Paediatrics: Birth trauma

Birth trauma

Risk factors

LGA, cephalic–pelvic disproportion, malpresentation, precipitate delivery, instrumental delivery, shoulder dystocia, prematurity.

Head

·  Caput succedaneum: oedema of the presenting scalp. Can be particularly large following ventouse delivery (chignon). Rapidly resolves.

·  Cephalhaematoma: common fluctuant swelling(s) due to subperiostial bleed(s). Most often occur over parietal bones. Swelling limited by suture lines. Resolves over weeks.

·  Subaponeurotic haematoma: rare; bleeding not confined by skull periostium, so can be large and life-threatening. Presents as fluctuant scalp swelling, not limited by suture lines.

Skin

·  Traumatic cyanosis: bruising and petechiae of presenting part.

·  Lacerations: caused by forceps, ventouse cap, scalp electrodes, scalp pH sampling, or scalpel wounds during CS. Close with Steri-Strips^® or suture if required.

Nerve palsies

·  Brachial plexus: commonest is Erb’s palsy (C5–C6 nerve routes). May result from difficult assisted delivery (e.g. shoulder dystocia); the arm is flaccid with pronated forearm and flexed wrist (waiter’s tip position). Complete recovery occurs within 6wks in two-thirds of cases. X-ray clavicle to exclude fractures. Refer to physiotherapy for assessment and follow-up.

·  Facial nerve palsy: follows pressure on face from either maternal ischial spine or forceps. Presents as facial asymmetry that is worse on crying (affected side shows lack of eye closure and lower facial movement; mouth is drawn to normal side). Majority recover in 1–2wks. May require eye care with methylcellulose and specialist referral.

Fractures

·  Clavicle (commonest).

·  Long bone fractures: usually lower avulsion fractures of the femoral or tibial epiphyses, or mid-shaft fractures of the femur or humerus. Infant presents as unsettled, with affected limb pseudo-paralysis, or obvious deformity or swelling. Confirm by X-ray.

·  Skull fracture: associated with forceps delivery and usually require no treatment unless depressed in which case neurosurgical referral is required.

·  Treatment: analgesia; limb immobilization (arm inside baby-grow), often do not require orthopaedic intervention, healed in a few weeks. Rapid healing and remodelling usually occur.

Soft tissue trauma

·Sternocleidomastoid tumour: overstretching of muscle leads to haematoma. Subsequent contraction of muscle results in non-tender ‘tumour’ and torticollis (head turns away from affected muscle). Physiotherapy almost always curative. Possible indication of malposition in-utero—consider increased risk of developmental dysplasia of the hip (DDH).

·  Fat necrosis Tender, red, subcutaneous swelling caused by pressure over bony prominences, e.g. forceps. It usually resolves spontaneously. May be extensive with risk of Rise Ca²⁺ and so there is a need to monitor serum level.