Birth injuries.pdf

BIRTH
INJURIES
Prepared By:
Reena Bhagat
Senior Nursing Instructor
Maternal Health Nursing
BPKIHS

Introduction
• Birth injury is damage that occurs as a result of physical
pressure during the birthing process, usually during
transit through the birth canal.
• Many newborns have minor injuries during birth.
Infrequently, nerves are damaged or bones are broken.
• Most injuries resolve without treatment.
• A difficult delivery, with the risk of injury to the baby,
may occur with extremely large fetuses or
• Injury is also more likely when the fetus is lying in an
abnormal position in the uterus before birth.
12/26/2022 Reena Bhagat 2

Definition
• Birth injuries is an impairment of the infant’s body
function or structure due to adverse influences that
occurred at birth. Injury commonly occurs during labor
or delivery.
• Birth injuries may be severe enough to cause neonatal
deaths, still births or number of morbidities.
• Birth injuries may result from:
Inappropriate or deficient medical skill or attention.
They may occur, despite skilled and competent obstetric
care.

Etiology
The birth process is a blend of compression,
contractions, torques and traction. When fetal size,
presentation or neurologic immaturity complicates this
event, such intrapartum forces may lead to tissue
damage, edema, hemorrhage or fracture in the neonate.
The use of obstetric instrumentation may further
amplify the effects of such forces or may induce injury
alone.
Under certain conditions, cesarean delivery can be an
acceptable alternative but does not guarantee an injury-
free birth.

High Risk Factors for Birth Injuries
Primigravida
Prolonged or obstructed labor
Fetal macrosomia
Cephalopelvic disproportion, small stature, maternal
pelvic anomalies.
Very low birth weight infant
Deep, transverse arrest of descent of presenting part of
the fetus.
Abnormal presentation (breech)

Contd..
Oligohydramnios
Instrumental delivery (forceps or ventouse)
Difficult labor
Shoulder dystocia
Precipitate labor
Fetal anomalies

Risk factors and related injuries
Risk factors Related Injuries
Prematurity Bruising, intracranial and extracranial
hemorrhages
Macrosomia Shoulder dystocia, clavicle and rib fracture,
cephalohematoma and caput succedaneum
Breech
Presentation
Brachial plexus palsy, intracranial hemorrhage,
gluteal lacerations, long bone fractures
Abnormal
Presentation
Excessive bruising, retinal hemorrhage,
lacerations
Forceps delivery Facial nerve injury
Vacuum
extractions
Depressed skull fracture, subgaleal hemorrhage

Types of Injury Organs affected
Soft Tissue Skin - Lacerations, abrasions, fat necrosis, petechiae
Muscle Sternocleidomastoid
Nerve Facial nerve, Brachial plexus, Spinal cord, Phrenic nerve
(C3, C4 or C), Horner’s syndrome, recurrent laryngeal
nerve
Eye Hemorrhages: Sub-conjunctiva, vitreous, retina
Viscera Rupture of liver, adrenal gland, spleen testicular injury
Scalp Laceration, abscess, hemorrhage, caput succedaneum
Dislocation Hip, shoulder, cervical vertebrae
Skull Cephalohematoma, subgaleal hematoma, fracture
Intracranial Hemorrhages—Intraventricular, Subdural, subarachnoid
Bones Mandible, Clavicle, Humerus, Femur, Skull and Nasal
bones

Extracranial Injuries
Cephalohematoma
Caput Succedaneum
Subgaleal Haemorrhage

Cephalohematoma
Subperiosteal collection of blood between the
pericranium and the flat bone of the skull.
Causes:
Caused by bleeding between the outer surface of
the skull bones and the scalp due to pressure on the
head during birth such as CPD, precipitate labor.

Cephalohematoma

Clinical features
Collection of blood in between the periosteum and the
flat bone of the skull. Cephalohematoma is
circumscribed, soft, fluctuant and incompressible.
It is never present at birth but gradually develops after
12- 24 hrs.
Does not cross suture lines and usually unilateral over
parietal bone.
No active treatment is needed.
The fullness of a cephalo-hematoma spontaneously
resolves in 3 to 6 weeks.

Contd..
Management:
• No active treatment is necessary, it gradually disappear
during the 6-8 weeks after birth. The blood is absorbed
and swelling subsides.
• Only observation in most cases.
• Prevention of infection and avoidance of trauma are
important.
• Vitamin K 1 mg IM should be given to correct any co-
existing coagulation defect.

