Neonatal Birth Injuries

Neonatal birth injuries
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Official reprint from UpToDate

www.uptodate.com 2016 UpToDate

Author
Tiffany M McKee-Garrett, MD
Section Editors
Leonard E Weisman, MD
William Phillips, MD
Marc C Patterson, MD, FRACP
Deputy Editor
Melanie S Kim, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jul 2016. | This topic last updated: Sep 21, 2015.
INTRODUCTION Birth injury is defined as an impairment of the neonate's body function or structure due to an
adverse event that occurred at birth. The overall incidence of birth injuries has declined with improvements in obstetrical
care and prenatal diagnosis. The reported incidence of birth injuries is about 2 and 1.1 percent in singleton vaginal
deliveries of fetuses in a cephalic position and in cesarean deliveries, respectively [1,2]. Injury may occur during labor,
delivery, or after delivery, especially in neonates who require resuscitation in the delivery room.
There is a wide spectrum of birth injuries ranging from minor and self-limited problems (eg, laceration or bruising) to
severe injuries that may result in significant neonatal morbidity or mortality (ie, spinal cord injuries).
The risk factors associated with birth trauma and specific birth injuries will be reviewed here.
RISK FACTORS The following factors that increase the risk of birth injuries may be due to the fetus (eg, fetal size
and presentation), the mother (eg, maternal size and the presence of pelvic anomalies), or the use of obstetrical
instrumentation during delivery:
Macrosomia When the fetal weight exceeds 4000 g, the incidence of birth injuries rises as the fetal size
increases. In one study, when compared with normosmic neonates, the incidence of birth injury was twofold
greater in infants weighing 4000 to 4499 g, three times greater in those with births weights between 4500 to 4999
g, and 4.5 times greater in those with a birth weight greater than 5000 g [3]. In another study, the incidence of fetal
injury was 7.7 percent in infants with birth weights greater than 4500 g [4].
The diagnosis of fetal macrosomia and its impact on shoulder dystocia are discussed in greater detail separately.
(See "Fetal macrosomia" and "Shoulder dystocia: Risk factors and planning delivery of at risk pregnancies",
section on 'Pregnancies where high birth weight is suspected'.)
Maternal obesity Maternal obesity (defined as a body mass index greater than 40 kg/m2) is associated with an
increased risk of birth injuries. This may be due to the greater use of instrumentation during delivery and/or these
mothers having an increased risk of delivering a large for gestational age infant with shoulder dystocia [5]. (See
"The impact of obesity on female fertility and pregnancy" and "Cesarean delivery of the obese woman".)
Abnormal fetal presentation Fetal presentation other than a vertex position, particularly breech presentation, is
associated with an increase in the risk of birth injury with vaginal delivery. Delivery by cesarean delivery reduces
the morbidity associated with vaginal delivery of breech infants and is discussed separately. (See "Overview of
issues related to breech presentation" and "Delivery of the fetus in breech presentation".)
Operative vaginal delivery Operative vaginal delivery refers to a delivery in which the clinician uses forceps or a
vacuum device to assist the mother in delivering the fetus to extrauterine life. The instrument is applied to the fetal
head, and then the clinician uses traction to extract the fetus, typically during a contraction while the mother is
pushing. Both forceps and vacuum delivery are associated with an increase in birth injury when compared with
nonoperative vaginal delivery (table 1). The sequential use of vacuum extraction and forceps increases the risk of
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birth injury greater than the use of either instrument alone (table 2). The neonatal complications of operative
vaginal deliveries are discussed in detail separately.
Cesarean delivery Cesarean delivery is generally found to have a lower risk of birth trauma compared with
vaginal deliveries. This finding was confirmed by an analysis of the Health Care Cost and Utilization Project
Nationwide Inpatient Sample that showed cesarean delivery was associated with a decreased likelihood of all birth
trauma compared with vaginal delivery (adjusted OR 0.55, 95% CI 0.53-0.58) [6]. However, when the analysis
used the definition of birth trauma developed by the Agency for Healthcare Research and Quality Patient Safety
Indicator (AHRQPSI), cesarean delivery was associated with an increased risk of birth trauma (adjusted OR 1.65,
95% CI 1.51-1.81). The AHRQPSI definition did not include clavicle fractures, or injuries to the brachial plexus and
scalp, which were more frequently seen in vaginal deliveries. These findings suggest that risk varies between
cesarean and vaginal delivery depending upon the type of birth injury.
Other factors One study reported an increased incidence of birth trauma to the head and neck in male infants
and in babies born to primiparous mothers [7]. Additionally, small maternal stature and the presence of maternal
pelvic anomalies are associated with an increased risk of birth injuries.
SOFT TISSUE INJURIES The most common form of traumatic birth injuries are soft-tissue injuries including bruising,
petechiae, subcutaneous fat necrosis, and lacerations [8].
Bruising and petechiae Bruising and petechiae are usually self-limiting and are often seen on the presenting portion
of the newborn's body.
Bruising and edema of the genitals are common findings in infants delivered from the breech position.
Petechiae of the head and face are often seen in infants delivered from the vertex position, especially with a face
presentation. Most often, petechiae are present at birth, do not progress, and are not associated with other
bleeding. A platelet count should be obtained to rule out thrombocytopenia if petechiae continue to develop or if
other bleeding is present.
Significant bruising has been recognized as a major risk factor for the development of severe hyperbilirubinemia.
Follow-up within two days of the newborn hospital discharge is recommended for infants with significant bruising in
