FORENSIC DIAGNOSIS OF BIRTH TRAUMA IN NEWBORNS: A LITERATURE REVIEW

Full Text

**INTRODUCTION**

Currently, the term “birth trauma” in forensic medicine is unequivocally defined as mechanical injury to the fetus during labor [1, 2, 3]. However, according to the International Classification of Diseases, 10th Revision (ICD-10), it is classified under Chapter XVI—“Certain conditions originating in the perinatal period”—under codes P10–P15.

According to the Russian Statistical Yearbook, infant mortality due to perinatal conditions in 2023 was 19.2 per 10,000 live births, maintaining its leading position among all causes of infant death [4]. In Russian-language literature, reported incidence rates of birth trauma vary significantly, largely depending on diagnostic practices.

For instance, Kravchenko (2009) reported that birth trauma accounted for 26.3–41.9% of all neonatal morbidity and 37.9% among deceased full-term newborns [5]. In contrast, recent studies indicate much lower rates: 3.6% in vaginal deliveries and 1.2% in cesarean sections [3]. This discrepancy suggests that low regional statistics do not reflect the absence of the problem but rather underdiagnosis—or possibly improved obstetric care—both of which necessitate objective, scientifically grounded forensic investigation.

In clinical practice, there is a tendency—driven by healthcare administrators’ negative perception of the diagnosis—to replace the term “birth trauma” with “hypoxic-ischemic encephalopathy” (HIE). HIE implies intrauterine fetal hypoxia rather than mechanical central nervous system injury [6], yet this substitution often lacks confirmation from normal oxygen saturation levels recorded at birth, as documented in criminal and civil case materials.

The intentional or unintentional concealment of true birth trauma rates negatively impacts early detection, timely treatment, and accurate epidemiological accounting, effectively erasing this condition from clinical management protocols.

The primary task of the forensic medical expert in examining newborns—regardless of gestational age—is to identify such injuries and establish a causal link either to the biomechanics of labor or to deficiencies (defects) in obstetric care [1, 7, 8].

When defects in medical care are identified, birth trauma is legally regarded as harm caused to the newborn’s health, provided a direct causal relationship exists between the injury and the identified deficiency [7].

Particular concern arises regarding the use of the Kristeller maneuver—a technique officially prohibited in the Russian Federation for preterm deliveries¹. Despite this ban, testimonies from mothers in criminal and civil cases frequently report its application during labor.

Forensic medicine has established that birth trauma in newborns is invariably combined and at minimum involves cranio-spinal injury [1, 7, 9], contributing significantly to childhood disability and mortality. Consequently, obstetricians involved in such deliveries may face criminal or civil liability for substandard care. Between 2016 and 2018, the number of forensic examinations in “medical malpractice” cases in Russia increased fourfold [10].

According to data from the Federal State Budgetary Institution “Russian Center of Forensic Medical Examination” (RCFME), out of 3,618 criminal cases reviewed between 2012 and 2021, 718 (15.3%) involved obstetrician-gynecologists².

Since 2012, Russia has adopted new medical criteria for live birth, now including infants with a birth weight of ≥500 g as subjects of forensic medical examination³.

Given that prematurity is a well-established risk factor for birth trauma [1, 7, 11], its detection in this vulnerable population is critically important.

Diagnostic algorithms for forensic identification of birth trauma in newborns weighing over 1,000 g are thoroughly described in both domestic and international literature, including all editions (2014–2024) of the *National Guidelines on Forensic Medicine* [1, 7, 10, 13, 14, 15].

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**BIOMECHANICS OF BIRTH TRAUMA TO THE NERVOUS SYSTEM**

From a forensic perspective, skull and spinal injuries in birth trauma are directly linked to the biomechanics of labor, particularly well-documented in full-term newborns. The principles for determining injury mechanisms are consistent across all fetal presentations [7].

During labor, expulsive forces act on the fetus:  
- **Upward pressure** from the uterine fundus,  
- **Circular constriction** from the uterine walls and cervix,  
- **Resistance** from maternal soft tissues opposing fetal descent [1, 7, 11].

This results in the “screwing-in” of the presenting part (head or breech) into the pelvis, with multidirectional compression (sagittal, frontal, diagonal). Maximum expulsive force is transmitted through the fetal spine, impacting the occipital condyles and basilar portion of the occipital bone [1, 7].

Although labor is a physiological process governed by natural laws, the expulsion phase—in classical obstetrics—is subdivided into distinct moments corresponding to fetal progression through the birth canal [16]. This temporal framework allows forensic experts to pinpoint when injuries occurred and correlate them with specific stages of obstetric intervention, thereby identifying or excluding care deficiencies [12].

The biomechanism of deformation and injury is best described for **anterior occiput presentation** (95% of physiological births).

**First moment (flexion of the head):**  
- Moderate flexion occurs if fetal head and maternal pelvis are proportionate; maximal flexion occurs in cephalopelvic disproportion.  
- The leading part compresses the cervical canal, causing skin-muscle flap indentation.  
- Simultaneously, central vault depression (parietal and occipital squama) leads to diploic vein rupture, subperiosteal hemorrhage, and early laminar cephalohematoma.  
- After full cervical dilation, a localized edema with hemorrhage—“caput succedaneum”—forms over the “leading point,” with underlying cephalohematoma.  
- Circumferential pressure induces sutural compression (sagittal, coronal, lambdoid, and squamous sutures), resulting in physiological or excessive **molding** of the fetal head.

**Occipital synchondroses** experience tensile stress intracranially and compressive stress externally. These structures tolerate ≤1 atm of force—the maximum in physiological labor. Exceeding this threshold causes:
- Rupture of intracranial synchondrotic connections,
- Displacement of bone fragments,
- Fractures and hemorrhages around lateral parts of the occipital bone [7],
- Epidural hemorrhages due to calvarial fractures [1].

