Berman S, "Birth Molding and Obstetric Trauma - Skull Joint Pathology and the Need for Treatment"
Dr. Stephen Berman is on the NCRT committee (Nasal Cranial Release Technique). NCRT refers to a variety of methods which utilize inflatable devices to assist the expansion of internal cranial sutures accessed through the nasal passages.
Birth molding is often the first, not to mention most serious head injury that an individual will ever suffer. Birth attendants usually consider these severe subluxations and dislocations of the skull benign and self-correcting, hence no treatment is applied to correct the neonate's traumatized skull - even in severe cases (Ehrenfest (1), Baxter (2), Swartz (3), DeSouza et al. (4), Kriewall et al. (5), Sorbe & Dalhgren (6)).
I suggest, however, that treatment of this widely recognized trauma is both logical, prudent, and essential. It should be noted that hydrostatic pressure differentials between the intra and extrauterine spaces may also contribute to birth molding (Swartz (3)). Several authors have indeed suggested treatments for birth molding. Swartz (3), in his monumental review of birth injury (which includes a bibliography with more than 2,000 references) issues an eloquent plea for attention to prevention and treatment of this earliest trauma. Papers by Clarren et al.(7) and Clarren (8) report the use of a 'helmet therapy' to reverse birth molding of the cranial portion of the skull. In this treatment, the skull is forced to conform to a helmet which the child may need to wear for several years. Even an editorial in Lancet from 1986 (9) advocated the need for development of strategies for treatment of these widespread but unattended injuries to our children.
The Birth Process
We are, with the exception of cesarean birth, born through the our mothers' pelvises. The pelvis is the boney obstacle presented by the mother to the birth; the head is the boney obstacle presented by the fetus/neonate. It is commonly accepted that impact between these boney structures causes damage to both mother and child. Cephalo-pelvic disproportion so severe as to cause the fetal head to jam in the birth canal commonly necessitates delivery by cesarean birth, forceps or suction devices, pitocin induced contractions, etc. Even despite intervention, some infant mortality and morbidity attributed to head trauma during delivery is inevitable.
Even though a child may survive the birth process, it may still suffer significant head trauma. Ironically, these non-life-threatening are labeled merely benign, non-pathological birth molding. This is a serious oversight. Following delivery, the mother (who underwent expansive trauma in the form of abrasions and tearing of her birth canal and perineum as well as stretching of the pelvic joints) is treated by stitching, bracing, adjustment, manipulation, and/or mobilization. The neonate, however, (who shows the compressive trauma of the birth in the form of its distorted (subluxated/dislocated) face and cranium, bruising, caput seccedoneum, cephalohematoma, and abrasions) is routinely left untreated. This injured child is merely cleaned and swaddled and dismissed as normal and suffering only trivial complaints. Conventional wisdom at this time is that birth molding spontaneously resolves over the first few days of life without any residua. The parents are often
told that "most" of the birth molding will resolve during the first few days following delivery. This, though, begs the question: "What about that portion that does not resolve in the first few days, and with what consequences?"
While it is true that the pull of the meningeal membranes and the internal pressure of the cerebral spinal fluid act to partially reverse the birth molding, the infant skull, formed by 73 ossification centers (many of which are still unfused at birth), is much too complicated and delicate to spontaneously "pop" back into perfect alignment after the significant insult of delivery. Residual displacements (subluxations) of the skull's bones and pressures upon the soft tissues within then cause various dysfunctions, many of which have been previously considered to be of "unknown" etiology.
The structure-function relationship is a well founded axiom within the health sciences. With the face and cranium housing the central nervous system, the cranial nerves, the neuro-endocdne system, the special senses, the proximal respiratory and gustatory functions (breathing, swallowing, chewing), as well as the many cranial articulations and their associated nerve fibers, it should be evident that it is vital that the skull's jointed relationships be intact for the skull to function normally. It is generally accepted that facial and cranial trauma FOLLOWING birth leads to dysfunction of the housed structures. It is not generally accepted that this same trauma DURING birth is just as damaging. This is a severe oversight!
Treatment is Needed
Why are we so callous towards this early trauma? I believe that because we do not see our children before birth, we interpret the physical condition of the molded skull as normal. If parents and birth attendants were able to compare the baby before and after labor, this author believes they would be extremely concerned. O'Doherty's comprehensive color photographic atlas of birth trauma(l0) often surprises those who are unfamiliar with the extent of these routine injuries. Even she labels pictures of significantly molded newborns as "normal" and suffering "trivial” complaints. This prejudiced view of the so-called normal newborn is tragic. We send our children out into life injured by birth trauma, untreated, and with the seeds of disability already planted. Some of these disabilities will manifest themselves early in life, others later.
REFERENCES
1. Ehrenfest H. Birth injuries of the child. New York: Appleton and Co., 1922.
2. Baxter J. Molding of the foetal head: a compensatory mechanism. Journal of Obstetrics & Gynocology of the British Empire 1946; 53 (3):212-8.
3. Swartz P. Birth injuries of the newborn. New York:Schweiz and Karger, 1961.
4. DeSouza SW, Ross J, Milner RDG. Alterations in head shape of newborn infants after Caesarean section or vaginal delivery. Archives of Disease in Childhood 1976; 51:624-7.
5. Kriewall TJ, Stys SJ, McPherson GK. Neonatal head shape after delivery: An Index of Molding. Journal of Perinatal Medicine 1977; 6:260-7.
6. Sorbe B, Dahlgren S. Some important factors in the molding of the fetal head during vaginal delivery-a photographic study. International Journal of Obstetrics 1983; 21:205-12.
7. Clarren S, Smith D, Hanson JW. Helmet treatment for plagiocephaly and congenital muscular torticollis. The Journal of Pediatrics 1979; 94 (1):43-6.
8. Clarren SK. Plagiocephaly and Torticollis: Etiology, Natural History, and Helmet Treatment. The Journal of Pediatrics 1981; 98(l):92-5.
9. Anonymous. Plagiocephaly and torticollis in young infants (Editorial). Lancet 1986; 2:789-90.
10. O'Doherty N. Atlas of the Newborn. Hingham, Ma.: MTP Press, 1985.