Neonatal birth injuries

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. 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.

In addition, there are separate topics on the following:

●Brachial plexus palsy – (See "Neonatal brachial plexus palsy".)

●Shoulder dystocia – (See "Shoulder dystocia: Intrapartum diagnosis, management, and outcome" and "Shoulder dystocia: Risk factors and planning birth of high-risk pregnancies".)

●Birth defects – (See "Congenital anomalies: Epidemiology, types, and patterns" and "Congenital anomalies: Approach to evaluation" and "Congenital anomalies: Causes".)

EPIDEMIOLOGY — The overall incidence of birth injuries ranges from 2 to 3 percent based on an analysis of neonatal discharge records between 2006 and 2014 from the Nationwide Inpatient Sample database [1]. In this study, 80 percent of birth injuries were due to scalp injuries (eg, lacerations and bruising) and the remaining were considered major trauma (eg, clavicular fractures, brachial plexus injuries, and intracranial hemorrhage). During the study period, the risk of scalp injuries increased while major trauma decreased. Major trauma was associated with a greater risk of other complications (eg, hypoxic-ischemic encephalopathy and seizures).

RISK FACTORS

●Increased risk of birth injury ‒ The following factors increase the risk of birth 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 normosomic 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 [2]. In another study, the incidence of fetal injury was 7.7 percent in infants with birth weights greater than 4500 g [3].

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 birth of high-risk pregnancies", section on 'Risk factors'.)

•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 or the increased risk of delivering a large for gestational age infant, which is associated with an increased risk of shoulder dystocia. [4]. (See "Obesity in pregnancy: Complications and maternal management" and "Cesarean birth: Overview of issues for patients with obesity".)

•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 breech presentation" and "Delivery of the singleton 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. 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 birth injury more than the use of either instrument alone. The neonatal complications of operative vaginal deliveries are discussed in detail separately. (See "Assisted (operative) vaginal birth", section on 'Neonatal complications'.)

•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 [5]. Additionally, small maternal stature and the presence of maternal pelvic anomalies are associated with an increased risk of birth injuries.

●Decreased risk of birth injury ‒ It is unclear whether cesarean delivery is protective with a lower risk of birth trauma compared with vaginal deliveries. Cesarean as a protective factor 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.

SOFT TISSUE INJURIES — The most common form of traumatic birth injuries are soft-tissue injuries including bruising, petechiae, subcutaneous fat necrosis, and lacerations [7].

Bruising and petechiae — Bruising and petechiae are usually self-limiting and are often seen on the presenting portion of the newborn's body.

●Genitalia ‒ Bruising and edema of the genitals are common findings in infants delivered from the breech position.

●Head and neck ‒ 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 risk factor for the development of early and/or severe hyperbilirubinemia. Close follow-up after the newborn hospital discharge is recommended for infants with significant bruising in order to assess for jaundice [8]. (See "Unconjugated hyperbilirubinemia in term and late preterm newborns: Screening".)

Subcutaneous fat necrosis — Subcutaneous fat necrosis (SCFN) is uncommon and usually occurs in the first few weeks of life as a result of ischemia to the adipose tissue, often adjacent to a bony structure, following a traumatic delivery. SCFN 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 (picture 1 and picture 2).

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. (See "Subcutaneous fat necrosis of the newborn".)

Lacerations — Fetal laceration has been reported as the most common birth injury associated with cesarean delivery [9]. In one study of 3108 cesarean deliveries, the fetal laceration rate was approximately 3 percent [10]. 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 Steri-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).

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 [11]. 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. [12]. Rarely, systemic infection may occur as a complication of an infected caput succedaneum [13].

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. (See "Assisted (operative) vaginal birth", section on 'Complications'.)

Ultrasound is useful for characterization of the fluid collection; however, it may not clearly depict the location of the hematoma relative to the skull sutures [14]. Imaging with computed tomography (CT) or magnetic resonance imaging (MRI) will confirm the subperiosteal location of the cephalohematoma and can also be useful for evaluating the presence (or absence) of associated osteomyelitis.

Cephalohematoma has been recognized as a risk factor for the development of early and/or severe hyperbilirubinemia. Close follow-up after the newborn hospital discharge is recommended for infants with cephalohematoma in order to assess for jaundice [8]. (See "Unconjugated hyperbilirubinemia in term and late preterm newborns: Screening".)

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 [15,16].

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. Needle aspiration and culture of the hematoma are considered to be mandatory to diagnose infection for suspected cases [17]. Osteomyelitis is a reported complication of an infected cephalohematoma [18]. 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 third-generation cephalosporin [cefotaxime or ceftazidime]).

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. SGH has been estimated to occur in 4 of 10,000 spontaneous vaginal deliveries and 59 of 10,000 vacuum-assisted deliveries [19].

