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48. Neonatal Injuries
Definition: Birth injury may be defined as an impairment of the infant’s body or structure due to adverse influences, which occurred at birth. Injury may occur during the antenatal or intrapartum period or even during resuscitation and is often unavoidable [1].
Birth injuries are commonly seen by physicians looking after newborn infants. They may range from the relatively common soft tissue injuries that most often require careful observation to the more severe injuries like intracranial bleeding that may be life-threatening and need immediate intervention. The risk of birth trauma does not decrease after a cesarean section, especially after failed forceps or vacuum extraction [2].
48.1 Risk Factors
In cases where labor is complicated by fetal size, prematurity, or malpresentation, normal intrapartum compressions, contortions, and forces can lead to injury. The following factors may increase the risk of birth injury:
- 1.
Primiparity
- 2.
Maternal short stature
- 3.
Maternal pelvic anomalies
- 1.
Macrosomia
- 2.
Very low birth weight
- 3.
Extreme prematurity
- 4.
Fetal anomalies
- 5.
Malpresentation (breech, face, shoulder dystocia)
- 1.
Prolonged labor
- 2.
Unusually rapid labor
- 3.
Use of forceps or vacuum extraction
48.2 Evaluation
A newborn at risk for birth injury should be thoroughly examined from head to toe, including a detailed neurological examination, as injury may be occult. Things to be looked for are symmetry of structure and function, cranial nerves, range of motion of individual joints, and integrity of the scalp and skin.
Common injuries encountered in a newborn
Type of injury | Example |
|---|---|
Soft tissue injuries | Abrasions, bruises, lacerations, subcutaneous fat necrosis |
Extracranial bleeding | Cephalhematoma, subgaleal bleed |
Intracranial bleeding | Subarachnoid, epidural, subdural, cerebral, cerebellar hemorrhage |
Nerve injuries | Facial nerve, brachial plexus, phrenic nerve, recurrent laryngeal nerve |
Spinal cord injuries | Epidural hemorrhage of the cervical cord |
Fractures/dislocations | Clavicle, humerus, femur, skull |
Torticollis | Due to bleeding in the sternocleidomastoid muscle |
Eye injuries | Subconjunctival, retinal, vitreous hemorrhage, orbital fracture |
Solid organ injury | Liver, spleen, adrenal gland |
48.3 Soft Tissue Injury
This is the most common form of traumatic birth injury and includes petechiae, ecchymosis, and bruising. Most of these injuries result from difficult extractions from the breech position, shoulder dystocia, and use of the vacuum or forceps. Soft tissue injuries, though usually minor, may increase the risk of significant hyperbilirubinemia.
Petechiae are usually present over the head, neck, and upper chest. These are present after birth, do not increase, and are not associated with bleeding from other sites. A platelet count should be obtained if there is bleeding from other sites or the petechiae progress. Breech delivery can lead to severe vaginal or scrotal edema and bruising. This usually resolves spontaneously, though drainage of a testicular hematoma may rarely be required [2].
An electrode placed on the scalp for fetal heart monitoring may cause abrasions or lacerations, which may get secondarily infected. If malpositioned, it may cause facial or ocular trauma.
Subcutaneous fat necrosis is an area of induration due to local ischemia from trauma. It is usually seen late during the first week, has red or purple discoloration, and resolves spontaneously by 6–8 weeks [2].
48.4 Sternocleidomastoid (SCM) Injury
Congenital muscular torticollis is seen in approximately 0.4% of births [4]. One of the mechanisms proposed to cause this condition is manual stretching of the neck causing rupture of the muscle with formation of a hematoma and subsequent fibrosis leading to torticollis. The infant usually presents at 2–3 weeks of age with head tilt to the side of the lesion, with a 1–2 cm palpable mass in SCM region.
Management involves physiotherapy, with stretching exercises done many times in a day, that results in 90% recovery within 3–4 months [4].
48.5 Extracranial Injuries
48.5.1 Caput Succedaneum
A caput succedaneum is a subcutaneous, extraperiosteal fluid collection that extends over the presenting portion of the scalp. It has poorly defined margins and extends across suture lines. It resolves spontaneously over a few days and no treatment is required.
48.5.2 Cephalhematoma
Neonate with a large cephalhematoma in the left parietal region
Diagnosis is clinical, but if there are neurological signs and symptoms, a computed tomography (CT) scan of the head must be done to rule out intracranial involvement.
Management involves observation only, as most lesions resolve spontaneously over a few weeks. Attempts at aspiration and incision may introduce infection and are contraindicated.
48.5.3 Subgaleal Hemorrhage
Hemorrhage under the aponeurosis of the scalp results in a subgaleal bleed. The overall incidence is 1 in 2000 births but may be as high as 1 in 200, most commonly seen in vacuum or forceps deliveries, especially with multiple attempts [2]. The injury results from rupture of emissary veins between the scalp and intracranial venous sinuses due to traction on the scalp. It is usually seen within the first few hours of birth as a fluctuant swelling that crosses suture lines.
Diagnosis is purely clinical. Blood loss may be significant and may result in shock. The newborn must therefore be monitored closely for signs of hypovolemia like tachycardia, feeble pulses, and prolonged capillary refill. Laboratory investigations include serial hematocrit monitoring and bilirubin levels. A coagulation profile may be considered to rule out a bleeding disorder [3].
Treatment is largely supportive. Significant bleeding may require fluid replacement or even blood transfusion.
48.6 Cranial Injuries
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