I. BACKGROUND. Birth injury is defined by the National Vital Statistics Report as “an impairment of the infant’s body function or structure due to adverse influences that occurred at birth.” Injury may occur antenatally, intrapartum, or during resuscitation and may be avoidable or unavoidable.

A. Incidence. The birth trauma and injury rate fell from 2.6 per 1,000 live births in 2004 to 1.9 per 1,000 live births in 2012.

B. Risk factors. When fetal size, immaturity, or malpresentation complicate delivery, the normal intrapartum compressions, contortions, and forces can lead to injury in the newborn. Obstetrical instrumentation may increase the mechanical forces, amplifying or inducing a birth injury. Breech presentation carries the greatest risk of injury; however, cesarean delivery without labor does not prevent all birth injuries. The following factors may contribute to an increased risk of birth injury:

1. Primiparity

2. Small maternal stature

3. Maternal pelvic anomalies

4. Prolonged or unusually rapid labor

5. Oligohydramnios

6. Malpresentation of the fetus

7. Use of midforceps or vacuum extraction

8. Versions and extraction

9. Very low birth weight or extreme prematurity

10. Fetal macrosomia or large fetal head

11. Fetal anomalies

12. Maternal obesity—body mass index >40 kg/m²

C. Evaluation. A newborn at risk for birth injury should have a thorough examination, including a detailed neurologic evaluation. Newborns who require resuscitation after birth should be evaluated because occult injury may be present. Particular attention should be paid to symmetry of structure and function, cranial nerves, range of motion of individual joints, and integrity of the scalp and skin.

1. Injuries associated with intrapartum fetal monitoring. Placement of an electrode on the fetal scalp or presenting part for fetal heart monitoring occasionally causes superficial abrasions or lacerations. These injuries require minimal local treatment, if any. Facial or ocular trauma may result from a malpositioned electrode. Abscesses rarely form at the electrode site.

i. Caput succedaneum is a commonly occurring subcutaneous, extraperiosteal fluid collection that is occasionally hemorrhagic. It has poorly defined margins and can extend over the midline and across suture lines. It typically extends over the presenting portion of the scalp and is usually associated with molding.

ii. The lesion usually resolves spontaneously without sequelae over the first several days after birth. It rarely causes significant blood loss or jaundice. There are rare reports of scalp necrosis with scarring.

iii. Vacuum caput is a caput succedaneum with margins well demarcated by the vacuum cup.

i. A cephalohematoma is a subperiosteal collection of blood resulting from rupture of the superficial veins between the skull and periosteum. The lesion is always confined by suture lines. It may occur in as many as 2.0% of all live births. It is more commonly seen in instrumented deliveries.

ii. An extensive cephalohematoma can result in significant hyperbilirubinemia. Hemorrhage is rarely serious enough to necessitate blood transfusion. Infection is also a rare complication and usually
occurs in association with septicemia and meningitis. Skull fractures have been associated with 5% of cephalohematomas. Head magnetic resonance imaging (MRI) should be obtained if neurologic symptoms are present. Most cephalohematomas resolve within 8 weeks. Occasionally, they calcify and persist for several months or years.

iii. Management is limited to observation in most cases. Incision and aspiration of a cephalohematoma may introduce infection and is contraindicated. Anemia or hyperbilirubinemia should be treated as needed.

i. Subgaleal hematoma is hemorrhage under the aponeurosis of the scalp. It is more often seen after vacuum- or forceps-assisted deliveries.

ii. Because the subgaleal or subaponeurotic space extends from the orbital ridges to the nape of the neck and laterally to the ears, the hemorrhage can spread across the entire calvarium.

iii. The initial presentation typically includes pallor, poor tone, and a fluctuant swelling on the scalp. The hematoma may grow slowly or increase rapidly and result in shock. With progressive spread, the ears may be displaced anteriorly and periorbital swelling can occur. Ecchymosis of the scalp may develop. The blood is resorbed slowly, and swelling gradually resolves. The morbidity may be significant in infants with severe hemorrhage who require intensive care for this lesion. The mortality rate can range from 12% to 14%. Death is attributed to significant volume loss, resulting in hypovolemic shock and coagulopathy.

iv. There is no specific therapy. The infant must be observed closely for signs of hypovolemia, and blood volume should be maintained as needed with transfusions. Phototherapy should be provided for hyperbilirubinemia. An investigation for a bleeding disorder should be considered. Surgical drainage should be considered only for unremitting clinical deterioration. A subgaleal hematoma associated with skin abrasions may become infected; it should be treated with antibiotics and may need drainage.

3. Intracranial hemorrhage (see Chapter 54)

a. 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.

b. 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.

c. Uncomplicated linear fractures usually require no therapy. The diagnosis is made by a radiograph of the skull. Head MRI should be obtained if intracranial injury is suspected or if neurologic symptoms develop. 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 obtained. Follow-up imaging should be performed at 8 to 12 weeks to evaluate possible leptomeningeal cyst formation.

a. 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.

b. 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.

c. Airway patency should be closely monitored. A plastic surgeon or otorhinolaryngologist should be consulted and appropriate radiographic studies obtained. Head computed tomography (CT) scan or 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.

a. 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 <1%.

b. 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.

c. 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.

d. If nasal dislocations are left untreated, there is an increased risk of long-term septal deformity.

a. 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 <0.5% of all deliveries.