Birth trauma to in delivery and its fatal consequences · Birth trauma is supposed to be the main factor responsible. Despite attempts to reduce the high mortality rate, the figures

Archives of Disease in Childhood, 1975, 50, 4.

Birth trauma to muscles in babies born by breechdelivery and its possible fatal consequences

Z. A. RALISFrom Cardiff Royal Infirmary

Rils, Z. A. (1975). Archives of Disease in Childhood, 50, 4. Birth trauma tomuscles in babies born by breech delivery and its possible fatal consequences.Dissection and histological examination was made of the muscles of 86 babies who diedafter breech delivery, and of 38 babies who died after vertex presentation. A controlgroup of 50 surviving breech-delivered babies was examined clinically and the resultscompared. It was concluded that the most common type of birth trauma to a babyborn by breech delivery is injury to muscles and soft tissues of the back and lowerextremities, which is often extensive. In some severely injured babies histologicalexamination of organs reveals signs of crush syndrome and disseminated intravascularcoagulation. It is suggested that the extensive muscle trauma forms the backgroundof these fatal conditions.

The mortality of babies born by breech presenta-tion exceeds the average neonatal mortality rate by15 to 20 times, reaching 5 to 15% (Kauffier, 1941;Elefant 1957; Burger, Milfort, and Denef, 1962).Birth trauma is supposed to be the main factorresponsible. Despite attempts to reduce the highmortality rate, the figures are still alarming and theproblem is far from being solved.

Birth injuries in breech delivery do not involveonly the CNS; a recent survey based on pub-lished reports during the last 45 years has shownthat breech delivery, especially when assisted, is themain cause of birth injuries to the liver, anus,genitalia, spine, spinal cord, all long bones, hip joint,and sciatic nerve (Ralis 1968a). Trauma tomuscles, however, though the most frequent andtypical consequence of breech delivery, is less wellrecognized, and it is only trauma of the sterno-mastoid muscle that is mentioned, because of theevident relation between breech delivery andtorticollis or clinically evident sternomastoid'tumour'. Trauma to and haemorrhage into themuscles of the lower back and lower extremities,though often deep and extensive, is usuallyconsidered to be superficial subcutaneous bruisingsimilar to caput succedaneum (Fig. 1).This study is mainly concerned with injuries to

the muscles in breech born babies.

Received 11 June 1974.

Material and methodsDuring the past 10 years necropsy dissections of the

muscles of 86 babies born by breech presentation and of38 babies bom by vertex presentation were carried out.In addition, 50 living term babies born by breechdelivery were clinically examined during the first weekafter birth (Table I). The series of dissections wasstarted in the Department of Traumatic and OrthopaedicSurgery and the Department of Pathology, Faculty ofPaediatrics, Charles University, Prague, and completedin the Department of Pathology, Sheffield Children'sHospital and Congenital Anomalies Research Unit,Department of Child Health, University of Sheffield.77 of the 86 breech-born babies dissected were selected atrandom from the pathological department whichnecropsied all fetuses and babies who died in thematernity hospitals during or immediately after birth, aswell as those babies who died later in the Children'sHospital. The remaining 9 babies dissected wererandomly selected from those who survived breechdelivery and died in the Children's Hospital. The livingbabies were examined in the Maternity Hospital, Facultyof Pacdiatrics, Prague, and the Children's Hospital,Sheffield.

Post-mortem dissections. Table I shows thedistribution and maturity ratio of the 124 babiesdissected; of 86 children born by breech presentation,two-thirds were preterm. Their age and sex are shownin Table II. 46% of the mothers were primipara andtheir average age was 25-5 years. 40% of the babieswere born by breech extraction.

