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 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 prognosis Infant mortality secondary to birth trauma has significantly decreased