• CAPUT SUCCEDANEUM
• SUBGALEAL HEMORRHAGE
• A caput succedaneum is a
serosanguinous fluid collection above the
periosteum. It presents as a soft tissue
swelling with purpura and ecchymosis
over the presenting portion of the scalp. It
may extend across the midline and across
• The edema disappears within the 1st few
days of life.
• Molding of the head and overriding of the
parietal bones disappear during the 1st
weeks of life.
• Rarely, a hemorrhagic caput may result in
shock and require blood transfusion.
• No specific treatment is needed
• But if extensive ecchymoses are
present, hyperbilirubinemia may develop
• Shock – Blood transfusion
• A cephalhematoma is a subperiosteal
blood collection caused by rupture of
vessels beneath the periosteum.
• Swelling, usually over a parietal or
• Swelling does not cross a suture line and
is often not associated with discoloration
of the overlying scalp.
• Limited to the surface of one cranial bone.
• If infection is suspected, aspiration of the
• If sepsis, antibiotics
• hyperbilirubinemia – photo therapy
• A subgaleal hemorrhage is bleeding
between the galea aponeurosis of the
scalp and the periosteum.
• A subgaleal hemorrhage presents as a
firm-to-fluctuant mass that crosses suture
• The mass is typically noted within 4 hours
• serial hemoglobin and hematocrit
• coagulation profile to investigate for the
presence of a coagulopathy.
• Bilirubin levels also need to be monitored
• Transfusions may be required if blood loss
• In severe cases, surgery may be required
to cauterize the bleeding vessels.
• These lesions typically resolve over a 2–3
• LINEAR SKULL FRACTURES
• DEPRESSED SKULL FRACTURES
LINEAR SKULL FRACTURES
• Usually affect the parietal bones.
• The pathogenesis is related to
compression from the application of
forceps, or from the skull pushing against
the maternal symphysis or ischeal spines.
• Rarely, a linear fracture may be
associated with a dural tear, with
subsequent development of a
DEPRESSED SKULL FRACTURES
• Indications for surgery include
• radiographic evidence of bone
fragments in the cerebrum
• presence of neurologic deficits
• signs of increased intracranial pressure
• signs of cerebrospinal fluid beneath the
• failure to respond to closed manipulation.
• Indications for nonsurgical management
• Depressions less than 2 cm in width and
depressions over a major venous sinus
• Without neurologic symptoms
• Bleeding can occur
– External to the brain into the
epidural, subdural or subarachnoid space
– In to the parenchyma of the cerebrum or
– Into the ventricles from the subependymal
germinal matrix or choroid plexus
prolonged second stage of labor
• Epidural hemorrhage primarily arises from
injury to the middle meningeal artery, and
is frequently associated with a
cephalhematoma or skull fracture.
• cranial computed tomography showing a
high-density lentiform lesion in the
• Skull radiographs
• Surgical management
• Aspiration of blood from the accompanying
• most frequent intracranial hemorrhage
related to birth trauma
• Laceration of the tentorium, with rupture of
the straight sinus, vein of Galen transverse
sinus, or infratentorial veins causing a
posterior fossa clot and brainstem
• Laceration of the falx, with rupture of the
inferior sagittal sinus resulting in a clot in
the longitudinal cerebral fissure
• Laceration of the superficial cerebral
vein, causing bleeding over the cerebral
• Occipital osteodiastasis, with rupture of
the occipital sinus, resulting in a posterior
Respiratory symptoms such as apnea
Focal neurologic deficits
Other neurologic symptoms
• Subarachnoid hemorrhage is caused by
rupture of the bridging veins of the
subarachnoid space or small
• Seizures, often occurring on the second
day of life
• Depressed level of consciousness
• Focal neurologic signs.
• Cranial computed tomography.
• Cranial ultrasonography
• Lumbar puncture shows an increased
number of red blood cells
• Resolves without intervention
• Monitoring head growth
• Intra cerebral
• rupture of an av malformation or aneurysm
• coagulation disturbances
• extracorporeal membrane oxygenation
• secondary to a large ICH in any other
• Intracerebellar :
more common in preterm than the
term babies. May be a primary
haemorrhage or may result from venous
hemorrhagic infarction or from extension
of GMH/ IVH
• In the preterm infant
– IPH is often clinically silent in either
intracranial fossa , unless the hemorrhage is
• In the term infant, manifestations are
– Gaze preference
– Depressed level of consciousness
• 5th and 6th cervical nerves injury
• The infant loses the power to abduct the
arm from the shoulder, rotate the arm
externally, and supinate the forearm
• Erb’s palsy may also be associated with
injury to the phrenic nerve,
which is innervated with
fibers from C3–C5
• Adduction and internal rotation of the arm
with pronation of the forearm.
• Biceps reflex is absent
• Moro reflex is absent on the affected side.
• The involved arm is held in the ‘‘waiter’s
tip’’ position, with adduction and internal
rotation of the shoulder, extension of the
elbow, pronation of the forearm, and
flexion of the wrist and fingers.
• Involves the C8 and T1 nerves, resulting in
weakness of the intrinsic hand muscles
and long flexors of the wrist and fingers
• The grasp reflex is absent but the biceps
reflex is present.
• Flaccid extremity with absent reflexes.
• Hematomas of the sternocleidomastoid
muscle, and fractures of the clavicle and
• Ipsilateral Horner’s syndrome
(ptosis, miosis, and anhydrosis) when
there is accompanying injury to the
sympathetic fibers of T1.