order to assess them for progressive jaundice [9].
Subcutaneous fat necrosis Subcutaneous fat necrosis (SFN) is uncommon and usually occurs in the first few
weeks of life as a result of ischemia to the adipose tissue following a traumatic delivery. SFN is characterized by firm,
indurated nodules and plaques on the back, buttocks, thighs, forearms, and cheeks. The nodules and plaques may be
erythematous, flesh colored, or blue [10].
Typically, this condition is self-limiting, with resolution usually occurring by six to eight weeks of age. These infants
require long-term follow-up for the development of hypercalcemia, which can occur up to six months after the initial
presentation of the skin lesions [10,11].
Lacerations Fetal laceration has been reported as the most common birth injury associated with cesarean delivery
[1]. In one study of 3108 cesarean deliveries, the fetal laceration rate was about 3 percent [12]. The lacerations occurred
most often on the presenting part of the fetus, typically the scalp and face; 78 percent of the lacerations took place when
the cesarean delivery was performed emergently. The majority of fetal lacerations were mild, requiring repair with sterile
strips only. However, 3 of the 97 lacerations (3 percent) were moderate or severe, located on the face or ocular area,
and required plastic surgery for repair.
EXTRACRANIAL INJURIES Extracranial injuries occur during delivery and are due to edema or bleeding into various
locations within the scalp and skull (figure 1).
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Caput succedaneum Caput succedaneum is an edematous swelling of the scalp above the periosteum, which is
occasionally hemorrhagic (figure 1). It presents at birth after prolonged engagement of the fetal head in the birth canal or
after vacuum extraction. Unlike cephalohematoma, it extends across the suture lines. Caput succedaneum is generally a
benign condition, and it usually resolves within a few days and requires no treatment.
There are reported complications in infants with caput succedaneum that include necrotic lesions resulting in long-term
scarring and alopecia [13]. Halo scalp ring is an annular alopecic ring that occurs in infants after a prolonged or difficult
labor due to compression from the bony prominence of the maternal pelvis. [14]. Rarely, systemic infection may occur as
a complication of an infected caput succedaneum [15].
Cephalohematoma Cephalohematoma is a subperiosteal collection of blood caused by rupture of vessels beneath
the periosteum (usually over the parietal or occipital bone), which presents as swelling that does not cross suture lines
(figure 1). The swelling may or may not be accompanied by discoloration, rarely expands after delivery, and does not
generally cause significant blood loss. Cephalohematoma is estimated to occur in 1 to 2 percent of all deliveries and is
much more common when forceps or vacuum delivery is performed (table 2). (See "Operative vaginal delivery", section
on 'Complications'.)
The majority of cephalohematomas will resolve spontaneously over the course of a few weeks without any intervention.
However, calcification of the hematoma can occur with a subsequent bony swelling that may persist for months.
Significant deformities of the skull may occur when calcification or ossification of the cephalohematoma occurs (image
1). Case reports have demonstrated successful surgical excision of these calcified or ossified hematomas [16,17].
Other complications of cephalohematoma include infection and sepsis, with Escherichia coli being the most commonly
reported causative agent. Infected cephalohematomas present as erythematous, fluctuant masses that may have
expanded from their baseline size. Imaging with computed tomography (CT) or magnetic resonance imaging (MRI) is
helpful in making the diagnosis. Needle aspiration and culture of the hematoma are considered to be mandatory for
suspected cases [18]. Osteomyelitis is a reported complication of an infected cephalohematoma [19]. In these affected
infants, treatment includes incision and drainage of the abscess with debridement of the necrotic skull, and a prolonged
course of parenteral antibiotics (eg, vancomycin, gentamicin, and cefotaxime).
Subgaleal hemorrhage Subgaleal hemorrhage (SGH) develops when blood accumulates in the loose areolar tissue
in the space between the periosteum of the skull and the aponeurosis (figure 1). The injury occurs when the emissary
veins between the scalp and dural sinuses are sheared or severed as a result of traction on the scalp during delivery.
The incidence of SGH has been estimated to occur in 4 of 10,000 spontaneous vaginal deliveries and 59 of 10,000
vacuum-assisted deliveries [20].
The potential for massive blood loss (20 to 40 percent of a neonate's blood volume resulting in a loss of 50 to 100 mL
[21]) into the subgaleal space contributes to the high mortality rate associated with this lesion. The subgaleal space
extends from the orbital ridges anteriorly to the nape of the neck posteriorly and to the level of the ears laterally. In
infants with SGH, the reported mortality is about 12 to 14 percent [22,23]. Infants who died had massive volume loss
resulting in shock and coagulopathy [23].
SGH presents as a diffuse, fluctuant swelling of the head that may shift with movement. Expansion of the swelling due to
continued bleeding may occur hours to days after delivery. Affected neonates may have tachycardia and pallor due to
blood loss, although blood loss may be massive before signs of hypovolemia become apparent.
Early recognition of this injury is crucial for survival [24]. Infants who have experienced a difficult operative delivery or
are suspected to have a SGH require ongoing monitoring including frequent vital signs (minimally every hour), and serial
measurements of hematocrits and their occipital frontal circumference, which increases 1 cm with each 40 mL of blood
deposited into the subgaleal space. Head imaging, using either CT or MRI, can be useful in differentiating subgaleal
hemorrhage from other cranial pathologic conditions. Coagulation studies are required to detect coagulopathy that may
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be associated with the bleeding.

