• Cephalhaematoma (Figs 10.4, 10.5) – haematoma from bleeding below the periosteum, confined within the margins of the skull sutures. It usually involves the parietal bone. The centre of the haematoma feels soft. It resolves over several weeks

• Chignon (Fig. 10.6) – oedema and bruising from Ventouse delivery

• Bruising to the face after a face presentation and to the genitalia and buttocks after breech delivery. Preterm infants bruise readily from even mild trauma

• Abrasions to the skin from scalp electrodes applied during labour or from accidental scalpel incision at Caesarean section

• Forceps marks to face from pressure of blades – transient

• Subaponeurotic haemorrhage (Fig. 10.4) (very uncommon) – diffuse, boggy swelling of scalp on examination, blood loss may be severe and lead to hypovolaemic shock and coagulopathy.

Nerve palsies

Brachial nerve palsy results from traction to the brachial plexus nerve roots. They may occur at breech deliveries or with shoulder dystocia. Upper nerve root (C5 and C6) injury results in an Erb palsy (Fig. 10.7). It may be accompanied by phrenic nerve palsy causing an elevated diaphragm. Most palsies resolve completely, but should be referred to an orthopaedic or plastic surgeon if not resolved by 2–3 months. Most recover by 2 years. A facial nerve palsy may result from compression of the facial nerve against the mother’s ischial spine. It is unilateral, and there is facial weakness on crying but the eye remains open. It is usually transient, but methylcellulose drops may be needed for the eye. Rarely, nerve palsies may be from damage to the cervical spine, when there is lack of movement below the level of the lesion.

Birth injuries

Soft tissue injuries

• Caput succedaneum, cephalhaematoma, chignon, bruises and abrasions

• Subaponeurotic haemorrhage

Nerve palsies

• Brachial plexus – Erb palsy

• Facial nerve palsy

Fractures

• Clavicle, humerus, femur

Fractures

Clavicle

Usually from shoulder dystocia. A snap may be heard at delivery or the infant may have reduced arm movement on the affected side, or a lump from callus formation may be noticed over the clavicle at several days of age. The prognosis is excellent and no specific treatment is required.

Humerus/femur

Usually mid-shaft, occurring at breech deliveries, or fracture of the humerus at shoulder dystocia. There is deformity, reduced movement of the limb and pain on movement. They heal rapidly with immobilisation.

Stabilising the preterm or sick infant

Preterm infants of <34 weeks’ gestation and newborn infants who become seriously ill require their condition to be stabilised and monitored (Fig. 10.8). Many of them will need respiratory and circulatory support.

Stabilising preterm or sick infants

Airway, breathing

• Respiratory distress: tachypnoea, laboured breathing with chest wall recession, nasal flaring, expiratory grunting, cyanosis

• Apnoea

Management, as required:

• Clear the airway

• Oxygen

• High-flow humidified oxygen therapy

• CPAP (continuous positive airway pressure)

• Mechanical ventilation

Monitoring

• Oxygen saturation (maintain at 88–95% if preterm)

• Place in plastic bag at birth to keep warm if extremely preterm

• Perform stabilisation under a radiant warmer or in a humidified incubator to avoid hypothermia.

Venous and arterial lines

Peripheral intravenous line

Required for intravenous fluids, antibiotics and other drugs.

Umbilical venous catheter

May be used for intravenous access at resuscitation, in extremely preterm infants for the first few days or to administer high osmolality fluids (e.g. high-concentration dextrose) or medications needing central delivery (e.g. inotropes).

Arterial line

• Inserted if frequent blood gas analysis, blood tests and continuous blood pressure monitoring are required. Usually umbilical artery catheter (UAC), sometimes peripheral cannula if for short period or no umbilical artery catheter possible.

• The arterial oxygen tension is maintained at 8–12 kPa (60–90 mmHg) and the CO₂ tension at 4.5–6.5 kPa (35–50 mmHg). Continuous non-invasive transcutaneous arterial blood gas monitoring may also be used.

Central venous line for parenteral nutrition, if indicated

Inserted peripherally when infant is stable.

Chest X-ray with or without abdominal X-ray

Assists in the diagnosis of respiratory disorders and to confirm the position of the tracheal tube and central lines.

Investigations

• Haemoglobin, neutrophil count, platelet count

• Blood urea, creatinine, electrolytes and lactate

• Culture – blood ± CSF ± urine

• Blood glucose

• CRP/acute phase reactant

• Coagulation screen if indicated

Antibiotics

Broad-spectrum antibiotics are given.

Minimal handling

All procedures, especially painful ones, adversely affect oxygenation and the circulation. Handling the infant is kept to a minimum and done as gently, rapidly and efficiently as possible. Analgesia should be provided to prevent pain as necessary.

Parents

Although medical and nursing staff are usually fully occupied stabilising the baby, time must be found for parents and immediate relatives to allow them to see and touch their baby and to be kept fully informed.

The preterm infant

The appearance, the likely clinical course, chances of survival and long-term prognosis depend on the gestational age at birth. The appearance and maturational changes of very preterm infants are described in Table 10.1 and the importance of parental involvement shown in Figures 10.10a and b. The external appearance and neurological findings can be scored to provide an estimate of an infant’s gestational age (see Appendix).