• Neuropraxia with temporary conduction
• Axonotmesis with a severed axon, but with
intact surrounding neuronal elements
• Neurotmesis with complete postganglionic
disruption of the nerve
• Avulsion with preganglionic disconnection
from the spinal cord
• Physical examination.
• Radiographs of the shoulder and upper
• Initial treatment is conservative.
• The arm is immobilized across the upper
abdomen during the first week
• Physical therapy with passive range-ofmotion exercises at the shoulder, elbow
and wrist should begin after the first week.
• Infants without recovery by 3 to 6 months
of age may be considered for surgical
FACIAL NERVE PALSY
• Risk factors
– forceps delivery
– prolonged second stage of labor
• weakness of both upper and lower facial
• At rest, the nasolabial fold is flattened and
the eye remains persistently open on the
• During crying, there is inability to wrinkle
the forehead or close the eye on the
ipsilateral side, and the mouth is drawn
awayfrom the affected side.
• lacerations and bruising
• neurologic findings
• protection of the involved eye by
application of artificial tears and taping to
prevent corneal injury.
• neurosurgical repair of the nerve should
be considered only after lack of resolution
during 1 year of observation
PHRENIC NERVE INJURY
• The phrenic nerve arises from the third
through fifth cervical nerve roots.
• Injury to the phrenic nerve leads to
paralysis of the ipsilateral diaphragm.
• respiratory distress, with diminished breath
sounds on the affected side.
• Chest radiographs show elevation of the
affected diaphragm, with mediastinal shift
to the contralateral side.
• Ultrasonography or fluoroscopy can
confirm the diagnosis by showing
paradoxical diaphragmatic movement
• Initial treatment is supportive
• Respiratory failure may be treated with
continuous positive airway pressure or
• Gavage feedings.
• Plication of the diaphragm
• Small frequent feedings may be required
to decrease the risk of aspiration.
• Bilateral paralysis tends to produce more
severe distress, and therefore requires
intubation and tracheostomy placement
SPINAL CORD INJURY
• Clinical findings
• decreased or absent spontaneous
• absent deep tendon reflexes
• absent or periodic breathing
• lack of response to painful stimuli below
the level of the lesion.
• Lesions above C4 are almost always
associated with apnea
• Lesions between C4 and T4 may have
respiratory distress secondary to varying
degrees of involvement of the phrenic
nerve and innervation to the intercostal
• If cord injury is suspected in the delivery
room, the head, neck, and spine should be
• Therapy is supportive.
• Nasal septal dislocation involves
dislocation of the triangular cartilaginous
portion of the septum from the vomerine
• airway obstruction.
• deviation of the nose to one side
• The nares are asymmetric, with flattening
of the side of the dislocation (Metzenbaum
• Application of pressure on the tip of the
nose (Jeppesen and Windfeld test) causes
collapse of the nostrils, and the deviated
septum becomes more apparent.
• Definitive diagnosis can be made by
• manual reduction performed by an
otolaryngologist using a nasal elevator.
• Reduction should be performed by 3 days
• Rupture of Descemet’s membrane of the
• lid lacerations
• hyphema (blood in anterior chamber)
• vitreous hemorrhage
• Purtscher’s retinopathy
• corneal edema,
• corneal abrasion
• atrophic muscle fibers surrounded by
collagen and fibroblasts.
• tearing of the muscle fibers or fascial
sheath with hematoma formation and
• The head is tilted toward the side of the
lesion and rotated to the contralateral side,
• chin is slightly elevated.
• If a mass is present, it is firm, spindleshaped, immobile, and located in the
midportion of the sternocleidomastoid
muscle, without accompanying
discoloration or inflammation.
• physical examination
• Radiographs should be obtained to rule
out abnormalities of the cervical spine.
• Ultrasonography may be useful both
diagnostically and prognostically.
• active and passive stretching
• clavicle is the most frequently fractured
bone during birth
higher birth weight
prolonged second stage of labor
• Asymptomatic incomplete fractures require
• Complete fractures are treated with
immobilization of the arm for 7 to 10 days
LONG BONE FRACTURES
• breech presentation
• cesarean delivery
• low birthweight
• decreased movement of the affected
extremity, swelling, pain with passive
movement, and crepitus
• Diagnosis is made radiographically
• immobilization and splinting
• Closed reduction and casting are required
only when the bones are displaced.
• Proximal femoral fractures may require a
spica cast or use of a Pavlik harness
Liver injury is the most common
Three potential mechanisms lead to intraabdominal injury:
(1) direct trauma,
(2) compression of the chest against the
surface of the spleen or liver
(3) chest compression leading to tearing of
the ligamentaous insertions of the liver or
• With hepatic or splenic rupture, patients
develop sudden pallor, hemorrhagic
shock, abdominal distention, and
• Presentation of a liver rupture with scrotal
swelling and discoloration has been
• Subcapsular hematomas may present
more insidiously, with anemia, poor
feeding, tachypnea, and tachycardia.
• Adrenal hemorrhage may present as a
• abdominal ultrasound
• Computed tomography
• Abdominal radiographs may show
nonspecific intraperitoneal fluid or
• Abdominal paracentesis is diagnostic if a
hemoperitoneum is present
• volume replacement and correction of any
• If the infant is hemodynamically
stable, conservative management is
• With rupture or hemodynamic instability, a
laparotomy is required to control the
• Patients with adrenal hemorrhage may
require hormone replacement therapy.
SOFT TISSUE INJURIES
• Petechiae and ecchymoses
• Lacerations and abrasions
• Subcutaneous fat necrosis