Contd…
• Advice the woman and family to return for care if
sign and symptoms worsen, danger signs arise.
• In case of infected hematoma, the condition is
treated with incision and drainage, systemic
antibiotics and monitoring of hematocrit and
bilirubin level.
• Symptomatic treatment of anemia and jaundice.

Caput Succedaneum
Caput succedaneum is an edematous swelling which
forms normally in the soft tissues over presenting part
of the scalp due to infiltration of serosanguinous fluid
by the pressure of girdle of contact i.e. the cervix,
bony pelvis or vulval ring.
The swelling is diffuse, boggy and is not limited by the
suture lines.
Causes:
Prolonged pressure on the head due to prolonged labor.

Contd.
Clinical Features:
A caput succedaneum is present at birth, does not tend to
enlarge.
Poorly defined margins.
Baby’s head - swelling, puffiness, and bruising present
at birth extends across suture lines of the fetal skull and
disappears spontaneously within 3-4 days. These are
hallmark symptoms of caput succedaneum.
Can extend over the presenting portion of the scalp and
usually associated with molding.
Usually present after birth and resolves spontaneously
without first few days after birth.

Contd
Management
• Reassure mother, it disappears. Spontaneously within a
few days( 2-3 days) after birth. Advice mother not to
apply pressure over caput.
• No special care is needed.
• Prevention of infection and avoidance of trauma.
• Baby should be handles gently and apply derssing on
abrasions.
• Advise women and family to return to care if signs and
symptoms worsen or danger signs arise. A head CT
should be obtained if neurological symptoms are present.

Subgaleal Hemorrhage
• A Subgaleal hemorrhage is bleeding between the
galeaaponeurosis of the scalp and the periosteum.
Causes:
Forces that compress and then drag the head through
the pelvic outlet
Increased use of the vacuum extractor at birth

Contd..
Clinical Features:
• Presents as a firm-to-fluctuant mass that crosses suture
lines.
• A boggy scalp, pallor, tachycardia, and increasing head
circumference – early signs.
• Forward and lateral positioning of the infant’s ear
because hematoma extends posteriorly.
• The mass is typically noted within 4 hours of birth.
• The bleeding extends beyond bone, often posteriorly
into neck and continues after birth.

Contd..
Diagnosis
• Serial hemoglobin and hematocrit monitoring-
decrease in hematocrit level.
• Monitor for level of consciousness.
• Coagulation profile to investigate for the presence of a
coagulopathy.
• Bilirubin levels also need to be monitored- increased
as a result of degrading blood cells.
• CT / MRI for confirming the diagnosis.

Contd.
Treatment
oSupportive.
oReplacement of lost blood and clotting factors is
required in acute cases of hemorrhage.
oTransfusions may be required if blood loss is
significant.
oIn severe cases, surgery may be required to cauterize
the bleeding vessels.
oThese lesions typically resolve over a 2–3 week
period.

Intracranial Injury
Traumatic Intracranial Hemorrhage
• Traumatic intracranial hemorrhage can be extradural or
subdural hemorrhage.
• Extradural hemorrhage is usually associated with fracture
skull bone.
• Subdural hemorrhage may occur following fracture of
skull bone, rupture of inferior sagittal sinus or small veins
of cortex producing hematoma.
Massive hemorrhage usually results from tear of tentorium
cerebelli thereby opening up straight sinus.

Contd...
Causes:
• Excessive molding in deflexed vertex with gross
disproportion.
• Preterm baby because of lack of protection by their
soft skull bone and wide sutures as well as delicacy of
the cerebral vessels and tissues are particularly prone
to intracranial injury and hemorrhage.
• Rapid compression of the head during delivery of the
after coming head of breech or in precipitate labor.
• Forcible forceps traction following wrong application
of the blades.

Contd..
Clinical features:
• The hemorrhage may be fetal and baby is delivered still
born or with severe respiratory depression having Apgar
0-3.
• Gradually the features of cerebral irritation appears such
as frequent high pitch cry, incoordinate ocular
movement, and convulsion, vomiting and bulging of
anterior fontanelle.
• Baby cannot establish respiration himself.

contd,..
• Difficult grunting expiration after most due to excess
of mucous. Sometimes shallow, rapid and irregular
with attack of apnea and cyanosis.
• Trunk and limbs may be rigid, first clenched, limpness
is also common.
• Eyes are wide open for long period, starring with
knowing look, sunken eyes and rigid neck.