Treatment includes volume resuscitation with packed red blood cells, fresh frozen plasma, and normal saline as
appropriate for ongoing bleeding and coagulopathy correction. Rarely has brain compression been reported that
required surgical evacuation of the hematoma [25].
Facial injuries
Nasal septal dislocation Nasal septal dislocation occurs in about 0.6 to 0.9 percent of deliveries due to
compression of the nose from the maternal symphysis pubis or sacral promontory during labor and delivery [26]. Infants
with significant trauma can present with respiratory distress due to airway obstruction.
The examination reveals deviation of the nose to one side with asymmetric nares and flattening of the dislocated side.
Depression of the tip of the nose can distinguish dislocation from a positional deformity or misshapen nose. The
pressure causes the nares to collapse, resulting in a more apparent deviated septum, which does not resume a normal
position when pressure is released.
The diagnosis is made by rhinoscopy. Manual reduction by an otolaryngologist using a nasal elevator should be
performed by three days of age [26]. No treatment or a delay in treatment may result in nasal septal deformity [26,27].
Ocular injuries Minor ocular trauma, such as retinal and subconjunctival hemorrhages, and lid edema, are
common and resolve spontaneously without affecting the infant [28]. Resolution of a retinal hemorrhage occurs within
one to five days and a subconjunctival hemorrhage within one to two weeks.
Significant ocular injuries include hyphema (blood in the anterior chamber), vitreous hemorrhage, orbital fracture,
lacrimal duct or gland injury, and disruption of Descemet's membrane of the cornea (which can result in astigmatism and
amblyopia). They occur in about 0.2 percent of deliveries with a higher incidence associated with forceps-assisted
delivery [28]. Prompt ophthalmologic consultation should be obtained for patients with, or suspected to have, these
injuries.
INTRACRANIAL HEMORRHAGE Intracranial hemorrhages (ICH) as a consequence of birth injury include subdural,
subarachnoid, epidural, intraventricular hemorrhages, and less frequently, intracerebral and intracerebellar hemorrhages
(table 3).
The risk of ICH increases with operative delivery, as shown by the reported incidences per 10,000 deliveries of
intracranial hemorrhage of 3.7, 17, and 16.2 for unassisted, forceps-assisted, or vacuum-assisted delivery, respectively
(table 2) [2]. This may be an underestimation as illustrated by a reported incidence of intracranial hemorrhages of 26
percent in spontaneous vaginal birth in a prospective study of neonatal brain development that screened asymptomatic
neonates by magnetic resonance imaging (MRI) [29].
Subdural hemorrhage Although the overall incidence is rare, subdural hemorrhage (SDH), or hematoma, is the most
common type of intracranial hemorrhage noted in neonates. SDH forms between the dura mater and arachnoid
membrane (figure 1). In one study based upon a California database of 583,340 live-born singleton infants born to
nulliparous women between 1992 and 1994, the reported incidences per 10,000 deliveries were 2.9, 8, and 9.8 for
spontaneous unassisted vaginal, vacuum-assisted, and forceps-assisted deliveries, respectively [30]. As would be
expected, the sequential use of vacuum and forceps increased the risk to 21.3 per 10,000 deliveries [30].
The location of SDH is most often tentorial and/or interhemispheric, and is best diagnosed by computed tomography
(CT) of the head [31]. The diagnosis may be made incidentally in asymptomatic neonates [29,32]. Symptomatic infants
usually present within the first 24 to 48 hours of life. Presenting symptoms or findings generally include respiratory
depression, apnea, and/or seizures [31,33]. Other symptoms include signs of neurologic dysfunction such as irritability
and altered tone and level of consciousness. Rarely, SDH is associated with increased intracranial pressure resulting in
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an increase in head circumference, tense fontanelle, apnea, bradycardia, and coma.

