Continuing Education Activity
Birth trauma describes physical injuries during labor and delivery, both to the neonate and to the birthing person, as well as psychological injuries or stress that can occur to the individual giving birth and those involved in the delivery process. The birthing process is a psychologically and physiologically stressful event for both the birthing person and the neonate.
Physical birth trauma can include damage to the maternal pelvic organs, including perineal lacerations, particularly second through fourth degree tears, which are among the most common maternal injuries, leading to long-term complications such as dyspareunia, urinary and fecal incontinence, and pelvic organ prolapse, as well as life-threatening hemorrhage. Neonatal birth trauma can include minor scalp swelling, significant intracranial hemorrhage, brachial plexus damage, broken bones, and the sequelae of decreased oxygenation to the fetal brain during the delivery process. Moreover, psychological stress can include negative emotional distress related to unexpected events during or after the delivery process or any adverse reaction to the birthing experience, which can lead to long-term sequelae such as posttraumatic stress disorder (PTSD).
This activity reviews common birth-related physical and psychological maternal and neonatal injuries, as well as the mechanism of injury, clinical features, and management of various birth-related traumatic events. This activity for healthcare professionals is designed to enhance the learner's competence in identifying and, when possible, preventing both physical and psychological birth trauma, performing the recommended evaluation, and implementing an appropriate interprofessional approach when managing this condition to optimize maternal and neonatal outcomes.
Objectives:
Identify the clinical manifestations of common intrapartum birth trauma injuries.
Evaluate the most common risk factors associated with psychological maternal birth trauma.
Determine the mechanism of injury underlying various types of birth trauma.
Assess the importance of interprofessional team training and collaboration in the prevention and management of all forms of birth trauma.
Access free multiple choice questions on this topic.
Introduction
Birth trauma refers to both physical and psychological trauma that occurs during, or as a result of, the birthing process, involving the individual giving birth, the neonate, or both. Although physical injuries are more frequently considered when birth trauma is considered, the birthing process is a psychologically and physiologically stressful event that can impact patients' mental health as well.
Maternal Birth Trauma
Maternal physical injuries primarily include perineal lacerations, which can have both short and long-term effects. Perineal lacerations are the most common somatic injury, occuring in up to 90% of vaginal deliveries. Perineal lacerations are graded from first degree (interruption of vaginal mucosal only) to fourth degree (injury comprising the vaginal mucosa, pelvic floor muscles, external and internal anal sphincters, and the rectal mucosa). Even after repair, lacerations often lead to pain, dyspareunia (pain with intercourse), pelvic floor dysfunction, and mood concerns.[1] Third and fourth degree lacerations involve obstetric anal sphincter injuries (OASI) and pelvic floor injuries of the levator ani muscles, which can lead to long term pelvic floor dysfunction including urinary or fecal incontinence and pelvic organ prolapse.[2] These physical complications can limit the birthing person's ability to care for their newborn and may impact their future sexual intimacy. Please see StatPearls' companion resources, "Perineal Lacerations" and "Pelvic Floor Dysfunction", for further information on these topics.
Psychological birth trauma includes posttraumatic stress disorder (PTSD), postpartum depression, anxiety, and other acute mood disorders.[3] Numerous risk factors contribute to this form of trauma, which often arises in conjunction with physical birth trauma rather than as an isolated experience. Psychological birth trauma, like its physical counterpart, can produce long-term consequences for both the birthing person and the newborn, affecting emotional well-being, maternal-infant bonding, and overall family health.
Neonatal Birth Trauma
Neonatal birth trauma encompasses a broad spectrum of injuries, ranging from minor to severe, caused by mechanical forces during labor and delivery. These injuries include head trauma, intracranial and extracranial hemorrhages, and brachial plexus injuries. Please see StatPearls' companion resource, "Brachial Plexus Injuries", for further information. Birth injuries differ from congenital malformations and can typically be distinguished through focused clinical assessment shortly after delivery.