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Birth trauma to muscles in babies born by breech delivery and its possible fatal consequences 5TABLE I

Total cases seen

Post-mortem dissections Clinical examinationTotal

Breech Vertexpresentation presentation Breech presentation

Term babies 26 18 50 94Preterm babies 60 20 _ 80

Total 86 38 50 174

TABLE IIAge and sex of 86 babies who died after breech delivery

and were dissected

AgeStillborn 24%O-2 h 19%2-24 h 21%1-7 d 21%More than 7 d 15%

SexMales 57%Females 43%

FIG. 1.-The dark discoloration of legs in this prematurebreech-born baby was clinically described as 'localizedcyanosis and asphyxia' and 'possible deep vein thrombosis'.The child survived the assisted breech delivery for 48 hours.Dissection revealed diffuse damage and haemorrhage ofsecond and third degree of most of the muscles and nerves of

lower extremities.

Routine post-mortem examinations were done in allcases and the spinal canal was opened in most of them.All areas of the skin, subcutaneous tissue, muscles, largenerves, and joints where birth trauma was expected weredissected. In addition, the lower extremities weredissected in all babies, whether or not any birth injurywas apparent. The topography and extent ofhaemorrhage in all tissues were recorded. Blocks formicroscopical examinations were taken from allspecimens and the sections stained by routine histologicalmethods. All data were put on punch cards and resultscalculated from these.

Living newborn babies. 50 living babies (30 boysand 20 girls) were examined during the first week aftertheir breech delivery. They were all term babies; 35%of them had a birthweight over 3 *5 kg. Any injuries ofthe skin, subcutaneous tissue, and organs found onclinical examination were recorded and these findingswere compared with the data obtained from the dissectedgroup.

ResultsPost-mortem dissections-breech delivery

(86 babies).

Skin and subcutaneous tissue. Skin damage wasthe most obvious. The changes ranged from tense,shiny, reddish skin to 'gangrenous' appearance ofpurple-black epidermis with blisters suggesting a


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6 Z. A. Ralissevere degree of post-traumatic oedema. Thedamage was found mainly in the gluteal region andin certain parts of the legs and trunk. Approxi-mately 30% of skin from all lower limbs dissectedwas damaged to some extent (Table III).

TABLE IIISkin and muscle damage in 172 babies dying after

breech delivery

Skin damage Muscle damage(% cases) (% cases)

Gluteal region 36 76Thigh 27 46Lower leg 33 30Foot 30 25

Haemorrhage into the subcutaneous tissue occurredmainly in preterm babies and followed the pattern ofthe skin damage. In term babies there was often astartling difference between the intact skin andsubcutaneous tissue present and the black mass ofseverely damaged muscles underneath. This factcould be clinically very important: in nearly half ofthe cases dissected there was no skin damageapparent over the injured gluteal or thigh muscles.Subcutaneous necrosis of the skin was not found,but sclerema of the lateral side of the thighs was seentwice and thrombosis of the long saphenous vein wasfound in one case.

Muscles of the lower extremities. Table IV showsthe frequency and amount of muscle damage andhaemorrhage in dissected individual muscles fromlower extremities. It is seen, for example, that 70%of all gluteus maximus muscles dissected weredamaged to some extent, and that the averagevolume of the muscle mass found to be damaged was50%. The localization of the damage in individualmuscles and the topographical distribution oftenfollowed a typical pattern.

Histologically, various degrees of haemorrhage,damage to muscle fibres, vascular damage andthrombosis, reparative changes and healing byfibrosis were seen. According to the intensity ofhaemorrhage, a scale of three degrees was used: thefirst degree showed oedema with extreme passivehyperaemia, small perivascular haemorrhages, andslight bleeding into the perimysial connective tissue.In the second degree, haemorrhage in theperimysium was diffusely spread and there was somebleeding in the endomysium. In the most severetrauma-in which the injured muscles appeared as ablack tar-like mass (third degree) all connective

TABLE IV

Incidence and amount of muscle damage in dissectedlower extremities of babies dying after breech delivery

Frequency of Average size ofMuscle muscles involved damaged area (%

(% of all muscles of total mass ofdissected) dissected muscle)

Gluteus maximus 70 50Gluteus medius 60 48Gluteus minimus 45 48Piriformis 31 48Obturator internus } 31 70

