Chapter 71

1. Problem. An infant is noted to have severe bruises after birth, and a nurse observes that the infant is not using his right arm. The birth was traumatic, and the nurse calls you to evaluate the infant. Birth injuries are injuries that occur during the birth process. The incidence is ~2–7 per 1000 live births.

2. Immediate questions

1. Is there any reason the infant would have a birth injury? Certain factors predispose the infant to birth injuries. These include fetal macrosomia, dystocia, prolonged or very rapid labor, abnormal presentation (especially breech), cephalopelvic disproportion, small maternal stature, maternal pelvic abnormalities, oligohydramnios, very low birthweight infant, fetal anomalies, use of forceps or vacuum extraction, and prematurity.

1. Is the injury so serious that it requires immediate attention? The majority of birth injuries are not serious and do not require immediate treatment. Significant injuries requiring immediate intervention, such as abdominal organ injuries that present as shock and require surgery, need to be identified early. It is important to distinguish and recognize the different injuries so that appropriate treatment can be given.

1. Was forceps or vacuum extraction used during the delivery? Studies suggest that the use of midforceps and vacuum extraction may increase the infant's risk of fractures and paralysis.

3. Differential diagnosis

1. Skin

1. Petechiae. In birth trauma, petechiae are usually localized (eg, on the head, neck, upper chest area, and lower back). There is no associated bleeding, and no new lesions appear. If petechiae are diffuse, suspect systemic disease. If there is associated bleeding, suspect disseminated intravascular coagulation.

1. Forceps injury. Frequently, linear marks are seen across both sides of the face. The area is usually red.

1. Subcutaneous fat necrosis typically involves the shoulders and the buttocks with a well-circumscribed lesion of the skin and underlying tissue. It usually appears between 6 and 10 days of age. Lesion size is 1–10 cm, it can be irregular and hard, and the overlying skin can be purple or colorless.

1. Ecchymoses. Bruising can occur after a traumatic delivery, especially when labor is rapid or the infant is premature.

1. Lacerations can occur secondary to the use of a scalpel during a cesarean delivery. They usually occur on the buttocks, scalp, or thigh.

1. Scalp electrode injury. The site of insertion of the scalp electrode can sometimes become infected (1% of cases) and rarely in premature infants can cause severe bleeding.

1. Caput succedaneum. This is an area of edema over the presenting part of the scalp during a vertex delivery. The area of edema is usually associated with bruising and petechiae. It crosses the midline of the skull and suture lines. The bleeding is external to the periosteum (see Figure 5–1). Hyperbilirubinemia rarely develops.

1. Cephalhematoma. Incidence is 1.5–2.5% of all deliveries. This is caused by bleeding that occurs below the periosteum overlying one cranial bone (usually the parietal bone). (See Figure 5–1.) There is no crossing of the suture lines. The overlying scalp is not discolored, and the swelling sometimes takes days to become apparent. The incidence ...

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