Over recent decades, birth trauma rates have declined due to advances in obstetrical techniques and an increased reliance on cesarean delivery, particularly in cases of labor dystocia where operative vaginal deliveries using vacuum or forceps might previously have been performed. Between 2004 and 2012, the rate of birth trauma dropped from 2.6 to 1.9 per 1,000 live births. This trend aligns with a consistent decrease in operative vaginal deliveries and a corresponding increase in cesarean section rates over the past 30 years.[4]
Issues of Concern
Risk factors for birth trauma fall into 3 main categories: fetal, maternal, and iatrogenic (eg, the use of instrumentation during delivery).[5][6] Psychological birth trauma risk factors are most effectively organized by timing, encompassing antenatal, intrapartum, and postnatal periods.
Physical Birth Trauma
Risk factors for physical birth trauma include the following:
Fetal and pregnancy-related factors
Macrosomia
Macrocephaly
Very low birth weight
Extreme prematurity
Congenital anomalies
Oligohydramnios and malpresentation, including breech presentation as well as other abnormal presentations (eg, the face, brow, or transverse)
Maternal factors
Obesity
Preexisting medical conditions, including diabetes or hypertension
Medical conditions diagnosed during pregnancy, including diabetes or hypertension
Cephalopelvic disproportion
Small maternal stature
Nulliparity
Labor dystocia and difficult fetal extraction
Use of vacuum or forceps
Prolonged or rapid labor
[7]
Psychological Birth Trauma
Risk factors for psychological birth trauma include the following:
Antenatal factors
Depression
Fear of childbirth
Poor maternal health
History of trauma or sexual abuse
Adverse childhood experiences
Lack of support
Housing and financial concerns
Maternal substance use disorder
Preexisting mental health concerns
[8][9]
Intrapartum factors
Preterm delivery
Negative subjective birth experience (eg, negative emotions during childbirth, lack of control or agency)
Operative birth (eg, vacuum or forceps-assisted delivery)
Obstetrical complications or unexpected outcomes (eg, neonatal birth injuries, stillbirth, emergency cesarean delivery)
Severe maternal morbidity (eg, ICU admission, preeclampsia, hemorrhage, sepsis)
Lack of support
Dissociation during childbirth
Postpartum factors
Postpartum depression
Postpartum physical complications (eg, postpartum hemorrhage, perinal lacerations, cesarean section wound complications)
Poor coping and stress
Lack of support
Housing and financial concerns
Maternal substance use disorder
Clinical Significance
Maternal Physical Birth Trauma
Physical birth trauma includes perineal lacerations, which can consist of OASI and damage to pelvic floor musculature. Perineal lacerations are the most common maternal obstetrics injury, occurring in up to 90% of vaginal births. Perineal lacerations are more common in nulliparous birthing people. (Please refer to the Issues of Concern section for more information for a more complete list of risk factors.)
Perineal lacerations are graded from first degree to fourth degree. A second degree tear, the most common obstetric laceration, involving the vaginal mucosa and pelvic floor musculature, increases the short and long term risk of stress urinary incontinence. One study demonstrated that in the first year following birth, 31% of women experienced stress urinary incontinence with a second-degree laceration as the primary risk factor.[10] Higher-degree perineal lacerations (third and fourth degrees) involve OASI, which can have a significant impact on a person's overall health, both physically and psychologically. Specifically, anal incontinence has been demonstrated in up to 10% to 14% of patients with OASI within the first year following delivery.[11] In another study evaluating the long term risk of anal incontinence, 58% of patients who had a third or fourth degree tear reported anal incontinence.[12]
Additionally, perineal lacerations increase the risk of dyspareunia following childbirth (31% to 41% for first and second degree tears, 62.5% for OASI).[10] No single effective strategy for the prevention of perineal lacerations has been demonstrated. Effective intrapartum methods, including manual perineal protection and decreased use of forceps or vacuums, can reduce the likelihood of perineal lacerations. Mediolateral episiotomy, defined by making an incision or cut with scissors at a 45 degree angle on either side of the vaginal opening, generally 3 to 4 cm in length involving the vaginal epithelium, tranverse perineal muscle, and bulbocavernosus muscle, when appropriate, can also decrease higher order lacerations and OASI. However, mediolateral episiotomy is associated with an increased risk of dyspareunia.[10] Standard repair of perineal lacerations and OASI should be performed to decrease the risk of long-term adverse effects.