Obturator extemus 17 46Quadratus femoris 17 82Sastorius 35 48Rectus femoris 30 35Vastus lateralis 50 35Vastus intermedius 24 38Vastus medialis 26 36Adductcr muscles 24 45Iliopsoas (extrapelvic) 10 43Biceps femoris 22 39Semitendinosus 16 49Semimembranosus 18 49Foreleg muscles 41 40

tissue spaces in the muscle were filled with bloodand individual muscle fibres were separated bycrowded red blood cells (Fig. 2).Muscle fibres in the areas ofhaemorrhage and also

around them showed a considerable amount ofdamage. The changes depended on the intensity ofhaemorrhage, the duration of labour and the lengthof survival. All degrees of muscle fibre damagewere present, ranging from cloudy swelling and lossof cross striation, through partial degeneration andfragmentation, up to total necrosis of fibres withextensive macrophagic reaction and phagocytosis oftheir remains (Figs. 2 and 3). Apart fromdestructive changes, the regeneration of musclefibres and proliferation of young connective tissuecould be seen in some areas 36 to 48 hours afterbirth.

In some muscles of those infants who survived 4to 6 weeks after breech delivery the necrotic zonewas replaced by dense fibrotic tissue; some of itselements gave a positive haemosiderin reaction. Asthis late scarring and permanent structure damage toinjured muscles and nerves may be responsible for a'congenital' orthopaedic deformity of the growinglimb, its detailed anatomy, topographical distribu-tion, and orthopaedic aspects are discussed in aseparate report.

In the present study the general and possibly fatalaspects of the injuries are discussed. For thispurpose an attempt has been made to assess thequantitative factors of the damage, i.e. the total


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Birth trauma to muscles in babies born by breech delivery and its possible fatal consequences

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FIG. 2.-Microscopical appearance of the damaged gracilis muscle in a premature baby who died 5 days after breechdelivery. Damage to musclefibres and haemorrhage of third degree. The vessel in the centre of thefigure (arrow) contains

an adherent fibrin-positive thrombus. (Goldner's Trichrome. x 85.)

volume of muscle mass damaged and the amount ofblood that escaped from circulation and wasarrested in it.The final figures obtained from detailed calcula-

tions indicate that the total amount of damagedmuscles in these neonates represents on average38% of total muscle mass of their lower extremities.The author has recently weighed all the individualmuscles from lower extremities in more than 30newborn babies of various ages and maturity whohave died from causes unrelated to any damage ofthe locomotor system. These measurements whencorrelated with body weight showed that the totalmuscle mass of lower extremities in the newborn ison average 6 *6% of its body weight. Provided thaton average 38% of their leg muscle mass was dam-aged, as was the case in the breech-born babiesdissected, this represents a muscle mass equivalentto 2 5% of the child's body weight. In a pretermbaby (about 1 500 g) this would be 37 * 5 g and in aterm baby (about 3 * 500 g) it would be 87 * 5 g. Only

the damaged muscles of the lower extremity wereinvolved in this calculation; as there was alsofrequent damage of muscles of the neck and lowerback, this average figure would have been higher ifall the damaged muscles had been considered.The blood volume is 108 ml/kg body weight in

preterm babies and 85 ml/kg in term babies (Smith,1966). Another figure quoted is 12% of the bodyweight. Thus, a preterm baby has about 150-200ml and a term baby about 300-400 ml of circulatingblood. In the present series the amount ofdamaged muscle mass with haemorrhage is theweight equivalent of 1/5-1/4 of the total circulatingblood. It is, of course, practically impossible toestimate quantitatively the exact volume of arrestedblood per volume unit of the damaged muscle, andour figures, therefore, can only be approximate.On the other hand, however, the quoted figures aretaken on average for all the cases dissected. Insome individual cases they would be 2 to 3 timeshigher.

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Z. A. R&lis

FIG. 3.-Gracilis muscle of a premature baby who died 4 days after breech delivery. This area of extensive musclenecrosis does not lie in the zone directly involved in haemorrhage. Mechanical trauma and ischaemia are the likely causes

of this damage to contractile muscle elements. (Haematoxylin and eosin. x 85.)