Anoxic Intracranial hemorrhage
• Anoxic intracranial hemorrhage can be
intraventricular, subarachnoid and intracerebral.
oIntraventricular: More common in premature infants.
The mechanism of hemorrhage is due to intense
congestion of fragile choroidal plexus due to anoxia
leading to rupture.
oSubarachnoid: due to tear of some tributary veins
running from brain to sinuses. Symptoms may appear
late. There may be twitching of extremities or in-
coordinated eye movement.

Contd..
oIntracerbral: Small petechial hemorrhage may be
due to anoxia. It usually occurs in mature babies
following prolonged labor. The features are flaccid
limbs or worried and anxious expression.

Contd..
Prevention
• Comprehensive antenatal and intranatal care is the
key to success in reduction of intracranial injuries.
• Avoid prolonged labor.
• To prevent or to detect at the earliest, intrauterine
fetal asphyxia by fetal monitoring, specially care
while conducting premature labor.
• In vacuum delivery, traction is made only after
proper cephalic application.

Contd..
• To avoid traumatic vaginal delivery in preference
to CS. Difficult forceps should be avoided.
• To extend the use of CS in breech more liberally. If
conduct vaginal breech delivery never be at haste
especially during delivery of head.
• Administration of vitamin K 1 mg IM soon after
deliveries in susceptible babies.

Contd..
Investigation
• Ultrasonography is used to detect intraventricular
hemorrhage.
• Doppler ultrasonography can detect any change in
cerebral circulation.
• CT scan is useful to detect cortical neuronal injury.
• MRI is used to evaluate any hypoxic ischemic brain
injury.

Contd.
Treatment:
• Incubator nursery is preferable to supply oxygen and
to maintain the temperature and humidity.
• To maintain cleanliness of the air passage, suction
immediately after birth to remove the secretions that
occlude the pharynx.
• To restrict handling of the baby, such as bathing,
weighing and measuring should be withheld.
• Feeding by nasogastric tube is advisable.
• Fluid balance is to be maintained, if necessary by
parenteral route.

Contd..
• To administer vitamin K 1mg IM to prevent further
bleeding due to hypoprothrombinemia.
• Close observation on vital signs, skin color, respiration
and convulsion.
• Prophylactic antibiotics is to be administered.
• Anticonvulsant: any of the following may be useful:
oPhenobarbitone 5-10 mg/kg/day is divided dose at 6
hourly interval intramuscularly.
oPhenytoin 10-15 mg/kg intravenously as loading dose
at the rate of 0.5mg/kg/minute followed by
maintenance dose of 5 mg/ kg/day with cardiac
monitoring.

Contd..
oDiazepam 0.1 mg/kg intramuscularly thrice daily
• Subdural hematoma
• Subdural tap
• Surgical removal of clot.
• Rarely subdural peritoneal shunting may be
needed.

Scalp Injuries
Minor injuries of the scalp are abrasion over the scalp.
Causes:
oForceps delivery
oIncised wound inflicted during cesarean section
oScalp electrodes placement
oEpisiotomy.

Contd..
Signs:
On occasion, the incised wound may cause brisk
hemorrhage which requires stitches.
Care: wound may bleed require stitches and which
should be dressed with antiseptic solution

FRACTURES

Fracture Bone
• Fractures are rare
• but most commonly affected bones are clavicle, humerus,
femur and those of skull, occasionally spinal fracture may
occur.
Diagnosis
• History: difficult birth
• Physical examination: displacement of bone from its normal
position. Pain(cry) when limb or shoulder is moved. Lack of
movement or asymmetrical movement of limb. Swelling
over bone.
• X-ray

Contd..
General Management
• Confirm the diagnosis with X-ray if available.
• Handle the baby gently when moving or turning and
teach the mother how to do so. Avoid movement of the
affected limb as possible.
• Immobilize the limb to reduce pain when baby is
handled.
• If the mother is able to care for the baby and there are
no other problems requiring hospitalization, discharge
the baby.

Contd..
• Explain to mother that fractures will heal
spontaneously, usually without residual deformity and
that a hard swelling ( callus) may be felt over the
fracture site at 2-3 weeks of age. This is normal part of
healing.
• Follow up in one month to verify that fracture has
healed.
• Refer babies with unhealed fractures or severe
deformities to a tertiary hospital oe specialized center
for orthopedic care, if possible.