Maternal Psychological Birth Trauma
Adverse birthing experiences put patients giving birth at risk for acute and chronic psychological concerns, including postpartum depression, anxiety, adjustment disorder, and PTSD.[13] A recent meta-analysis and systematic review analyzed 154 studies to determine the prevalence of meeting all criteria for PTSD and posttraumatic stress symptoms (PTSS) in individuals giving birth and their partners. They found the mean prevalence of meeting all criteria for PTSD to be 4.7% in birthing people. Notably, 12.3% of patients in this study exhibited PTSS. However, in prior studies, up to 50% of women have described their births as traumatic and display some symptoms of PTSD.[3]
As expected, specific patient characteristics were identified as more likely to result in higher rates of PTSD, including experiencing a traumatic birth, having a basline fear of childbirth, delivering prematurely, having a newborn who requires admission to the neonatal intensive care unit (NICU), undergoing an emergency cesarean section, experiencing a stillbirth, having pregnancy complications, being of an ethnic minority, and having a maternal history of trauma.[14]
The diagnosis of PTSD and other mood disorders is made via the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). In general, symptoms of PTSD include intrusive symptoms, eg, distressing dreams or memories of the traumatic event, hyperarousal defined as intense or prolonged psychological or physiologic responses to anything related to the traumatic event, negative changes to mood or cognition, and avoidance of certain stimuli. One aspect of the diagnostic criteria for PTSD includes a disturbance that causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Please see StatPearls' companion resource, "Posttraumatic Stress Disorder", for further information on diagnostic criteria and management of this condition.
Birth-related PTSD carries numerous adverse consequences. The condition can disrupt parent-child bonding and attachment, reduce breastfeeding initiation or continuation, and increase the preference for elective cesarean delivery in future pregnancies.[3] Beyond pregnancy, PTSD may lead to difficulties with intimacy, family discord, loss of identity, a diminished sense of parenthood, or even suicidal ideation.[15] Evidence also links maternal PTSD to adverse outcomes for children, including increased sleep disturbances and impaired overall development.
Effective management of PTSD following birth trauma involves multiple layers of care. Primary prevention should begin with reducing modifiable risk factors, including offering delivery debriefings. Although a 2015 meta-analysis of 7 studies involving over 1,700 patients found no significant PTSD symptom improvement with routine debriefing, targeted debriefing for those who perceived their birth as traumatic has shown benefit.[16][17][18][19] Secondary interventions include evidence-based medication management and psychotherapy. Please see StatPearls' companion resource, "Posttraumatic Stress Disorder", for further information on diagnostic criteria and management of this condition.
Early postpartum therapies have also demonstrated value in mitigating PTSD symptoms when implemented within the first days and weeks following delivery.[20] Additionally, trauma-informed care has gained recognition as a vital approach to management. This model emphasizes awareness of trauma and its effects, recognition of trauma-related symptoms, implementation of appropriate responses, and prevention of retraumatization—known as the "4 R’s." Consistent use of trauma-informed care throughout the healthcare continuum, especially during pregnancy, creates a critical opportunity to identify and address PTSD risk factors in populations that may have limited interaction with healthcare outside of the perinatal period.
Neonatal Physical Birth Trauma
Clinical management and prognosis of infants with birth injuries depend primarily on the type and severity of the injury. The most frequently affected areas include the head, neck, and shoulders, while less commonly involved sites encompass the face, abdomen, and lower limbs. Head trauma can include superficial lesions or lacerations, extracranial and intracranial hemorrhages, and fractures of the skull bones.
Caput succedaneum
Caput succedaneum represents a common form of scalp swelling in newborns. This subcutaneous edema develops between the skin and the periosteum as a result of local venous congestion caused by pressure from the birth canal on the presenting part. Because the swelling occurs above the periosteal plane, it typically crosses suture lines. Intervention is not necessary, as the edema generally resolves within the first few postnatal days. Although rare, complications may include skin bruising over the swelling, which can lead to necrosis, scarring, and alopecia. Infrequently, systemic infection may also develop.
Skull fractures
Skull fractures associated with birth trauma most often occur following instrument-assisted vaginal deliveries. These fractures may be linear or depressed and tend to remain asymptomatic unless accompanied by intracranial injury. Plain skull radiographs usually confirm the diagnosis. When neurologic symptoms or signs of intracranial injury are present, further evaluation with computed tomography (CT) or magnetic resonance imaging (MRI) of the brain is recommended.