Excessive suture diastasis combined with vault depression collapses the superior sagittal sinus, stretching and tearing the falx cerebri and tentorial attachments, leading to:
- Bilateral intradural hemorrhages,
- Hemorrhages in anterior/posterior atlanto-occipital membranes due to flexion-rotation,
- Prolonged molding (>5 days) due to tentorial strain [7].

Cortical and subarachnoid hemorrhages form along displaced bone edges and dural tension lines—known as the “step sign” (V. V. Vlasyuk) [11]. Sagittal sinus collapse impairs venous drainage, causing subependymal hemorrhages that may rupture into ventricles [1, 7, 11]. Complete exhaustion of cranial reserve space leads to symmetric cerebral compression and bilateral subependymal bleeds [7]. Blood from choroid plexus or terminal veins can fill the entire ventricular system [1].

**Second moment (internal rotation):**  
Asymmetric tensile forces arise from spinal pressure during rotational resistance, producing:
- Crossed or circular (Vlasyuk-type) excessive molding,
- Occipital squama displacement into the cranial cavity at the leading point,
- Contralateral tentorial tearing and rupture,
- Subdural hemorrhages from transverse/straight sinus or vein of Galen injury,
- Asymmetric cerebral compression and intraparenchymal hemorrhages [7].

**Third moment (extension):**  
Only vertical spinal pressure on the skull base occurs, exacerbating existing injuries.  
**Fourth moment:** No new cranial birth trauma occurs.

Concurrently, axial loading with rotation and flexion-extension causes **spinal trauma**, manifesting as:
- Hemorrhages in atlanto-occipital membranes,
- Ligamentous hemorrhages in atlanto-occipital and atlantoaxial joints (with possible hematomas),
- Intervertebral ligament and epidural hemorrhages in the cervical spine,
- Vertebral column deformation,
- Vertebral artery or radial branch injuries.

Cervical injuries occur during moments 1–2 alongside cranial trauma; thoracic/lumbar injuries may occur in moment 4 [7].

Forensic medicine has established a **complex of 12 mandatory findings** in craniovertebral birth trauma, the presence and severity of which confirm the biomechanism and distinguish obstetric injury from postnatal trauma:

1. Scalp and subaponeurotic hemorrhages at the “leading point”  
2. Cephalohematoma  
3. Dural injuries at venous sinus confluences  
4. Marked head molding  
5. Hemorrhages in anterior/posterior atlanto-occipital membranes  
6. Ligamentous hemorrhages in craniovertebral joints  
7. Localized epidural spinal hemorrhages  
8. Cervical spine deformation and intervertebral ligament hemorrhages  
9. Vertebral artery injuries  
10. Hypoxic and/or traumatic spinal cord lesions  
11. Fractures/cracks at cranial base synchondroses  
12. Intradural hemorrhages and tears in dural partitions [12]

Clinically, cephalohematoma is the most frequent finding—reported in 94% of birth trauma cases by Sergeychik et al., predominantly parietal (unilateral or bilateral), with 4% occipital and rare parieto-occipital forms [17]. International data corroborate this, reporting ~404 cases per 1,000 live births [18, 19].

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**CONCLUSION**

Available literature comprehensively describes the biomechanism of birth trauma in full-term newborns, enabling forensic linkage to labor dynamics, obstetric maneuvers, and care deficiencies.

Meanwhile, between 2016 and 2018, Russia saw a 5.6% increase in infants with **extremely low birth weight (ELBW: 500–999 g)**—rising from 0.36% to 0.38% of all births. Leading causes of death in this group include:
- Respiratory disorders (42.4‰ → 36.0‰),
- Perinatal infections (31.0‰ → 26.5‰),
- Intraventricular hemorrhage (30.1‰ → 35.1‰) [20].

We propose that a significant portion of these hemorrhagic and neurological injuries represent **unavoidable birth trauma**, resulting from the morpho-functional immaturity of organs and systems in ELBW newborns.

Notably, no forensic diagnostic criteria for birth trauma in ELBW infants currently exist in Russian literature. To address this gap, we advocate applying established autopsy protocols for full-term newborns to ELBW cases.

Identifying and scientifically justifying birth trauma in ELBW newborns—as injury to pathologically immature tissues, irrespective of delivery method—is essential for resolving medico-legal disputes, given the high mortality in this population.

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**Footnotes**  
¹ Order of the Ministry of Healthcare and Goskomstat of the Russian Federation No. 318/190, December 4, 1992.  
² Source: Medvestnik, October 4, 2022.  
³ Order of the Ministry of Healthcare and Social Development of the Russian Federation No. 1687n, December 27, 2011 (amended October 13, 2021).

About the authors

Leonid Shmarov

Russian Centre of Forensic Medical Expertise, Ministry of Health of the Russia

Author for correspondence.
Email: shmarov@rc-sme.ru
ORCID iD: 0000-0002-4233-3538

Doctor of Medical Sciences, Deputy Director for Expert Work

Russian Federation

Ekaterina Gorun

Email: katuhka30@mail.ru
ORCID iD: 0000-0002-7008-2975

Airat Khalikov

Email: airat.expert@mail.ru
ORCID iD: 0000-0003-1045-5677

Sergey Parilov

Email: parilov.s@mail.ru
ORCID iD: 0000-0001-9888-4534

Alexandr Maximov

Email: av.maksimov@guppros.ru
ORCID iD: 0000-0003-1936-4448

Alexandra Dygalo

Email: aleksandradyqaio@mail.ru
ORCID iD: 0009-0000-9277-9223

References

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