Clavicle fracture
The clavicle is the most frequently fractured bone in the
neonate during birth; this is most unpredictable,
unavoidable complication of normal birth.
Diagnosis
• Examination may reveal crepitus, palpable bony
irregularity and sternocleidomastoid muscle spasm.
• Radiographic studies confirm the fracture.

Contd,..
Treatment:
• Fracture of clavicle require no specific treatment.
• Healing usually occurs in 7-10 days. In order to
decrease pain, arm motion may be limited.
• Assess the other associated injury to the spine, brachial
plexuses , or humerus.
Prognosis:
Stable union of a fractured clavicle usually occurs in 7-
10 days.

Humerus fracture
• Mid shaft fractures can occur if there is shoulder
dystocia or during a birth by the breech when the
extended arm is brought down and born.
• The clinical features include limitation of movement,
deformity and crepitus at the site of fracture along with
pain

Femur fracture
• Mid shaft fractures can occur if there is shoulder dystocia
or during a birth by the breech when the extended legs are
brought down and born.
• Considerable deformity is evident on examination and the
baby will be reluctant to move the leg lowing to the pain.
Management
• Radiographic studies of the limb confirm the diagnosis
and distinguish this condition from septic arthritis
• Careful handling, cleaning and dressing of te baby to
reduce discomfort.

Contd..
• Analgesics as per instruction
• Position the baby on the back or unaffected side is
likely to be more comfortable.
• Femoral and humeral shaft fractures are treated with
splinting. In fractures of the humerus, immobilization of
the arms is achieved by placing a pad in the axilla and
splinting the arm to chest with a bandage. application
should be firm but should not embarrass respirations. In
the fracture of femur, immobilization of the leg is
relatively easy using a splint and a bandage.
• Close reduction and casting is necessary only when
displaced.

Contd...
• Watch for evidence of radial nerve injury with humeral
fracture.
• Callus formation occurs, and complete recovery is
expected in 2-4 weeks. In 8-10 days, callus formation
is sufficient to discontinue immobilization.
• Orthopedic consultation is recommended.
Prognosis
• Stable union of a fracture humerus and femur take 2-3
weeks. Deformity is a rare condition and found when
the fracture bone end is not in a good alignment.

Skull Fracture
Fracture of the vault of the skull (frontal or anterior part
of the parietal bone) may be linear or depressed type.
Causes:
oEffect of difficult forceps delivery in disproportion or
due to wrong application of the forceps (blades not
placed over the bi-parietal diameter).
oProjected sacral promontory of the flat pelvis may
produce depressed fracture even though the delivery is
spontaneous.

SKULL FRACTURE
Diastatic Depressed Linear Basilar
Diastatic fractures
occur across the line of
a skull suture, pushing
the bony plates apart.
In infants, undiagnosed
diastatic fractures can
quickly turn into
"growing" fractures, in
which the break
continues to expand
after the initial
traumatic event.
Growing fractures can
be very serious.
Or "ping-pong")
fractures happen when
the skull is forced
downward toward the
brain, like an
indentation.
Depressed skull
fractures can be very
severe, since broken
bits of bone can apply
pressure to the brain,
ultimately leading to
brain damage.
Many infants will
require surgical
intervention.
Linear fractures
occur when the
bone splits into
two separate
pieces,
but neither
portion moves
out of position.
Linear fractures
usually heal on
their own with
adequate medical
supervision.
Any break in a
bone below the
neurocranium (the
part of skull that
holds the brain)
falls under this
category,
including
fractures in the
eye sockets, nose
bones, ear bones
or in the occipital
bone, which
forms the base of
the skull, directly
above the neck.

Contd..
Minor & Severe Fractures
In terms of severity, we can divide all broken bones into
two basic categories:
• Greenstick fractures are incomplete. Instead of breaking
into pieces, the bone bends and cracks, but this crack
doesn't run all the way through the bone.
• Complete fractures occur when the bone is snapped into
two distinct pieces.

Contd..
Clinical Features:
• It may be associated with cephalo-hematoma,
extradural or subdural hemorrhage or a hematoma
or brain contusion.
• Depressed fractures cases some pressure effect.
• Neurological manifestation- occur later due to
compression effect.
• Leakage of cerebrospinal fluid
• Seizures

Contd..
Diagnosis
• History
• Physical Examination
• X-ray or CT scan study can confirm in diagnosis
Treatment:
Conservative in symptomless cases.
Antibiotic is started.
The depressed bone has to be elevated or subdural hematoma
may have to be aspirated or excised surgically.
Follow-up imaging should be performed at 8-12 weeks to
evaluate any cyst formation.