The rate and severity of problems associated with prematurity decline markedly with increasing gestation. Infants born at 23–26 weeks’ gestation encounter many problems (Box 10.1), require many weeks of intensive and special care in hospital and have a high overall mortality. With modern intensive care, the prognosis is excellent after 32 weeks’ gestational age. The severity of an infant’s respiratory disease and of any episodes of infection largely determine the neonatal course and outcome.

Box 10.1 Medical problems of preterm infants

• Need for resuscitation at birth

• Respiratory

– Respiratory distress syndrome (RDS)

– Pneumothorax

– Apnoea and bradycardia

• Hypotension

• Patent ductus arteriosus

• Temperature control

• Metabolic

– Hypoglycaemia

– Hypocalcaemia

– Electrolyte imbalance

– Osteopenia of prematurity

• Nutrition

• Infection

• Jaundice

• Intraventricular haemorrhage/periventricular leukomalacia

• Necrotising enterocolitis

• Retinopathy of prematurity

• Anaemia of prematurity

• Iatrogenic

• Bronchopulmonary dysplasia (chronic lung disease)

• Inguinal hernias.

Respiratory distress syndrome

In respiratory distress syndrome (RDS), (also called hyaline membrane disease), there is a deficiency of surfactant, which lowers surface tension. Surfactant is a mixture of phospholipids and proteins excreted by the type II pneumocytes of the alveolar epithelium. Surfactant deficiency leads to widespread alveolar collapse and inadequate gas exchange. The more preterm the infant, the higher the incidence of RDS; it is common in infants born before 28 weeks’ gestation and tends to be more severe in boys than girls. Surfactant deficiency is rare at term but may occur in infants of diabetic mothers. The term hyaline membrane disease derives from a proteinaceous exudate seen in the airways on histology. Glucocorticoids, given antenatally to the mother, stimulate fetal surfactant production and are given if preterm delivery is anticipated (see Ch. 9.)

The development of surfactant therapy has been a major advance. The preparations are natural, derived from extracts of calf or pig lung. They are instilled directly into the lung via a tracheal tube. Multinational placebo-controlled trials show that surfactant treatment reduces mortality from RDS by about 40%, without increasing the morbidity rate (Fig. 10.11).

At delivery or within 4 h of birth, babies with RDS develop clinical signs of:

• tachypnoea >60 breaths/min

• laboured breathing with chest wall recession (particularly sternal and subcostal indrawing) and nasal flaring

• expiratory grunting in order to try to create positive airway pressure during expiration and maintain functional residual capacity

• cyanosis if severe.

The characteristic chest X-ray appearance is shown in Figure 10.12. Treatment with raised ambient oxygen is required, which may need to be supplemented with continuous positive airway pressure (delivered via nasal cannulae) or artificial ventilation via a tracheal tube. The ventilatory requirements need to be adjusted according to the infant’s oxygenation (which is measured continuously), chest wall movements and blood gas analyses. Mechanical ventilation (with intermittent positive pressure ventilation or high-frequency oscillation) may be required. High-flow humidified oxygen therapy, via nasal cannulae, may be used to wean babies from added oxygen therapy.

Surfactant therapy reduces morbidity and mortality of preterm infants with respiratory distress syndrome.

The preterm infant: maturational changes in appearance and development

Table 10.1

The preterm infant compared with the term infant

Gestation	23–27 weeks	Term (37–42 weeks)
Birthweight (50th centile)	At 24 weeks – male 700 g, female 620 g	At 40 weeks – male 3.55 kg, female 3.4 kg
Skin	Very thin (Fig. 10.9a)	Thick skin (Fig. 10.9b)
	Dark red colour all over body	Pale pink colour
Ears	Pinna soft, no recoil	Pinna firm, cartilage to edge, immediate recoil
Breast tissue	No breast tissue palpable	One or both nodules >1 cm
Genitalia	Male – scrotum smooth, no testes in scrotum	Male – scrotum has rugae, testes in scrotum
	Female – prominent clitoris, labia majora widely separated, labia minora protruding	Female – labia minora and clitoris covered
Breathing	Needs respiratory support. Apnoea common	Rarely needs respiratory support. Apnoea rare
Sucking and swallowing	No coordinated sucking	Coordinated (from 34–35 weeks)
Feeding	Usually needs TPN (total parenteral nutrition), then tube feeding	Cries when hungry. Feeds on demand
Cry	Faint	Loud
Vision, interaction	Eyelids may be fused. Infrequent eye movements. Not available for interaction	Makes eye contact, alert wakefulness
Hearing	Startles to loud noise	Responds to sound
Posture	Limbs extended, jerky movements	Flexed posture, smooth movements

Respiratory distress syndrome

• Common in very preterm infants

• Caused by surfactant deficiency

• Antenatal corticosteroids and surfactant therapy markedly reduce morbidity and mortality.

Pneumothorax

In respiratory distress syndrome, air from the overdistended alveoli may track into the interstitium, resulting in pulmonary interstitial emphysema (PIE). In up to 10% of infants ventilated for RDS, air leaks into the pleural cavity and causes a pneumothorax (Fig. 10.13). When this occurs, the infant’s oxygen requirement usually increases, and the breath sounds and chest movement on the affected side are reduced, although this can be difficult to detect clinically. A pneumothorax may be demonstrated by transillumination with a bright fibreoptic light source applied to the chest wall. A tension pneumothorax is treated by inserting a chest drain. In order to try and prevent pneumothoraces, infants are ventilated with the lowest pressures that provide adequate chest movement and satisfactory blood gases.