability, arching of the back with the neck hyperextended backward, and continued poor feeding. The late stage involves stupor or coma, inability to feed, shrill cry, muscle rigidity, and seizures.

There is no treatment once chronic bilirubin encephalopathy develops. Prevention is key and involves treating hyperbilirubinemia before it reaches dangerous levels. Treatment options include phototherapy, where special blue lights break down bilirubin in the skin, and exchange transfusion for severe cases, where the baby’s blood is gradually replaced with donor blood to rapidly lower bilirubin levels.

 Seizures in Newborns

Seizures in newborns occur in 1-3 per 1,000 infants born at term. The most common underlying cause is hypoxic-ischemic injury, which may occur before, during, or after delivery. Other causes include ischemic stroke, intracranial hemorrhage, infections such as meningitis or encephalitis, brain tumors or malformations, and metabolic disorders including low blood sugar (hypoglycemia), low calcium (hypocalcemia), or low sodium (hyponatremia).

The most common diagnosis in neonates with seizures is hypoxic-ischemic encephalopathy, accounting for 23.9% of cases, followed by hypoglycemia at 10.22%.

Neonatal seizures can be difficult to recognize because they often appear subtle compared to seizures in older children or adults. Symptoms may include uncontrolled jerking motions of the arms or legs, muscles suddenly becoming stiff, both legs jerking up toward the belly, upper body jerking forward, sudden unexplained grimacing, and rapid changes in breathing or heart rate.

Focal clonic seizure, rhythmic jerking limited to one side or one limb, is the most common clinical presentation of perinatal arterial ischemic stroke. When babies with neonatal hypoxia are treated with therapeutic hypothermia, seizures may initially be less severe but can recur during the rewarming process.

The mortality rate among babies with neonatal seizures is 11.36% during follow-up. Neurodevelopmental assessments show 64% have normal development, 27% have global developmental delay, and 9% have motor delay as their primary issue.

Birth Injuries and Complications in Premature Babies

Babies born prematurely face unique vulnerabilities that increase their risk for certain types of injuries and complications.

Medical Complications Premature Babies Face After Birth

Premature birth is associated with numerous long-term complications across multiple organ systems. Prematurity increases the likelihood of respiratory distress syndrome, cerebral palsy, and developmental abnormalities.

Long-term complications can include cerebral palsy due to brain infection, poor blood flow, or injury; learning disabilities; vision problems including retinopathy of prematurity where abnormal blood vessels grow in the retina; hearing loss; dental problems affecting both baby and permanent teeth; behavioral and mental health challenges; and ongoing health issues that may persist throughout childhood.

Preterm infants frequently experience respiratory distress syndrome when their lungs are underdeveloped and unable to produce enough surfactant, the substance that keeps air sacs open. Without adequate surfactant, breathing requires tremendous effort and the baby may not maintain adequate oxygen levels.

Necrotizing enterocolitis, which causes inflammation and damage to the intestines, affects premature infants more commonly than term babies. The intestinal wall can become so damaged that perforation occurs, allowing intestinal contents to leak into the abdominal cavity. This can lead to sepsis.

Preterm infants have higher risk for intraventricular hemorrhage, bleeding into the brain’s ventricles, which can result in lasting neurological complications including hydrocephalus and cerebral palsy.

Compared to term-born infants, preterm infants are more likely to develop cognitive deficits that continue through adolescence and adulthood. The earlier the birth and the lower the birth weight, the greater the risk for these long-term challenges.

Hydrocephalus

Hydrocephalus involves accumulation of cerebrospinal fluid within the brain’s ventricles, causing them to enlarge and potentially increase pressure inside the skull. The condition can be congenital, present from birth, or acquired, developing after birth.

Congenital hydrocephalus results from a complex interaction of genetic and environmental factors during fetal development. The most common cause is aqueductal stenosis, an obstruction of the narrow passageway connecting the third and fourth ventricles. This obstruction may result from infection, hemorrhage, or tumor. Other causes include neural tube defects such as myelomeningocele or spina bifida, arachnoid cysts, X-linked genetic mutations, and genetic disorders like Dandy-Walker malformation where parts of the cerebellum don’t develop properly.

Acquired hydrocephalus develops after birth from conditions such as head trauma, brain tumor, cyst, intraventricular hemorrhage, or infection. When small blood vessels along the ventricular lining rupture in premature newborns, blood can block or scar the ventricles or plug the arachnoid villi, the structures that normally absorb cerebrospinal fluid. When absorption is impaired, fluid accumulates.

Meningitis can scar the delicate membranes lining the cerebrospinal fluid pathway, obstructing normal flow. The fluid then backs up, enlarging the ventricles.

Signs of hydrocephalus in infants include rapidly increasing head circumference, bulging fontanelle, prominent scalp veins, eyes that gaze downward (called sunsetting), irritability, poor feeding, and vomiting.

Treatment typically involves surgical placement of a shunt, a thin tube that drains excess fluid from the ventricles to another part of the body where it can be absorbed, usually the abdominal cavity. Some cases may be treated with endoscopic third ventriculostomy, where a small hole is made in the floor of the third ventricle to allow fluid to bypass the obstruction.

Pregnancy Complications That Can Lead to Birth Injuries

Certain complications that occur during pregnancy can significantly impact the baby’s wellbeing and increase injury risk.

Placental Abruption

Placental abruption occurs when the placenta separates from the uterine wall before delivery. This results in increased risk of low birth weight, preterm delivery, stillbirth, and death around the time of birth.

The risk of stillbirth increases dramatically with severe placental separation. When 50% or more of the placenta separates, the adjusted risk of stillbirth is 31.5 times higher than normal. However, even lesser degrees of separation cause problems. With 25% placental separation, the risk of preterm delivery is 5.5 times higher.