Spinal fracture
• It may occur due to acute bending of spine during
delivery of after coming head in breech.
• Fracture or dislocation of fifth sixth cervical vertebrae
may occur and result in instant death of the baby due to
compression of medulla.
• The neonate may present with flaccid paraplegia with
retention of urine and overflow incontinence.
• Respiratory failure due to diaphragmatic paralysis may
dominate the clinical picture.
• There may be dull or absent sensations below the site of
lesion.

Contd..
Management
• Consultation with orthopedic surgeon.
• General management of fracture:
Confirm the diagnosis with X-ray
Handle the baby gently when moving or turning and
teach mother how to do so. Avoid movement of
affected limb as much as possible.
Immobilize the limb to reduce pain when baby is
handled.

Contd..
If mother is able to acre for baby and there are no
other problems requiring hospitalization, discharge
the baby.
Explain mother fractures will heal spontaneously,
usually without residual deformity and that hard,
callus may be felt over the fracture site at 2-3 weeks
of age and this is the part of normal healing process.

Dislocations
• The common sites of dislocations of joints are
shoulder, hip, jaw and fifth-sixth cervical
vertebrae.
• Confirmation is done by radiology or
ultrasonography and the help of an orthopedic
surgeon should be sought.

Skin and Subcutaneous Tissues
• Bruises and lacerations on the face are usually caused by
forceps blades.
• These are treated with application of 1% lotion
mercurochrome.
• Buttocks in breech presentation, or eyelids, lips or nose
in face presentation, similarly become edematous and
congested.
• No treatment is required.

Contd..
• Scalpel cut or laceration injury may occur during
cesarean section.
• They usually occur on the buttocks, scalp or thigh.
Small cut heals spontaneously.
• Laceration injury may need repair by stitches with
7-0 nylon.
• Healing is usually rapid.

Muscles
Sternocleidomastoid(SCM)
injury
(congenital torticollis) is
characterized by a well
circumscribed immobile mass
in the mid point of the
Sternocleidomastoid.
The head tilts towards the
involved side. The patient
cannot move the head
normally.

Contd..
Sternomastoid hematoma usually appears about 7–10
days after birth and is usually situated at the mid position
of the muscle.
• It is caused by rupture of the muscle fibers and blood
vessels, followed by a hematoma.
• It may be associated with difficult breech delivery or
attempted delivery following shoulder dystocia or
excessive lateral flexion of the neck even during normal
delivery.
• There is transient torticollis and it is wise not to
massage.
• Treatment is conservative.

Contd..
• Stretching of the involved muscle should be done several
times a day.
• Recovery is rapid in majority of cases.
• Surgery is needed if it persists after 6 months of physical
therapy.
Necrosis of the subcutaneous tissue may occur while the
superficial skin remains intact.
• After a few days, a small hard subcutaneous nodule appears.
It is the result of the fat necrosis due to pressure, and takes
many weeks to disappear.
• No treatment is required and it has no clinical importance.

Nerve Injuries
Facial palsy (peripheral):
It is involved by direct pressure of the forceps blades or by
hemorrhage and edema around the nerve.
It may even be involved in spontaneous delivery when too
much pressure is applied on the ramus of the mandible
where the nerve crosses superficially.
Diagnosis is made by noting the eye of the affected side
which remains open and eyelids are immobile.

• On crying , the angle of the
mouth is drawn over to the
unaffected side.
• Sucking remains unaffected.
• Treatment aims at protecting
the eye, which remains open
even during sleep, with
synthetic tears (1% methyl
cellulose drops).
• The condition usually
disappears within weeks
unless complicated by
intracranial damage.

Brachial palsy
• Either the nerve roots or the trunk of the brachial plexus
are involved.
• The damage of the nerve is due to stretching (common)
or effusion or hemorrhage inside the sheath.
• The cause is undue traction on the neck during attempted
delivery of the shoulder. The affection is due to
hyperextension of neck to one side with forcible digital
extension and abduction of the arm in an attempt to
deliver the shoulders.
• Unilateral involvement is common.

Erb’s palsy
This is the most common type when the 5th and 6th and
rarely the 7th cervical nerve roots are involved.
The resulting paralysis causes the arm to lie on the side
with extension of the elbow, pronation of the forearm
and flexion of the wrist (Waiter’s tip).
Winging of the scapula is common. Moro reflex is
absent. There may be associated ipsilateral phrenic nerve
paralysis (C3, 4, 5).