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 [20]) 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 approximately 12 to 14 percent [21,22]. Infants who died had massive volume loss resulting in shock and coagulopathy [22].

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 [23]. 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 for differentiating subgaleal hemorrhage from other sources of cranial bleeding. Head ultrasound is useful for the diagnosis of SGH in the hands of an operator experienced in imaging the neonatal head and scalp, and is preferable to CT due to lack of ionizing radiation (image 2). Coagulation studies are required to detect coagulopathy that may 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 [24].

Facial injuries

●Nasal septal dislocation ‒ Nasal septal dislocation occurs in approximately 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 [25]. 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. With positional deformity, the septum remains straight even though the nares appear uneven. 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 [25]. No treatment or a delay in treatment may result in nasal septal deformity [25,26].

●Ocular injuries ‒ Minor ocular trauma, such as retinal and subconjunctival hemorrhages, and lid edema, are common and resolve spontaneously without affecting the infant [27]. 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 approximately 0.2 percent of deliveries with a higher incidence associated with forceps-assisted delivery [27]. Prompt ophthalmologic consultation should be obtained for patients with, or suspected to have, these injuries.

INTRACRANIAL HEMORRHAGE

Overview — Intracranial hemorrhages (ICH) as a consequence of birth injury include subdural, subarachnoid, epidural, intraventricular hemorrhages, and less frequently, intracerebral and intracerebellar hemorrhages (table 1).

The risk of ICH increases with operative delivery (reported incidence of 3.7 per 10,000 unassisted deliveries, 16.2 per 10,000 vacuum-assisted deliveries, and 17 per 10,000 forceps-assisted deliveries) [28]. 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.

●Location ‒ SDH forms between the dura mater and arachnoid membrane (figure 1) [29-31]. The location of SDH is most often tentorial and/or interhemispheric.

●Risk factors ‒ The rate of intracranial hemorrhage is higher among infants delivered by vacuum extraction, forceps, or cesarean section during labor than among infants delivered spontaneously [30].

●Presentation and clinical findings ‒ 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 seizures, respiratory depression, and apnea [33,34]. 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 an increase in head circumference, tense fontanelle, apnea, bradycardia, and coma.

●Imaging and diagnosis ‒ The diagnosis is made with cranial imaging, either computed tomography [CT] or MRI. However, CT is generally accepted as the standard modality for diagnosis of SDH, particularly in emergent situations, due to ease of access, shorter scan time, and faster result time [33].

●Management ‒ 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 [34]. 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 antiseizure medication therapy. We prefer to use phenobarbital (loading dose of 20 mg/kg) as the initial antiseizure medication therapy. (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 [29,33], the risk of SAH increases with operative vaginal deliveries (reported incidences of 1.3 per 10,000 for spontaneous unassisted deliveries, 2.3 per 10,000 vacuum-assisted deliveries, 3.3 per 10,000 forceps-assisted deliveries, and 10.7 per 10,000 combined vacuum- and forceps-assisted vaginal deliveries, respectively) (table 1) [30].

As with subdural hemorrhage, newborns with SAH most often present at 24 to 48 hours of life with apnea, respiratory depression, and seizures [35]. The diagnosis is made by CT of the head or, in nonemergent scenarios, MRI 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 [36]. EDH and cephalohematoma can coexist when accompanied by an underlying skull fracture due to communication through the skull fracture (figure 1) [37].

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 [36]. When accompanied by a cephalohematoma, needle aspiration of the cephalohematoma may result in the resolution of the EDH [38].

Intraventricular hemorrhage — Although intraventricular hemorrhage (IVH) is usually associated with preterm 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 [39]. All the hemorrhages were subependymal in location (grade 1 IVH). The risk of IVH increases with operative deliveries (reported incidences of 1.1 per 10,000 unassisted deliveries, 1.5 per 10,000 vacuum-assisted deliveries, 2.6 per 10,000 forceps-assisted deliveries, and 3.7 per 10,000 combined vacuum- and forceps-assisted deliveries, respectively) (table 1) [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 "Germinal matrix and intraventricular hemorrhage (GMH-IVH) in the newborn: Risk factors, clinical features, screening, and diagnosis".)

FRACTURES

Clavicle — Clavicular fractures are the most commonly reported fractures in neonates (image 3).

●Incidence and risk factors ‒ Based upon data from large case series, the incidence of clavicle fractures due to birth trauma ranges from 0.5 to 1.6 percent [40-42]. 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. Reported risk factors for clavicular fractures include operative delivery, shoulder dystocia, increased maternal age, increased birth weight (particularly if >4 kg), and lower mean head-to-abdominal circumference ratio [40-42].

●Presentation ‒ The timing of the presentation 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.

●Diagnosis ‒ 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 [43]. 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 "Neonatal brachial plexus palsy", section on 'Evaluation and diagnosis'.)

●Management ‒ 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

●Incidence and risk factors ‒ 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 4 and image 5) [44].