The management of SDH depends upon the location and extent of the bleed. Most cases can be managed with
conservative therapy without surgical intervention. This is likely due to the plasticity of the neonatal skull, which allows
for some degree of expansion without development of increased intracranial pressure [33]. Surgical evacuation is
necessary for infants with SDH and signs of increased intracranial pressure. SDH that occurs in the posterior fossa, an
area of the brain with less skull plasticity, may cause brainstem compression that requires emergent surgical evacuation.
Serial hematocrits should be performed to assess for ongoing blood loss. In patients with significant blood loss resulting
in signs of hypovolemia, normal saline is initially administered for volume replacement, followed by whole blood
transfusion. Investigation of a congenital coagulopathy should be considered for infants with an extensive SDH in the
absence of overt birth trauma.
Seizure disorders should be treated with antiepileptic drug therapy (AED). We prefer to use phenobarbital (loading dose
of 20 mg/kg) as the initial AED. (See "Treatment of neonatal seizures".)
Subarachnoid hemorrhage Subarachnoid hemorrhage (SAH) represents the second most commonly detected
neonatal intracranial hemorrhage. It is most often caused by rupture of bridging veins in the subarachnoid space or small
leptomeningeal vessels. Although SAH can occur with normal, spontaneous vaginal deliveries [29,31], the risk of SAH is
higher with operative vaginal deliveries, with reported incidences per 10,000 deliveries of 1.3, 2.3, 3.3, and 10.7 for
spontaneous, vacuum-assisted, forceps-assisted, and combined vacuum- and forceps-assisted vaginal deliveries,
respectively (table 3) [30].
As with subdural hemorrhage, newborns with SAH most often present at 24 to 48 hours of life with apnea, respiratory
depression, and seizures [34]. The diagnosis is made by CT of the head. Treatment is usually conservative. Rarely, a
large SAH can cause posthemorrhagic hydrocephalus.
Epidural hemorrhage Epidural hemorrhage (EDH) is very rare in neonates and is found between the dura and inner
table of the skull (figure 1). Usually caused by injury to the middle meningeal artery, the rarity of neonatal EDH is
attributed to the absence of the middle meningeal artery groove in the neonatal cranial bones, thus making it more
difficult to injure the artery. EDH is often accompanied by a linear skull fracture, and is usually located in the
parietotemporal area. Like the other types of intracranial birth injuries, EDH is often associated with operative deliveries
and primiparous mothers [35]. EDH and cephalohematoma can coexist when accompanied by an underlying skull
fracture due to communication through the skull fracture (figure 1) [36].
Neonates with EDH present with nonspecific neurologic symptoms, such as seizures and hypotonia. Increased
intracranial pressure may develop and is manifested as a bulging fontanelle, changes in vital signs, and level of
consciousness.
The diagnosis of EDH is made by CT or MRI of the head, which may differentiate it from subdural hemorrhage. This
condition has the potential to deteriorate quickly because of the arterial source of bleeding. As a result, frequent serial
studies are required, and the infant should be followed closely with neurosurgery.
Patients with very small lesions and a stable clinical course may be managed with supportive therapy. Surgical
evacuation is necessary when there is evidence of increased intracranial pressure and/or the EDH is large. In one case
series, surgical treatment was reserved for infants with large hematomas (greater than 1 cm thick and 4 cm long),
depressed skull fractures, hydrocephalus, and/or shifting of the brain parenchyma [35]. When accompanied by a
cephalohematoma, needle aspiration of the cephalohematoma may result in the resolution of the EDH [37].
Intraventricular hemorrhage Although intraventricular hemorrhage (IVH) is usually associated with premature
delivery, IVH is also reported as a consequence of birth injury in term infants. In a study of 505 healthy asymptomatic
term infants who underwent head ultrasonography within 72 hours of life, the incidence of IVH was 4 percent [38]. All the
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hemorrhages were subependymal in location (grade 1 IVH). The risk of IVH increases with operative deliveries, with
reported incidences per 10,000 deliveries of 1.1, 1.5, 2.6, and 3.7 for spontaneous, vacuum-assisted, forceps-assisted,
and combined vacuum- and forceps-assisted deliveries, respectively (table 3) [30].
In the absence of a clotting disorder or severe asphyxia, most IVH in term infants will resolve spontaneously with no
long-term sequelae. For infants with IVH due to significant birth trauma, close monitoring is required due to the risk of
extension of the hemorrhage into the surrounding parenchyma and the development of post-hemorrhagic
hydrocephalus. (See "Clinical manifestations and diagnosis of intraventricular hemorrhage in the newborn".)
FRACTURES
Clavicle Clavicular fractures are the most commonly reported fractures in neonates (image 2). Based upon data from
large case series, the incidence of clavicle fractures due to birth trauma ranges from 0.5 to 1.6 percent [39-41].
Fractured clavicles are often associated with difficult vaginal delivery; however, clavicular fractures also occur in infants
who are products of a normal spontaneous vaginal or cesarean delivery.
Multiple risk factors for clavicular fractures have been reported, as illustrated by the following studies:
In a review of 9540 deliveries with an incidence of clavicular fracture of 1.6 percent, operative delivery and
shoulder dystocia were the primary risk factors for clavicle fracture [41].
In another large case series of 4297 deliveries with an incidence of clavicular fracture of 0.5 percent, increased
maternal age and a birth weight greater than 4 kg were significantly associated with clavicular fracture [39].
In a prospective study of 4789 deliveries with an incidence of clavicular fracture of 1.1 percent, higher birth weight
and a lower mean head-to-abdominal circumference ratio were predictive of a clavicular fracture [40].
The timing of the presentation and diagnosis of neonatal fractures of the clavicle is dependent on whether the fracture is
displaced or nondisplaced.
Displaced (complete) fractured clavicles are more likely to be accompanied by physical findings in the immediate
post-delivery time period. These include crepitus, edema, lack of movement of the affected extremity, asymmetrical
bone contour, and crying with passive motion.
The diagnosis of nondisplaced clavicular fracture is often delayed by days or weeks until there is a formation of a
visible or palpable callous because the neonate is usually asymptomatic.
The diagnosis is made by a radiograph of the clavicle, which differentiates clavicular fracture from brachial plexus injury,
traumatic separation of the proximal humeral epiphysis, humeral shaft fractures, and dislocations of the shoulder [42].
When evaluating a neonate for suspected clavicle fracture, obtaining a full radiograph of the chest and upper extremities
is suggested because these other diagnoses, which present with similar findings, may be detected in the fuller view. In
addition, the presence of a clavicle fracture warrants further investigation for accompanying brachial plexus injury. (See
"Brachial plexus syndromes", section on 'Neonatal brachial plexus palsy'.)
Because clavicular fractures in infants heal spontaneously with no long-term sequelae, parental reassurance and gentle
handling are all that are required for management. Analgesics may be given to decrease the pain. For comfort, the arm
on the affected side can be placed in a long-sleeved garment and pinned to the chest with the elbow at 90 degrees of
flexion. Although a repeat radiograph at two weeks of age can help determine whether or not there is proper healing of
the bone, callus formation and lack of tenderness detected on physical examination are usually predictive of appropriate
healing.
Humerus Although it is the most common long bone neonatal fracture, humeral fractures are rare with a reported
incidence of 0.2 per 1000 deliveries (image 3 and image 4) [43]. Most fractures occur at the proximal third of the
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humerus, and are transverse and complete [44].