Klumpke’s palsy
• This type of palsy is due to the affection of the lower
cords of the plexus involving 7th and 8th cervical or
even the first thoracic nerve roots.
• There is paralysis of the muscles of the forearm. The
arm is flexed at the elbow, the wrist is extended.
• The forearm is supinated and a claw-like deformity of
the hand is observed. When the first thoracic nerve is
involved, there may be homolateral ptosis with small
pupil due to sympathetic nerve involvement (Horner’s
syndrome).

Contd..
• Treatment consists of immobilization and prevention of
contractures. Physical therapy and passive movements
are advocated.
• Full recovery takes weeks or even months. Severe injury
may produce permanent disability.
• Prognosis is usually good, if it is due to stretching. But if
it is due to hemorrhage or avulsion, the deformity may be
permanent.
Brachial plexus injury: The incidence is about 0.1 to
0.2% of shoulder dystocia, even in normal delivery,
macrosomia, malpresentation and instrumental deliveries

Phrenic nerve injury
• Phrenic nerve injury (C3, 4 or 5) cause paralysis of the
ipsilateral diaphragm. This is due to excessive stretching
of the neck at birth.
• Risk factors are : Breech or difficult forceps delivery.
Infants present with respiratory distress, cyanosis,
tachypnea.
• Diagnosis is made by USG showing paradoxical
movement of the diaphragm.
• Treatment is supportive.
• Continuous positive airway pressure (CPAP) or
mechanical ventilation may be needed. Recovery is
usually complete in 1–3 months time.

Visceral injuries
Liver, kidneys, adrenals or lungs are commonly injured
mainly during breech delivery.
The most common result of the injury is hemorrhage. Severe
hemorrhage is fatal.
In minor hemorrhage, the baby presents features of blood loss
in addition to the disturbed function of the organ involved.
Treatment is directed:
1. To correct hypovolemia, anemia and coagulation
disorders;
2. Specific management—surgical or otherwise, to tackle
the injured viscera.

Prevention of birth Injuries
• The incidence of birth injuries can be reduced by
comprehensive antenatal and intranatal care. Preventive
measures should be emphasized to minimize birth
injuries and permanent disabilities.
Antenatal period:
• Identification of high risk cases( especially which may
cause traumatic delivery) is very important for early
and subsequent management ( elective cesarean section
is important for contracted pelvis , CPD or
malpresentation like breech and transverse).

Contd..
Intranatal period:
During intranatal period, following practices can be
reducing the incidence of birth injuries:
• Continue fetal monitoring if available to detect early
evidences of fetal distress, manage it to prevent
cerebral anoxia.
• Episiotomy is to be done carefully to prevent injury to
scalp.
• The neck should not be unduly stretched during
delivery of shoulder to prevent injuries to brachial
plexus or sternomastoid muscle.

Contd..
• Special care to be taken in preterm delivery to prevent anoxic
or traumatic delivery. Ventouse delivery should be avoided in
preterm babies.
• Liberal episiotomy and use of forceps to minimize
intracranial compression.
• Administer vitamin K 1mg intramuscularly to prevent or
minimize hemorrhage from traumatized area.
• Precautions to be followed during forceps delivery to prevent
injuries.
• Vaginal breech delivery should be done by skilled personnel
with gentle and careful approach to prevent intracranial
injuries, spinal injuries and other injuries.
• Prolonged labor should be managed carefully.

References:
 Dutta DC. Textbook of Obstetric including Perinatology
and Contraception. 7th ed. Jaypee Brothers Medical
Publishers (P) Ltd. New Delhi, India: 2013; Page No.: 483-
487.
 Myles Textbook of Midwives, 16th edition, United
Kingdom, Churchill Livingstone Elsevier ltd., 2014, Page
No. 629-634
 Subedi DP. A Textbook of Midwifery Nursing(Postpartum
Care) Part III. First ed. Reprint:2020. Akshav Publication
Kathmandu; Page No. 419-436

Birth injuries.pdf

Empfohlen

Empfohlen

Weitere ähnliche Inhalte

Was ist angesagt?

Was ist angesagt? (20)

Ähnlich wie Birth injuries.pdf

Ähnlich wie Birth injuries.pdf (20)

Mehr von Reena Bhagat

Mehr von Reena Bhagat (14)

Kürzlich hochgeladen

Kürzlich hochgeladen (20)

Birth injuries.pdf