For the baby, placental abruption can lead to restricted growth from not receiving enough nutrients, oxygen deprivation as the separating placenta can’t exchange gases effectively, premature birth as abruption often triggers labor, and stillbirth in severe cases.

Babies can suffer brain injuries from oxygen deprivation when placental abruption is present. The degree of injury depends on how much of the placenta has separated and how quickly delivery occurs after the abruption.

For the mother, complications include shock from blood loss, blood clotting problems as substances released from the separating placenta activate the clotting system, possible need for blood transfusion, kidney or other organ failure if blood loss is severe, and rarely the need for hysterectomy.

Medical Risk Factors That Increase the Chance of Birth Injuries

Understanding what increases the likelihood of birth injuries helps with prevention and early recognition. Risk factors fall into several categories.

Maternal Health Conditions That Increase Birth Injury Risk

Nulliparity, meaning this is the mother’s first pregnancy and birth, increases risk for several types of birth injuries. First-time mothers have a longer average labor, and the baby must navigate a birth canal that has never stretched to accommodate a baby before.

Maternal obesity increases risk through several mechanisms. Larger maternal size can make it more difficult to accurately assess the baby’s size and position. Obesity associates with larger babies and with complications like gestational diabetes.

Maternal diabetes, whether pre-existing or gestational, increases the baby’s risk of being large for gestational age with disproportionate growth patterns. The shoulders and body may be larger relative to the head, increasing difficulty during delivery.

Preeclampsia and gestational hypertension can affect blood flow to the placenta, potentially limiting oxygen delivery to the baby. These conditions also increase risk for placental abruption.

Maternal fever and chorioamnionitis, infection of the membranes surrounding the baby, increase risk for neonatal infection and are associated with increased risk of cerebral palsy.

Prolonged rupture of membranes increases infection risk. Advanced maternal age and inadequate prenatal care also elevate risk through various mechanisms.

Baby Size and Position Factors That Increase Injury Risk

Macrosomia, defined as birth weight over 4,000 grams (8 pounds 13 ounces), is one of the strongest risk factors for birth injuries. Larger babies have more difficulty navigating the birth canal, increasing risk for shoulder dystocia, brachial plexus injuries, and clavicle fractures.

Prematurity, especially birth before 34 weeks gestation, creates vulnerability. The premature infant’s skull bones are softer and more susceptible to pressure injuries. Blood vessels in the brain are more fragile, increasing risk for intracranial hemorrhage. Lungs may be immature, increasing risk for respiratory distress.

Multiple gestation increases risk for prematurity, abnormal positioning, and complications during delivery. Abnormal fetal positioning, including breech (feet or bottom first) and transverse (sideways), increases delivery difficulty and injury risk.

Intrauterine growth restriction, where the baby hasn’t grown as expected, can indicate placental insufficiency. These babies may have less reserve to tolerate labor stress.

Male sex is associated with higher birth injury rates, primarily because male babies on average are larger than female babies.

Post-term pregnancy, continuing beyond 41 weeks, increases risk as babies continue growing and the placenta may function less efficiently.

Labor and Delivery Complications That Increase Birth Injury Risk

Prolonged labor, particularly a second stage exceeding 60 minutes, increases risk for multiple types of injuries. The longer the baby is compressed in the birth canal, the greater the potential for nerve compression, bleeding, and oxygen deprivation.

Precipitous delivery, an extremely rapid birth, can also cause injury as the baby’s head doesn’t have time to gradually mold to the birth canal.

Shoulder dystocia is both a complication itself and a risk factor for specific injuries including brachial plexus palsy, clavicle fractures, and hypoxic brain injury.

Operative vaginal delivery using forceps or vacuum extraction increases risk for scalp injuries, intracranial hemorrhage, facial nerve palsy, and other trauma.

Fetal distress and abnormal heart rate patterns indicate the baby is not tolerating labor well, often due to insufficient oxygen. When these warning signs aren’t recognized and addressed promptly, injury can result.

Emergency cesarean section, particularly when performed after prolonged labor or when the baby’s head is deeply wedged in the pelvis, carries its own set of risks including lacerations and skull fractures.

Thick meconium in the amniotic fluid indicates fetal stress and increases risk for meconium aspiration syndrome.

How Location and Demographics Affect Birth Injury Rates

Interestingly, where you deliver matters. Rural areas experience 33% higher birth injury rates compared to large metropolitan areas. This likely reflects differences in immediate access to specialists, equipment, and interventions when complications arise.

The Northeast United States demonstrates 24-32% higher birth injury rates than other regions. The reasons for regional variations are complex and may involve differences in practice patterns, patient populations, and other factors.

Race and ethnicity also play a role in birth injury rates, with Asian ethnicity showing increased rates for certain types of injuries. These differences may reflect variations in average baby size, pelvic anatomy, and other factors.

Understanding Your Baby’s Birth Injury and the Next Steps

Birth injuries represent a spectrum from minor conditions that resolve without lasting effects to severe injuries requiring lifelong care. The declining rates over the past decades reflect improvements in prenatal care, labor monitoring, and delivery practices.

Understanding the types of birth injuries, their warning signs, and their risk factors empowers better conversations with healthcare providers, more informed decision-making, and appropriate action when concerns arise.

Many birth injuries are unavoidable complications of labor rather than preventable events. However, prompt recognition, accurate diagnosis, and immediate appropriate treatment make meaningful differences in outcomes. When providers fail to recognize risk factors, don’t respond appropriately to warning signs, or make errors in judgment or technique, preventable injuries can occur.

The information here provides a foundation for understanding what different birth injuries are, how they happen, and what they mean for the baby. Each baby’s situation is unique, and outcomes depend on many factors including the severity of the initial injury, how quickly treatment begins, and the quality of ongoing care and therapy.