Risk factors for humeral fractures include shoulder dystocia, macrosomia, cesarean delivery, breech delivery, and low
birth weight [44-46].
Clinical manifestations of a neonatal humeral fracture include decreased movement of the affected arm, decreased Moro
reflex, localized swelling and crepitation, and an increased pain response with palpation and movement of the arm. A
careful examination for evidence of brachial plexus injury should be performed, as this is a common associated finding in
infants with humeral fractures.
The diagnosis is generally made by a plain radiograph of the arm. In rare instances of very proximal or distal humeral
fractures (ie, near the epiphysis), ultrasonography or magnetic resonance imaging (MRI) is a more useful diagnostic tool
because plain radiography is less reliable due to the lack of ossification of the epiphysis [47,48]. MRI may be a less
painful (but more expensive) procedure compared with ultrasound. These studies can differentiate proximal and distal
humeral fractures from shoulder and elbow dislocation, respectively, in order to provide the appropriate treatment to the
neonate.
Treatment of humeral fractures consists of immobilization of the affected arm with the elbow in 90 degrees flexion to
prevent rotational deformities [49]. The humerus can be stabilized against the thorax by an elastic wrap or long-sleeved
shirt. Outcome is excellent with evidence of callus formation usually seen on radiography by 7 to 10 days. Regaining of
spontaneous movement of the arm will coincide with fracture healing. Radiographs to confirm healing can be performed
at three to four weeks post-injury. Parents should be reassured that angulation will remodel as the infant grows.
Femur Fractures of the femur as a result of birth trauma are rare, with a reported incidence of 0.13 per 1000 live
births [50]. The fracture is typically spiral and involves the proximal half of the femur.
In a large series of 55,296 live births, risk factors for femoral fractures include twin pregnancies, breech presentations,
prematurity, and diffuse osteoporosis [50].
Neonates with femoral fractures may initially be asymptomatic with only an increased pain response upon manipulation
of the affected extremity. For infants delivered by vaginal breech extraction, the obstetrician may note a "pop" or "snap"
upon delivery of the legs, thus prompting an investigation. In some cases, swelling of the affected leg may be present.
The diagnosis of femoral fracture is generally made by a plain radiograph of the leg. It may be an incidental finding.
The Pavlik harness is generally used to treat neonatal femoral fractures [51]. The fracture is reduced by adjustment of
the harness straps. A poorly fitting Pavlik harness can lead to femoral nerve palsies and avascular necrosis of the hip, so
care needs to be taken when applying this device. Spica casting is a less frequently used option, but may be more
practical in certain populations, such as in infants with myelomeningocele [50]. A more complete discussion on the use
of the Pavlik harness is found separately. (See "Developmental dysplasia of the hip: Treatment and outcome", section on
'Pavlik harness'.)
Outcome is excellent with evidence of callus formation usually seen on radiography by 7 to 10 days. Radiographs to
confirm healing can be performed at three to four weeks post-injury. Nonanatomic alignment is common and acceptable,
and parents should be reassured that angulation will remodel as the infant grows.
Skull Skull fractures as a result of birth trauma include linear and depressed skull fractures. Depressed skull fractures
are due to the inward buckling of the skull bones and are often associated with forceps-assisted deliveries. In one report,
the incidence of depressed skull fractures is 3.7 per 100,000 deliveries [52]. Of the 68 depressed skull fractures, 50
occurred in forceps-assisted delivery. The remaining skull fractures were seen in both spontaneous unassisted and
elective cesarean delivery, most likely due to pressure upon the soft fetal skull during labor and delivery from maternal
structures (eg, lumbar vertebrae, sacral promontory, symphysis pubis, and uterine myoma).
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The diagnosis is made by a plain radiograph of the head.

