Unusual birth trauma involving face: a completely preventable iatrogenic injury.

Birth injuries involving face are easily recognizable, but are often under-reported. Most of these injuries are associated with face presentation. We report an iatrogenic, but potentially preventable facial birth injury sustained by an unborn child in institutional setup.

INTRODUCTION

Neonatal facial birth injuries are easily recognizable, but most under-reported form of birth injuries.[1] They are often associated with face presentations, which occur in every 600-800 births at term gestation.[2] Face presentation usually presents as a deflexed head which becomes extended at pelvic inlet during labor. Anything that delays or prevents flexion such as fetal anomalies, contracted pelvis, fetopelvic disproportion or cord around the neck can contribute to face presentation.[3] Diagnosis is by abdominal palpation and pelvic examination. On pelvic examination, the presenting part may feel soft and lumpy and the landmarks of the face are felt. The bridge of the nose is an important landmark and often the baby will suck on the examining finger due to rooting reflex. Repeated per vaginal examination to assess the presenting part and the progress of labor may lead to bruises in the face as well as damage to the eyes. Parents must be counseled about the possibility of facial swelling and bruises before delivery. We describe one such potential case of preventable birth injury involving face, sustained by an unborn child with face presentation, in an institutional delivery.

A 22-year-old primigravida was admitted at term with active labor in our tertiary care teaching hospital. Per vaginal examination at admission revealed that it was a face presentation. As face presentation was quite uncommon, all our enthusiastic residents as well as the medical students posted in labor room wanted to have a feel of the face during labor. This resulted in repeated unofficial per vaginal examinations in spite of having strict guidelines in place. After delivery, baby was noted to have prominent ulcerations, bleeding and edema of the face [Figure 1]. The infant also had injury to right eye with eyelid ulceration, swelling, subconjunctival hemorrhage and difficulty in breathing due to swollen tongue. The infant was shifted to neonatal intensive care and was stabilized. Skull radiograph did not reveal any fractures. There was no evidence of nerve injuries. Neurosonogram did not reveal any abnormality. Respiratory distress settled within 2 days and the child was finally discharged after 7 days of hospitalization.

Figure 1

Facial ulcerations secondary to per vaginal examinations in face presentation

Iatrogenic neonatal facial injuries are rare, but are one of the most easily preventable neonatal injuries.[1] Overenthusiastic per vaginal examination in face presentation during labor should be avoided. Teaching institutions should have strict guidelines in place in order to avoid iatrogenic birth injuries.