Other muscles. Trauma to muscles in other partsof the body was more frequent than expected. Itstopographical distribution depended on the type ofbreech delivery. Maximum damage was found inwhichever part of the body was either leading,obstructed, or held back during delivery. Themuscles most frequently damaged were those of thelower back, spinal and paravertebral muscles,scapular muscles, suboccipital muscles, sterno-mastoid, temporal, and facial muscles, trapezius,latissimus dorsi, and muscles of the pelvic floor.Occasionally extensive damage to the muscles of thearm was found in cases of delivery with an extendedupper extremity. This haemorrhage was usuallyassociated with bleeding into hemithorax andparietal pleura on the same side.

Trauma found on routine post-mortem examination.Damage to the brain was recorded in 48% ofbreech-delivered babies. These figures includeboth damage due to asphyxia and to mechanical

trauma. Fracture of the skull was found twice andcephalhaematoma three times, always in the occipitalregion.

Liver subcapsular haemorrhage was recorded in 6cases and haemorrhage into adrenals in one.The anus and genitalia were frequently damaged;

this was sometimes the only damage visible on thechild. Haemorrhage into the anus was alwaysaccompanied with severe bleeding into muscles ofthe pelvic floor; it was found in one-third of cases.The external genitalia were damaged in abouttwo-thirds of cases. The changes varied inintensity from the haemorrhagic oedema of scrotumand vulva to massive haemorrhagic infarction of alltissues.Trauma to the testicles was frequent and was

obviously of mechanical origin since its prevalenceafter breech delivery was highly significant whencompared with vertex delivery. A severelydamaged testicle was found within the inguinal canalin 2 cases.

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Birth trauma to muscles in babies born by breech delivery and its possible fatal consequences 9Histological changes suggesting the presence of crush

syndrome and/or disseminated intravascular coagula-tion. The author did not have the opportunity toexamine histologically every organ in all babiesdissected and studied for this report. However, thecrush syndrome character of the trauma and thepossibility of diagnosing disseminated intravascularcoagulation (DIC) by microscopy led to the decisionto screen histologically all organs in a selected groupof breech-born babies who died with extensivemuscle damage. The purpose was to find anypositive pathological signs of crush syndrome,shock, or DIC.From 10 babies completely screened, 6 had

survived breech delivery for a period long enough todevelop these conditions. They died between 9hours and 9 days after birth. In 3 of them thefollowing features were found. (1) Moderate tomassive obstruction of the distal renal tubules byhaemoglobin and pigmented casts. These weresometimes formed by masses of compressed redblood cells or their fragments, or by lumps and clotsof fibrin-positive material (Fig. 4). In some areassuch casts could be seen in practically all tubules.Many tubules were grossly distended and showedextensive pressure changes and degeneration of theirepithelium. These changes do not differ fromthose seen in the lower nephron in cases of

crush syndrome. (2) The presence of scatteredmicrothrombi and deposits of fibrin in capillaries orblood sinuses of organs not directly involved in birthtrauma (Fig. 5), together with occasional focal tissuenecrosis. Microthrombi were found in sectionsfrom lungs, liver, kidneys, and also from badlytraumatized muscles. These features represent anepisode of DIC, well recognized in connexion withsevere stress syndromes, including traumatic andhaemorrhagic shock (Hardaway, 1966).

Severity of muscle injury. In order to findsupport for the hypothesis that in the most severecases muscle trauma was indeed the main factorresponsible for the death of the child, the babieswere divided into two groups showing slight or noinjury, and severe injury. Trauma withhaemorrhage of second and third degree, involvingat least one big muscle or several small muscles, wasclassified as severe trauma. The results showed thatthere was a significant difference between these twogroups in the length of survival, since this was only2 *4 days in the group of severely traumatized babiesas compared with 12 2 days in the other group.Thus, the babies with slight or no muscle injurylived five times longer than the severely traumatizedbabies. The mechanism responsible for severemuscle trauma might of course also have been

FIG. 4.-Multiple casts composed ofred cells, theirfragments, andfibrin-positive material in kidney of a premature breech-born baby. (Goldner's Trichrome. x 30.)


