Skull fractures may be either linear, usually involving the parietal bone, or depressed, involving the parietal or frontal bones. The latter are often associated with forceps use. Occipital bone fractures are most often associated with breech deliveries.

Most infants with linear or depressed skull fractures are asymptomatic unless there is an associated intracranial hemorrhage (e.g., subdural or subarachnoid hemorrhage). Occipital osteodiastasis is a separation of the basal and squamous portions of the occipital bone that often results in cerebellar contusion and significant hemorrhage. It may be a lethal complication in breech deliveries. A linear fracture that is associated with a dural tear may lead to herniation of the meninges and brain, with development of a leptomeningeal cyst.

Uncomplicated linear fractures usually require no therapy. The diagnosis is made by taking a skull x-ray. Head CT scan should be obtained if intracranial injury is suspected. Depressed skull fractures require neurosurgical evaluation. Some may be elevated using closed techniques. Comminuted or large skull fractures associated with neurologic findings need immediate neurosurgical evaluation. If leakage of cerebrospinal fluid from the nares or ears is noted, antibiotic therapy should be started and neurosurgical consultation should be obtained. Follow-up imaging should be performed at 8 to 12 weeks to evaluate possible leptomeningeal cyst formation.

Facial fractures can be caused by numerous forces, including natural passage through the birth canal, forceps use, or delivery of the head in breech presentation.

Fractures of the mandible, maxilla, and lacrimal bones warrant immediate attention. They may present as facial asymmetry with ecchymoses, edema, and crepitance, or respiratory distress with poor feeding. Untreated fractures can lead to facial deformities, with subsequent malocclusion and mastication difficulties. Treatment should begin promptly because maxillar and lacrimal fractures begin to heal within 7 to 10 days, and mandibular fractures start to repair at 10 to 14 days. Treated fractures usually heal without complication.

Airway patency should be closely monitored. A plastic surgeon or otorhinolaryngologist should be consulted immediately and appropriate radiographic studies obtained. Head CT scan or magnetic resonance imaging (MRI) may be necessary to evaluate for retro-orbital or cribriform plate disruption. Antibiotics should be administered for fractures involving the sinuses or middle ear.

Nasal fracture and dislocation may occur during the birth process. The most frequent nasal injury is dislocation of the nasal cartilage, which may result from pressure applied by the maternal symphysis pubis or sacral promontory. The reported prevalence of dislocation is less than 1%.

Infants with significant nasal trauma may develop respiratory distress. Similar to facial fractures, nasal fractures begin to heal in 7 to 10 days and must be treated promptly. Rapid healing usually occurs once treatment is initiated. If treatment is delayed, deformities are common.

A misshapen nose may appear dislocated. To differentiate dislocation from a temporary deformation, compress the tip of the nose. With septal dislocation, the nares collapse and the deviated septum is more apparent. With a misshapen nose, no nasal deviation occurs. Nasal edema from repeated suctioning may mimic partial obstruction. Patency can be assessed with a cotton wisp under the nares. Management involves protection of the airway and otorhinolaryngology consultation.

If nasal dislocations are left untreated, there is an increased risk of longterm septal deformity.

Retinal and subconjunctival hemorrhages are commonly seen after vaginal delivery. They result from increased venous congestion and pressure during delivery. Malpositioned forceps can result in ocular and periorbital injury, including hyphema, vitreous hemorrhage, lacerations, orbital fracture, lacrimal duct or gland injury, and disruption of Descemet’s membrane of the cornea (which can lead to astigmatism and amblyopia). Significant ocular trauma occurs in 0.19% of all deliveries.

Retinal hemorrhages usually resolve within 1 to 5 days. Subconjunctival hemorrhages resorb within 1 to 2 weeks. No long-term complications usually occur. For other ocular injuries, prompt diagnosis and treatment are necessary to ensure a good long-term outcome.

Management. Prompt ophthalmologic consultation should be obtained.

Ears are susceptible to injury, particularly with forceps application. More significant injuries occur with fetal malposition. Abrasions, hematomas, and lacerations may develop.