Skull fractures in infants of unassisted vaginal births are rarely associated with neurological sequelae. In these cases,
reassurance and, perhaps, repeat skull radiographs are all that is required.
In contrast, there is an increased risk of intracranial bleeding and/or cephalohematoma in forceps-assisted delivered
infants with depressed skull fractures. Further imaging with computed tomography (CT) is required to determine the
presence or absence of intracranial lesions. Neurosurgical consultation should be obtained in those with evidence of an
intracranial process, and if the depression is greater than 1 cm, as these often require surgical intervention. Smaller
fractures (ie, less than 1 cm) without any intracranial injury can be managed conservatively with observation. The use of
a vacuum extractor to elevate significant fractures has been reported, but should not be used routinely until further
studies demonstrate that it is a safe, effective method that is easily performed and can be applied for universal use.
Premature infants Premature infants are at higher risk for birth-associated fractures compared with term infants,
especially multiple fractures [50,53]. In a case series of preterm infants, 71 fractures were reported in 27 infants (mean
gestational age 27 weeks) during admission to a neonatal intensive care unit [53]. Ribs were the most common site of
fractures (n = 45).
DISLOCATIONS Dislocations caused by birth trauma are rare (picture 1). In many cases, the dislocations, especially
of the hip and knee, are due to intrauterine positional deformities or congenital malformations.
In addition, a separation of the epiphyseal plate (Salter-Harris type I fracture) from the metaphysis is often misdiagnosed
as a dislocation [54,55]. This can occur at the shoulder, elbow, or hip. Because management differs, it is important to
differentiate between these two conditions. Dislocations are distinguished from epiphyseal plate separations by clinical
examination and imaging studies. The lack of ossification in neonates limits the utility of plain radiographs in diagnosing
dislocations, and other modalities, such as ultrasound, magnetic resonance imaging, and arthrography, may be needed.
NEUROLOGIC INJURIES Neurologic injuries include the following:
Brachial plexus injury is one of the most common neurologic birth injuries, with an incidence of 0.04 to 0.2 percent
of births. It is discussed in greater detail separately. (See "Brachial plexus syndromes", section on 'Neonatal
brachial plexus palsy'.)
Facial nerve injury occurs in 0.1 to 0.7 percent of births and is usually due to compression of the nerve by forceps
or a prominent maternal sacral promontory. Typically, only the mandibular branch of the facial nerve is affected,
and the infant will have diminished movement on the affected side of the face. There is often loss of the nasolabial
fold, partial closing of the eye, and the inability to contract the lower facial muscles on the affected side, leading to
the appearance of a "drooping" mouth. When crying, the mouth is drawn over to the unaffected side.
Traumatic facial nerve palsy needs to be differentiated from those due to developmental or syndromic etiologies.
Traumatic facial nerve palsy has an excellent outcome with spontaneous resolution usually within the first two
weeks of life. (See "Facial nerve palsy in children".)
Phrenic nerve injury is often associated with brachial plexus injury. Clinical manifestations include respiratory
distress with diminished breath sounds on the affected side. Symptoms typically present on the first day of life. The
diagnosis and management of neonatal diaphragmatic paralysis are discussed separately. (See "Diaphragmatic
paralysis in the newborn", section on 'Birth injury'.)
Laryngeal nerve injury during birth may cause vocal cord paralysis. Symptoms include stridor, respiratory distress,
hoarse, faint, or absent cry, dysphagia, and aspiration. The diagnosis is made by direct laryngoscopy. Treatment is
dependent upon the severity of the injury. Paralysis will usually resolve over time. (See "Hoarseness in children:
Etiology and management", section on 'Vocal fold paralysis'.)
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Spinal cord injuries are rare with an incidence of 0.14 per 10,000 live births [56]. They occur more frequently in the
upper cervical spine because of the greater likelihood of injury due to traction or rotation of that area of the cord
during delivery. Injuries include spinal epidural hematoma, vertebral artery injuries, traumatic cervical
hematomyelia, spinal artery occlusion, and transection of the cord. Risk factors include forceps-assisted delivery
and breech vaginal delivery [56].
Presentation is dependent upon the severity and spinal level of the injury. The outcome of severe high cervical or
brainstem lesions is poor with a high mortality rate [56]. Lower lesions may result in significant morbidity with permanent
neurologic impairment. The diagnosis is often initially made by ultrasonography, although magnetic resonance imaging
(MRI) provides better visualization of the spinal cord and is the preferred modality, if available.