Extracranial hemorrhages
Cephalohematoma
Cephalohematoma refers to a localized subperiosteal blood collection caused by the rupture of blood vessels extending from the skull to the periosteum. Confined by the periosteal attachment to the skull bones, the swelling remains within suture lines and typically presents unilaterally.
This condition occurs more frequently in vacuum- or forceps-assisted deliveries and affects up to 2.5% of all births.[21] Most cases resolve spontaneously within 2 weeks to 3 months without intervention. However, complications may include calcification, skull deformities, infection, and osteomyelitis.
Subgaleal hemorrhage
Subgaleal hemorrhage involves bleeding into the loose areolar tissue space between the galea aponeurotica and the skull’s periosteum. This injury results from traction that separates the scalp from the underlying bony calvarium, leading to the shearing or rupture of bridging vessels. Forceps- or vacuum-assisted vaginal deliveries represent the most common precipitating events.
The condition occurs in approximately 4 out of 10,000 spontaneous vaginal deliveries and 59 out of 10,000 vacuum-assisted deliveries.[22] Because of the space's capacity to accommodate large volumes of blood, subgaleal hemorrhage can cause acute hypovolemic shock, multiorgan failure, and death. Management focuses on early recognition and supportive care, including blood or fresh frozen plasma transfusions to restore circulating volume. The hemorrhage itself remains undrained and gradually resorbs over time.
Intracranial hemorrhages
Traumatic intracranial hemorrhages primarily include the following types of intracranial hemorrhage:
Epidural hemorrhage: Epidural hemorrhage is rare in neonates and usually accompanies linear skull fractures in the parietal-temporal region following an operative delivery. Signs include bulging fontanelle, bradycardia, hypotension, irritability, altered consciousness, hypotonia, and seizures. Diagnosis is via CT or MRI of the head, which shows a convex appearance of blood collection in the epidural space. Prompt neurosurgical intervention is necessary due to the potential for rapid deterioration.
Subdural hemorrhage: This type of intracranial hemorrhage is the most common type in neonates. Operative vaginal delivery is a significant risk factor, and hemorrhage over the cerebral convexities is the most common site. Presenting clinical features include bulging fontanelle, altered consciousness, irritability, respiratory depression, apnea, bradycardia, altered tone, and seizures. Subdural hemorrhages can occasionally be found incidentally in asymptomatic neonates. Management depends on the location and extent of the bleeding. Surgical evacuation is reserved for extensive hemorrhages causing raised intracranial pressure and associated clinical signs.
Subarachnoid hemorrhage: This is the second most common type of neonatal intracranial hemorrhage and is usually the result of the rupture of bridging veins in the subarachnoid space. Operative vaginal delivery is a risk factor, and affected infants are typically asymptomatic unless the hemorrhage is extensive. Ruptured vascular malformations are a rare cause of subarachnoid hemorrhages, even in the neonatal population. Treatment is usually conservative.
Intraventricular hemorrhage: Intraventricular hemorrhage is most commonly seen in premature infants but can also occur in term infants, depending on the nature and extent of the birth injury.
[23]
Brachial plexus injuries
Brachial plexus injuries occur in up to 2.5 per 1000 live births and result from stretching of the cervical nerve roots during delivery. These injuries are usually unilateral, and risk factors include macrosomia, shoulder dystocia, prolonged fetal extraction at the time of delivery, breech position, multiparity, and operative deliveries.[24] The following palsies are associated with the nerve roots injured:
Erb-Duchenne palsy: Injury involving the fifth and sixth cervical nerve roots results in Erb-Duchenne palsy, manifested by weakness in the upper arm. Adduction and internal rotation of the arm with flexion of the fingers are presenting symptoms. This is the most common form of brachial plexus injury.
Klumpke palsy: Injury to the eighth cervical and first thoracic nerves results in Klumpke palsy, manifested by paralysis of the hand's muscles, absent grasp reflex, and sensory impairment along the ulnar side of the forearm and arm.
Total arm paralysis: Injury to all the nerve roots can result in total arm paralysis.
Phrenic nerve injury: Injury to the phrenic nerve can be an associated feature of brachial plexus palsy. Clinical manifestations include tachypnea, asymmetric chest motion, and diminished breath sounds on the affected side.