Risk factors for humeral fractures include shoulder dystocia, macrosomia, cesarean delivery, breech delivery, and low birth weight [45-47].

●Clinical manifestations ‒ Most fractures occur at the proximal third of the humerus and are transverse and complete [45].

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.

●Diagnosis ‒ 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 [48,49]. 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.

●Management ‒ Treatment of humeral fractures consists of immobilization of the affected arm with the elbow in 90 degrees flexion to prevent rotational deformities [50]. 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

●Incidence and risk factors ‒ Fractures of the femur as a result of birth trauma are rare, with a reported incidence of 0.13 per 1000 live births [51]. 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 [51].

●Clinical manifestations ‒ The fracture is typically spiral and involves the proximal half of the femur. 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.

●Diagnosis ‒ The diagnosis of femoral fracture is generally made by a plain radiograph of the leg. It may be an incidental finding.

●Management ‒ The Pavlik harness is generally used to treat neonatal femoral fractures [52]. 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 [51]. 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 ‒ 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 — Birth trauma can result in linear and depressed skull fractures.

●Incidence and risk factors – Depressed skull fractures are due to the inward buckling of the skull bones and are often associated with forceps-assisted deliveries. In one report, depressed skull fractures occurred in 3.7 per 100,000 deliveries [53]. Of the 68 depressed skull fractures, 50 occurred with 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).

●Evaluation and diagnosis – Fractures may present with swelling and ecchymosis of the head, with or without an indentation, or depression, of the skull. If a fracture is suspected, diagnosis can be made with plain radiographs of the skull, CT or MRI.

If there is a palpable indentation, the possibility of a depressed skull fracture should be considered, and in such cases, we suggest a CT to assess for underlying intracranial bleeding. If available, MRI can also be performed for non-urgent diagnosis; however this modality often requires newborn sedation to achieve good imaging results. (See 'Intracranial hemorrhage' above.)

●Management – Skull fractures in infants of unassisted vaginal births are rarely associated with neurological sequelae. In these cases, reassurance and, perhaps, repeat skull radiographs to demonstrate fracture healing are all that is required.

In contrast, infants who underwent forceps-assisted deliveries and have depressed skull fractures have an increased risk of intracranial bleeding and/or cephalohematoma. Neurosurgical consultation should be obtained in those who have evidence of an intracranial process on imaging, and in those who have a depression greater than 1 cm; these cases often require surgical intervention. Smaller fractures (ie, less than 1 cm) without any intracranial injury can be managed conservatively with observation only. The use of a vacuum extractor to elevate significant fractures has been reported [54].

Preterm infants — Preterm infants are at higher risk for birth-associated fractures compared with term infants, especially multiple fractures [51,55]. 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 [55]. Ribs were the most common site of fractures (n = 45).

DISLOCATIONS — Dislocations caused by birth trauma are rare (picture 3). 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 [56,57]. 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. It is discussed in greater detail separately. (See "Neonatal brachial plexus palsy".)

●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'.)

●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".)

●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 "Common causes of hoarseness in children", section on 'Vocal fold paralysis'.)

●Spinal cord injuries are rare with an incidence of 0.14 per 10,000 live births [58]. 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 [58].

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 [58]. Lower lesions may result in significant morbidity with permanent neurologic impairment. The diagnosis is often initially made by ultrasonography. If available, magnetic resonance imaging (MRI) provides better visualization of the spinal cord and is the preferred modality.

ABDOMINAL INJURIES — Intra-abdominal birth trauma is uncommon and primarily consists of rupture or subcapsular hemorrhage into the liver, spleen, and adrenal gland [59].

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. Macrosomia, breech delivery, and the use of instrumentation during delivery have been reported as risk factors for abdominal birth injuries [60].

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 [59].

SUMMARY AND RECOMMENDATIONS

●Incidence ‒ The overall incidence of birth injuries is approximately 2 and 1.1 percent in singleton vaginal and cesarean deliveries, respectively. (See 'Epidemiology' above.)

●Risk factors ‒ 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) (table 1), small maternal size, and the presence of maternal pelvic anomalies. (See 'Risk factors' above.)

●Soft tissue injuries ‒ The most common form of traumatic birth injuries are soft-tissue injuries including bruising, petechiae, subcutaneous fat necrosis (picture 1 and picture 2), 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.)

●Extracranial injuries (figure 1) ‒ 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 ‒ 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 hemorrhage ‒ Intracranial hemorrhages include subdural, subarachnoid, epidural, and intraventricular hemorrhage. The decision 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 ‒ Fractures due to birth trauma include clavicular (image 3), humeral (image 4 and image 5), 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.)

●Dislocations ‒ Dislocations caused by birth trauma are rare (picture 3). (See 'Dislocations' above.)

●Neurologic injuries ‒ Neurologic injuries 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 ‒ 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.)