ABDOMINAL INJURIES Intra-abdominal birth trauma is uncommon and primarily consists of rupture or subcapsular
hemorrhage into the liver, spleen, and adrenal gland [57]. The clinical presentation is dependent upon the amount of
blood loss. Infants with hepatic and splenic rupture may present with sudden pallor, signs of hemorrhagic shock, and
abdominal distension and discoloration, whereas infants with subcapsular hematoma may have a delayed or more
insidious onset of symptoms of anemia, which include poor feeding, tachycardia, and tachypnea. Unilateral adrenal
hemorrhage may present as an abdominal mass.
Ultrasonography is the best modality to diagnose intra-abdominal birth injuries and can be performed at the bedside.
Computed tomography (CT) can also provide useful diagnostic information, but transport of a critically ill infant to the
scanner is more difficult.
The management includes fluid resuscitation with blood products and normal saline as appropriate. Fresh frozen plasma
may be needed to correct any coagulopathy associated with the injury. In infants with hepatic or splenic rupture or who
are hemodynamically unstable, laparotomy may be is required to control the bleeding [57].
SUMMARY AND RECOMMENDATIONS
The overall incidence of birth injuries is about 2 and 1.1 percent in singleton vaginal and cesarean deliveries,
respectively.
Factors that increase the risk of birth injuries include macrosomia (fetal weight greater than 4000 g), maternal
obesity, breech presentation, operative vaginal delivery (ie, the use of forceps or vacuum during delivery), small
maternal size, and the presence of maternal pelvic anomalies. (See 'Risk factors' above.)
The most common form of traumatic birth injuries are soft-tissue injuries including bruising, petechiae,
subcutaneous fat necrosis, and lacerations. Lacerations are the most common injury associated with cesarean
delivery and are generally mild, requiring repair only with sterile strips. The other three conditions are generally
self-limited and resolve without any intervention. (See 'Soft tissue injuries' above.)
The extracranial injuries of caput succedaneum (edema and bleeding above the periosteum) and
cephalohematoma (subperiosteal collection of blood) usually resolve spontaneously without any intervention. In
contrast, subgaleal hemorrhage (bleeding in the loose areolar tissue in the space between the periosteum of the
skull and the aponeurosis) may result in massive blood loss that, if not detected and managed appropriately, may
lead to shock and death. (See 'Extracranial injuries' above.)
Facial injuries include nasal septal dislocation, which requires reduction by three days of life to avoid nasal septal
deformity, and ocular injuries, which are usually mild and resolve without any intervention. In cases of suspected
severe ocular injury (eg, hyphema and vitreous hemorrhage), ophthalmologic consultation should be obtained.
(See 'Facial injuries' above.)
Intracranial hemorrhages include subdural, subarachnoid, epidural, and intraventricular hemorrhage. The decision
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for neurosurgical intervention is based upon the clinical condition of the patient including evidence of increased
intracranial pressure, and the nature and size of the injury. (See 'Intracranial hemorrhage' above.)
Fractures due to birth trauma include clavicular, humeral, femoral, and skull fractures. Since most clavicular and
skull fractures resolve spontaneously, they are managed conservatively with observation alone. Humeral and
femoral fractures require immobilization, and generally resolve within four weeks. Virtually any malalignment will
remodel as the infant grows. (See 'Fractures' above.)
Neurologic injury includes injury to peripheral nerves including the brachial plexus and facial, phrenic, and
laryngeal nerves. These typically resolve with time. Although spinal cord injuries are rare, they generally have a
poor prognosis due to high mortality rate and increased likelihood of permanent neurologic impairment in survivors.
(See 'Neurologic injuries' above.)
Intra-abdominal injuries due to birth trauma are rare and primarily are due to rupture and subcapsular hemorrhage
into the liver, spleen, and adrenal gland. Clinical presentation and management vary depending upon the degree of
bleeding. (See 'Abdominal injuries' above.)
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Topic 5031 Version 12.0
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GRAPHICS
Neonatal morbidity and mortality data by delivery type for the United
States, 1995 to 1998 (rates are per 10,000 deliveries)
Outcome
Spontaneous
Forceps delivery
Vacuum delivery
Neonatal death
3.7
5.0
4.7
Birth injury
21.4
109.1
76.1
Neonatal seizures
5.0
8.7
6.5
Assisted ventilation <30 minutes
147
293
250
Data from: Demissie K, Rhoads GG, Smulian JC, et al. Operative vaginal delivery and neonatal and infant
adverse outcomes: population based retrospective analysis. BMJ 2004; 329:24.
Graphic 70509 Version 4.0
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Neonatal morbidity and mortality data by delivery type, New Jersey