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Z. A. Ralis

m~u~uiwFIG. 5.-Multiple antemortem thrombi (arrowed) in liver. (Goldner's Trichrome. x 330.)

responsible for severe brain injury. In such cases,however, evidence of mechanical trauma to the brainand its meninges and vessels should be found.

Post-mortem dissection-vertex presenta-tion (38 babies). The findings in 38 dissectedbabies born by normal delivery are shown in TableV. The damage was overall less frequent, lessextensive, and histologically of milder degree.Nevertheless, the incidence of minor damage,especially in the neck and extremities, wassurprisingly high. A comparison between thisgroup and the group of breech presentation is shownin Table V.

Babies surviving breech delivery (50 babies).Findings on 50 living mature babies examined

TABLE VDistribution of muscle damage in babies dissected

Vertex presentation Breech presentation(38 babies) (86 babies)(% cases) (% cases)

Head and neck 36 35Upper limb 16 21Trunk 8 21Lower limb 29 92Genitalia and anus 5 69

during the first week after birth are shown in TableVI. The most frequent damage was skin bruisingin the gluteal region, usually unilateral, and oedemaof external genitalia. The area of skin involved wassmaller on average and the damage was found lessfrequently than in those children who died. Thefact that these babies with less extensive muscledamage survived breech delivery may be important.

TABLE VIDistribution of muscle damage in babies dying after

breech presentation

Clinical Post-mortemexamination dissection(50 babies) (86 babies)(% cases) (% cases)

Gluteal region 64 86Thigh 6 78Lower leg 6 47Foot 10 37Genitalia and anus 24 69

DiscussionInjuries to muscles (with the exception of

sternomastoid) in babies born by breech presenta-iton are not generally recognized. A few reportsbriefly mention 'caput succedaneum' in the gluteal

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Birth trauma to muscles in babies born by breech delivery and its possible fatal consequences 11region or illustrate it among adjacent findings indescriptions of other neonatal damage (Nielson,Ferris, and Logan, 1948; Schwartz, 1964).Benesova (1958; personal communication, 1963) and0. Hnevkovsky (personal communication, 1963)suggested their possible significance and the authoris indebted to both for their encouragement in hisearly studies (Ralis 1964, 1968a, b).

All injuries during breech delivery mentionedabove are the result of the specific character of thislabour. There is inadequate dilatation of the birthcanal. The majority of the mothers are olderprimiparas whose babies also have the greatestmortality after breech delivery (Gaehtgens, 1942;Brosset, 1956; Hedberg, 1957). The membranesruptured early in labour in 20-380°/ of cases(Kauffler, 1941; Todd and Steer, 1963), thus givingno protection to the leading part. The size of thepart delivered first is also important: breech deliveryby one foot is twice as dangerous as delivery by bothfeet (Zacharias and Heery, 1950). The leading partis usually represented by the huge muscle mass ofthe lower back, buttocks, and thighs. Thealternation of positive pressure with negativepressure causes direct mechanical damage to themuscle fibres, soft tissue, and blood vessels.Venous infarction with perivascular and massiveendomysial bleeding impairs the situation by localischaemia and accelerates the necrosis of alreadydamaged muscle fibres. Mechanical trauma,ischaemia, and haemorrhagic shock damagecapillaries, produce intravascular clotting withfurther depletion of clotting factors, and furtherincrease the bleeding. Thus there is a vicious circleof progressive bleeding into muscles alreadymechanically injured. The situation can be furtherimpaired by the 'release' syndrome (Benison) whichforms the background of 'tourniquet shock',whereby the circulation is suddenly deluged withdisintegrated products from the crushed musclesand by toxic products of haemolysis, as soon as thedamaged part is delivered and released.

