Updated: 9/10/2019

Neonatal Birth Injuries

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Snapshot
  • An infant is born to a G2P2 mother via vacuum extraction. On physical exam, there is an edematous swelling on the scalp that extends across the midline and crosses the suture lines of the skull. There is erythema over the swelling and upon palpation it appears to be above the periosteum. (Caput succedaneum)
Introduction
  • Clinical definition
    • an impairment in the function or structure of the neonate's body secondary to an adverse birth event
  • Epidemiology
    • incidence
      • approximately 2%
    • location
      • soft tissue
      • extracranially
      • intracranially
      • fractures
    • risk factors
      • macrosomnia
      • maternal obesity
      • breech position
      • forceps or vacuum assisted device
    • prognosis
      • infant mortality secondary to birth trauma has significantly decreased
Cranial Injuries


  • Caput succedaneum 
    • clinical definition
      • edematous scalp swelling above the periosteum that crosses the suture lines
    • pathophysiology
      • pathoanatomy
        • prolonged fetal head engagement in the birth canal or vacuum assisted device use leads to blood and serum accumulation above the periosteum (above the galea aponeurotica) and under the skin  
    • presentation
      • physical exam
        • swelling above the scalp that may have
          • erythema, petechiae, and ecchymosis
    • studies
      • diagnostic criteria
        • usually a clinical diagnosis
    • differential
      • cephalohematoma
      • iatrogenic encephalocele
    • treatment
      • conservative
        • watchful waiting
          • indication
            • caput succedaneum typically resolves in 4-6 days
  • Cephalohematoma
    • clinical definition
      • subperiosteal bleeding that does not cross suture lines 
    • pathophysiology
      • pathoanatomy
        • subperiosteal vessels rupture leading to the accumulation of blood underneath the periosteum
          • usually involves vessels over the parietal and occipital bone
          • after resolution of the cephalohematoma, calcification may arise, leaving a subcutaneous nodule that will later reabsorb in months
    • presentation
      • physical exam
        • swelling above the scalp that is unilateral
          • discoloration may or may not be present
        • erythematous and fluctuant scalp mass is concerning for
          • infection (Escherichia coli is the most common causative agent)
    • imaging
      • radiography or computerized tomography (CT) of the head
        • indications
          • when neurologic impairment is present
          • when there is concern for a skull fracture
    • studies
      • diagnostic criteria
        • usually a clinical diagnosis
    • differential
      • caput succedaneum
      • cranial meningocele
    • treatment
      • conservative
        • watchful waiting
          • indication
            • cephalohematoma typically resolves over the course of 3-4 weeks
  • Subgaleal hemorrhage
    • clinical definition
      • blood accumulation between the periosteum of the skull and the epicranial aponeurosis
    • pathophysiology
      • pathoanatomy
        • rupture of emissary veins located between the scap and dural sinuses results in blood to accumulate between the periosteum of the skull and epicranial aponeurosis
          • this can result from scalp traction during delivery
    • presentation
      • physical exam
        • diffuse and fluctuant head swelling
          • can expand over time
        • tachycardia and pallor secondary to
          • blood loss
        • increasing occipital frontal circumference
    • studies
      • labs
        • hematocrit
        • coagulation studies
    • differential
      • caput succedaneum
      • cephalohematoma
    • treatment
      • medical
        • intravenous fluids
          • indications
            • fluids are given for volume resuscitation
        • blood products (packed red blood cells, fresh frozen plasma, cryoprecipitate, and platelets)
          • indications
            • when appropriate to control bleeding and correct coagulopathy
Nerve Injuries
  • Brachial plexus injury (BPI)
    • clinical definition
      • lesion of the brachial plexus that results in paralysis of the upper arm muscles
    • pathophysiology
      • pathoanatomy
        • a cause can be lateral traction on the fetal head during birth
          • however, BPI can still occur even with appropriate axial traction
    • presentation
      • physical exam
        • Erb-Duchenne palsy when C5-6 is involved
        • Klumpke palsy when C8-T1 is involved
        • total arm paralysis when all nerve roots are involved
        • Horner syndrome when the sympathetic outflow root is involved at T1
    • studies
      • diagnostic criteria
        • clinical diagnosis
    • treatment
      • conservative
        • physical therapy
          • if no improvement after 3 months, this raises concern for nerve root avulsion of the brachial plexus and an orthopedic/hand surgeon should be consulted
Fractures
  • Clavicle fracture
    • presentation
      • physical exam
        • in displaced factures one can find
          • edema
          • immobility of the affected extremity
          • abnormal bone contour
          • crying when the affected extremity is passively moved
          • crepitus
    • imaging
      • radiography of the chest and upper extremity
        • indications
          • obtain when there is concern for a calvicular fracture
    • studies
      • diagnostic criteria
        • based on physical exam findings and radiography
    • treatment
      • conservative
        • watchful waiting
          • indications
            • clavicular fratures heal spontaneously in infants

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