1989 to 1993, rate per 10,000 deliveries
Outcome
Unassisted
Forceps
Vacuum
Vacuum
(spontaneous) delivery
delivery
delivery
plus forceps
Cephalohematoma
167
635
1117
1361
Facial nerve injury
2.4
37.0
5.2
52.9
Intracranial
hemorrhage
3.7
17.0
16.2
26.5
Mechanical
ventilation
23.5
31.3
40.3
74.1
Retinal
hemorrhage
18.2
19.3
15.7
31.8
Data from: Demissie K, Rhoads GG, Smulian JC, et al. Operative vaginal delivery and neonatal and infant
adverse outcomes: population based retrospective analysis. BMJ 2004; 329:24.
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Neonatal extracranial and intracranial birth injuries
Modified from: Volpe JJ. Neurology of the Newborn, 4th ed, WB Saunders, Philadelphia
2001.
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5-week-old with calcifying cephalohematoma
Courtesy of Rajvee Shah, MD.

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Frequency of birth trauma related to mode of delivery cases per 10,000

births
Cesarean
with
Spontaneous
birth
Vacuum
assisted
Forceps
assisted
Cesarean
no labor
Subdural or cerebral
hemorrhage
2.9
8.0
9.8
4.1
7.4
Intraventricular
hemorrhage
1.1
1.5
2.6
0.8
2.5
Subarachnoid
hemorrhage
1.3
2.2
3.3
0.0
1.2
Facial nerve injury
3.3
4.6
45.4
4.9
3.1
Brachial plexus injury
7.7
17.6
25.0
4.1
1.8
Convulsions
6.4
11.7
9.8
8.6
21.3
CNS depression
3.1
9.2
5.2
6.7
9.6
Feeding difficulty
68.5
72.1
74.6
106.3
117.2
Mechanical ventilation
25.8
39.1
45.4
71.3
103.2
Trauma
labor
CNS: central nervous system.

Data from: Towner D, Castro MA, Eby-Wilkens E, et al. Effect of mode of delivery in nulliparous women on
neonatal intracranial injury. N Engl J Med 1999; 341:1709.
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Newborn with left mid clavicle fracture

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9 week old with mid left humerus fracture

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Left distal humerus fracture

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Neonate knee dislocation
Courtesy of Gerardo Cabrera-Meza, MD.

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Contributor Disclosures
Tiffany M McKee-Garrett, MD Nothing to disclose. Leonard E Weisman, MD Grant/Research/Clinical Trial Support:
Vax-Immune [Ureaplasma diagnosis, vaccines, and antibodies]. Consultant/Advisory Boards: Glaxo-Smith Kline [Malaria
vaccine]; NIAID [Staphylococcus aureus (Mupirocin)]. Patent Holder: Baylor College of Medicine [Ureaplasma diagnosis,
vaccines, antibodies, process for preparing biological samples]. Equity Ownership/Stock Options: Vax-Immune
[Ureaplasma diagnosis, vaccines, and antibodies]. William Phillips, MD Nothing to disclose. Marc C Patterson, MD,
FRACP Grant/Research/Clinical Trial Support: Vtesse [Niemann-Pick C (Cyclodextrin)]. Consultant/Advisory Boards:
Actelion [Niemann-Pick C (Miglustat)]; Agios [CGD]; Amicus [Fabry, Gaucher, Pompe [(Migalastat)]; Novartis [MS]; Shire
[MLD]; Vtesse [Niemann-Pick C]. Other Financial Interest: Sage [Honorarium as Editor-in-Chief of Journal of Child
Neurology and Child Neurology Open]. Melanie S Kim, MD Nothing to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by
vetting through a multi-level review process, and through requirements for references to be provided to support the
content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of
evidence.
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