This 'peripheral' trauma also touches on thewidely discussed problem of whether birth injuriesare due to asphyxia or to mechanical factors.During breech delivery the umbilical cord is oftencompressed in the narrow birth canal by theaftercoming head, causing severe asphyxia. Theasphyxia not only damages the fetus generally butalso affects its capillaries locally and impairs thecirculatory metabolic conditions in the damagedtissue. It seems, however, that in term babies thereis a prevalence of mechanical factors, as there is adirect relation between the severity of these injuriesand the dilatation of the birth canal, the size of the

fetus, and the time of rupture of membranes. Thelocalization of bruising in various regions regularlyfollows the same pattern, and, in addition, there ishistological evidence of direct trauma to musclefibres. Prematurity also no doubt plays animportant role in the trauma, as in preterm babieswith immaturity of organs, fragility of vessels,disturbance of blood coagulation, and lack ofprotective subcutaneous tissue, injuries are moresevere (Table VII).

TABLE VIISeverity of trauma in 86 breech-born babies:

significance of prematurity

Preterm babiesTerm babies

No injury(% cases)

54

Slight injury(% cases)

854

Severe injury(% cases)

8742

What are the possible consequences of traumawhich the baby suffers during breech delivery ? Inbabies that survive, smaller haemorrhages intomuscles can be resolved, as would be expected fromwhat is known about the excellent healingcapabilities of newborn tissues. In more severemuscle damage and bruising, however, there is thepossibility that repair by fibrosis may interfere withfuture limb development.The findings of lower nephron nephrosis with

fibrin-positive casts and evidence of scatteredmicrothrombosis in 3 of 6 children who died shortlyafter birth with severe muscle injury, suggests thatthey suffered from crush syndrome and an episodeof DIC. The complete necropsy on these babies,including dissection of the locomotor system, offersone possible explanation for these fatal conditions:extensive birth damage and haemorrhage intomuscles resulting in haemorrhagic and traumaticshock. There are several published reportsdescribing the presence of these fatal conditions innewborn babies.

Indirect clinical evidence that the muscles inbreech delivery are crushed and damaged wassupplied by Rudolph and Gross (1966), who studiedthe level of creatine phosphokinase in children aftervarious types of delivery. Comparison of some ofhis figures from breech delivery and normalpresentation shows that the highest level of thisenzyme was found in breech-born babies. Amechanism similar to the damage of an extremityresulting from a long and difficult labour was

reported by Muller and Muller (1952) in a case offatal crush syndrome in a child where muscles of the

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12 Z. A. Rfils'trunk and arm were damaged and showedhaemorrhage in the area of the mouth of a suctionconduit to which the child had been stuck.Lower nephron nephrosis in 3 newborns was

described by Jonsson (1951). The babies, all bornof primipara, suffered from 'severe asphyxia andshock, and acute renal insufficiency. Necropsy onone of the children revealed numerous brownishcasts in distal renal tubules containing haemoglobin,and also multiple fibrinous thrombi and scatteredareas of focal necrosis in liver. This appearance ofcasts in kidneys, which the author attributed tosevere asphyxia and shock, is consistent with ourfindings of massively blocked renal tubulessuggesting that traumatic uraemia (crush syndrome)took place.The occasionally severe consequences of blood

loss in newborn babies with large cephal-haematomata have been documented (Bernard andSansot et Rapezzi, 1960; Tosovsky, Stryhal, andSyrovatka, 1961; Janovsky, 1963), and in our casesthe volume of blood in crushed muscles was suchthat haemorrhagic shock may occur in these babies.The loss of blood could be especially dangerouswhen haemolysis or myolysis is present, since it isknown that patients with crush syndrome tolerateblood loss badly. In Hardaway et al's experiments(1964) the mortality of haemorrhagic shock in dogsincreased from 13% to 91% after the injection of 22ml of their own haemolysed blood.