The majority of brachial plexus injuries are stretch injuries, and treatment is typically conservative, with physical therapy playing a significant role in the gradual return of function.[25] Rare, severe cases of brachial plexus injuries result in lasting weakness on the affected side. Around 70% to 80% of children recover fully from a brachial plexus injury sustained at the time of birth. Children without full recovery by 3 months of age are likely to have some residual impairment, most commonly to the shoulder, elbow, or forearm. Early referral to a brachial plexus birth injury clinic is important to allow for the institution of physical therapy, occupational therapy, and surgical intervention if required.[BMJ Best Practice US]
Other Issues
Birth Trauma Preventative Strategies
Preventing birth trauma requires a proactive, interprofessional approach involving obstetricians, midwives, neonatologists, pediatricians, nurses, social workers, mental health professionals, and other ancillary staff. Advances in antenatal care have improved the detection of fetal anomalies and malpresentations, allowing teams to anticipate complications and prepare for high-risk deliveries. Coordinated prenatal education across the care team reinforces best practices and reduces the likelihood of adverse outcomes. Early identification of risk factors—both physical and psychological—must be prioritized, and effective communication among team members is essential. For instance, sharing concerns about fetal size, position, maternal pelvic structure, or the patient’s mental health history before delivery can significantly enhance team readiness and maternal-newborn safety.
Clearly defined roles and targeted training during the intrapartum period further strengthen outcomes. Familiarity with obstetric emergencies, such as shoulder dystocia, and ensuring that all team members—including physicians, midwives, nurse practitioners, and nurses—are trained in appropriate interventions directly contributes to reduced maternal and neonatal morbidity and mortality. While not all birth injuries are preventable, the care team must remain vigilant in identifying trauma early and providing appropriate counseling and follow-up care. Postpartum care teams should remain alert to signs of depression, anxiety, or PTSD and provide early mental health support to all birthing individuals.
From a pediatric standpoint, the presentation of birth trauma varies depending on the nature and severity of the injury, ranging from minor symptoms to life-threatening complications. Accurate diagnosis begins with a comprehensive newborn exam and continues through open communication between obstetric and pediatric teams to review labor and delivery events. Pediatricians and neonatologists play a vital role in examining newborns for signs of injury, coordinating with obstetric teams to understand the labor and delivery context, and initiating early interventions when needed. For example, in cases involving operative vaginal delivery, clinicians should maintain heightened awareness for potential injuries, eg, intracranial hemorrhage. Prompt recognition and intervention can significantly improve neonatal outcomes. Infants affected by birth trauma face an increased risk for neurodevelopmental delays and benefit from coordinated follow-up by an interprofessional team. Early involvement of services such as speech and occupational therapy helps support optimal developmental progress and long-term well-being.[What is “Early Intervention”?, CDC]
Enhancing Healthcare Team Outcomes
Effective prevention and management of birth trauma rely on the coordinated efforts of an interprofessional team comprising obstetricians, midwives, neonatologists, pediatricians, nurses, mental health professionals, social workers, and ancillary staff. Each team member plays a critical role in identifying, communicating, and mitigating risk factors during the prenatal, intrapartum, and postpartum phases of care. Advances in antenatal diagnostics allow clinicians to anticipate complications such as fetal malpresentation or congenital anomalies, thereby facilitating early preparation for high-risk deliveries. Clear communication between antepartum and intrapartum teams about potential physical and psychological risk factors—including fetal size, maternal pelvic anatomy, and mental health history—enhances preparedness and promotes patient-centered care. Collaborative education and planning, involving all members of the care team, reinforces high-quality prenatal management and reduces the likelihood of adverse events during labor and delivery.
During the intrapartum period, structured role delineation and shared protocols enhance team performance and patient safety. Coordinated educational training among physicians, midwives, nurse practitioners, and nurses on maneuvers for resolving obstetric emergencies, such as shoulder dystocia, can reduce maternal and neonatal complications. Communication between pediatric and obstetric teams becomes especially important in scenarios like operative vaginal deliveries, where certain injuries are more likely. Newborns with birth trauma require ongoing monitoring by an interprofessional team to assess neurodevelopmental progress and implement early interventions, eg, occupational and speech therapy, when necessary. This integrative, patient-centered approach strengthens outcomes, supports family well-being, and reinforces safety and accountability throughout the perinatal care continuum.