Finally, babies with severe muscle traumaresulting in stagnant capillary circulation, acidosis,and myolytic and haemolytic products accumulatedin crushed tissues provide all the conditionsnecessary for development of DIC (Hardaway andJohnson, 1963; Hardaway, 1966; R. M. Hardaway,personal communication, 1970). Leissring andVorlick5 (1968) reported a case of a newborn babywith asphyxia, brain damage, and haemorrhagicdiathesis, in whom post-mortem microscopicalexamination revealed typical features of DIC. Thebaby with '. . . petechial rash over the buttocks anddiffuse ecchymosis of the left flank. . .' was born to a30-year-old primpara and died 7 days after breechextraction. Jonsson (1951) reported 3 newbornbabies with acute renal insufficiency and 'severeasphyxia and shock', and described the typical DICappearance in liver and brain of one. Theappearance of microthrombi in our materialresembles that in experimental traumatic shock andin DIC. Though the microthrombi are not alwayseasy to find as they soon disappear, probably beinglysed by endogenous fibrinolysin and then washedout. On the other hand, these changes are notmerely 'agonal', as they are frequently seen in

association with cellular infiltration and small areasof necrosis, and are never found in cases of traumaresulting in immediate death (Hardaway, 1966).The majority of statistics dealing with neonatal

mortality are based on routine post-mortemexamination which does not usually involvedissection of the muscles, and though reporting onhundreds of babies dying after breech presentation,Gordon, Garlic, and Oginz (1934), Kauffler (1941),Schmitz, Smith, and Clumpner (1955), and Morganand Kane (1964) failed to mention trauma to mus-cles among the possible causes of death. Thesesurveys do state that in a proportion, 16% accordingto Schimitz et al., of cases the cause of death is un-explained. If analysis of the cause of the child'sdeath is to be accurate, systematic post-mortemdissection of the muscles should be done after everydifficult labour and malpresentation, timeconsuming though it admittedly is.

I thank Professor J. L. Emery, Sheffield Children'sHospital, for his encouragement.

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Benesova, D. (1958). Pathomorphological classification of the birthdamage. Sborn. 9. ped. sjezdu, Brno, 1957. SPN, Praha(in Czech).

Bernard, R., and Sansot et Rapezzi, M. (1960). Anemia caused byextensive hematoma of the scalp in the newborn (apropos of fiverecent cases). Pediatrie, 15, 588.

Brosset, A. (1956). Maternal morbidity and foetal mortalityassociated with breech presentation. Acta Obstetricia etGynecologica Scandinavica, 35, 546.

Burger, P., Milfort, J., and Denef, R. (1962). Some considerationson breech presentation following new data on this subject.Gynicologie et Obstitrique (in French), 61, 461.

Elefant, E. (1957). One year's experience with babies born by breechpresentation and Caesarean section. Ceskoslovensk4 Pediatrie(in Czech), 12, 687.

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Gordon, C. A., Garlick, R., and Oginz, P. (1934). Analysis of 3301breech deliveries in hospitals of Brooklyn, New York.American Journal of Obstetrics and Gynecology, 28, 140.

Hardaway, R. M. (1966). Syndromes of Disseminated IntravascularCoagulation. Thomas, Springfield, Illinois.

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Hedberg, E. (1957). Breech deliveries: with special reference tofoetal mortality. Acta Obstetricia et Gynecologica Scandinavica,36, 356.

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Leissring, J. C., and Vorlickt, L. N. (1968). Disseminated intra-vascular coagulation in a neonate. American Journal of Discasesof Children, 115, 100.

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Ralis, Z. A. (1968b). Trauma to newborn babies during breechdelivery. Part 2. Muscle damage. M.D. Thesis. Facultyof Paediatrics, Charles University, Prague.

Rudolph, N., and Gross, R. T. (1966). Creatine phosphokinaseactivity in serum of newborn infants as an indicator of fetaltrauma during birth. Pediatrics, 38, 1039.

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Correspondence to Mr. Z. A. RAlis, Department ofTraumatic and Orthopaedic Surgery, Cardiff RoyalInfirmary, Cardiff CF2 1SZ.


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Birth trauma to in delivery and its fatal consequences · Birth trauma is supposed to be the main factor responsible. Despite attempts to reduce the high mortality rate, the figures