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SKULL INJURIES AND SOFT
B.Sc. Nursing 4th year
At the end of this session, B.Sc. Nursing 3rd
year students will be able to explain about
skull injuries and soft tissue injuries in
At the end of this session, B.Sc. Nursing 3rd
year students will be able to :
• define birth injuries.
• list out the risk factors for birth injuries.
• list out the common birth injuries.
• define skull injuries.
• explain about caput succaedaneum.
• explain about cephalohematoma.
• discuss about scalp injuries.
• explain about skull fracture.
• describe about intracranial injuries.
• define soft tissue injuries.
• explain the injury to skin and
• explain about muscle trauma.
• discuss about visceral injuries.
Birth injuries are an impairment of the
infant’s body function or structure due to
adverse influences that occurred at birth.
Birth injuries may be severe enough to
cause neonatal deaths, still births or
number of morbidities.
• Skull injuries are those injuries that
impairs the structure of the skull and
functions of the underlying organs in the
• The most common site of birth injury is
head, because 96% babies are delivered
by cephalic presentation.
I. Caput Succedaneum
A caput succedaneum is an edematous
swelling which forms normally in the soft
tissues over the presenting part of the scalp
due to infiltration of serosanguinous fluid by
the pressure of girdle of contact.
Mechanism of Formation
• It occurs due to compression of tissues in
the girdle of contact which results
interference of the venous return and
lymphatic drainage from the unsupported
area of scalp that causes stagnation of
fluid and appearance of a swelling in the
• Reassure the mother that it disappears
spontaneously within 2-3 days after birth,
therefore no special care is needed.
• Advice the woman and family to avoid
applying pressure on caput and to return
for care if signs and symptoms worsen or
danger signs arise.
It is a subperiosteal collection of blood in
between the pericranium/periosteum and the
flat bone of the skull, usually unilateral and
over a parietal bone.
It is due to rupture of a small vein from the
skull that may be from :
• Friction between bones of maternal pelvis
and fetal skull as in cephalopelvic
disproportion or precipitate labour.
• Complicated or forceps delivery but may
also be seen following normal delivery and
may be associated with fracture of the
• The swelling is usually never at birth,
gradually develops a few hours after birth
and may persist for weeks.
• It is circumscribed, incompressible and
never crosses the suture line.
• The overlying scalp may show
• The condition may be confused with caput
succedaneum or meningocele.
Meningocele lies over a suture line or
fontanelle and there is impulse on crying.
• Rarely suppuration occurs.
• No active treatment is necessary unless it
becomes infected or complicated.
• A head CT should be obtained if neurological
symptoms are present.
• Vitamin K 1-2 mg IM should be given to
correct any co-existant coagulation defect.
• In case of infected hematoma, the
condition is treated with incision and
drainage, systematic antibiotics and
monitoring of hematocrit and bilirubin
• Advice the woman and family to avoid hot
compress by using oil and to return for
care if signs and symptoms worsen or
danger signs arise.
III. Scalp Injuries
Scalp injuries are those injuries that are
characterized by impairment in integrity of
the scalp tissue.
• Forceps delivery (tip of the blades)
• Incised wound inflicted during cesarean
• Scalp-electrode placement
• The wound should be dressed with an
antiseptic solution like 2%
• On occasion, the incised wound may
cause brisk hemorrhage and requires
IV. Skull Fracture
Fracture of the vault of the skull (frontal
bone or anterior part of the parietal bone) is
defined as distortion in the continuity of skull
bone which may be of fissure/linear or
• Effect of difficult forceps delivery or due to
wrong application of forceps.
• Projected sacral promontory of the flat
• Fissure fracture if uncomplicated is usually
• Depressed fracture may be associated
with neurological manifestations.
• Signs of associated complications such as
intracranial hemorrhage, raised
intracranial pressure, leakage of CSF.
• History of type of delivery, other injuries to
head during birth.
• Physical examination
• X-ray can confirm diagnosis.
• Linear or fissure fracture requires no
• Depressed fracture may require surgical
• If there is leakage of cerebral fluid through
nose, antibiotic therapy is indicated.
V. Intracranial Injuries
Intracranial injuries are the injuries to the
structures inside the cranium during the
process of the birth that is characterized by
abnormal neurological manifestations within
first 48 hours of life.
Types of Intracranial
1. Traumatic Intracranial
It is defined as hemorrhage inside cranium
due to trauma and it can be extradural or
Extradural hemorrhage: It is defined as
hemorrhage in space between cranial
bones and outer layer of duramater. It is
usually associated with fractured skull
Subdural hemorrhage: It is defined as
hemorrhage in the space between
arachnoid mater and inner layer of
Slight subdural hemorrhage may occur
following fracture of skull bone ,rupture of
the inferior sagittal sinus and rupture of
small veins leaving the cortex.
Massive subdural hemorrhage usually
results from tear of tentorium cerebelli
thereby opening up the straight sinus and
injury to superior sagittal sinus.
Causes of Traumatic ICH
• Excessive moulding in deflexed vertex.
• Rapid compression of the head during delivery of the
after-coming head of breech or in precipitate labor.
• Forcible forceps traction following wrong
application of the blades
Clinical Features of Traumatic ICH
• The hemorrhage may be fatal and the
baby is delivered stillborn or with severe
respiratory depression(APGAR score:0-3).
• Gradually, the features of cerebral irritation
• Hydrocephalus and mental retardation
may be a late sequelae.
2. Anoxic Intracranial Hemorrhage
• It is defined as hemorrhage inside the
cranium due to perinatal asphyxia, trauma
• It can be intraventricular, subarachnoid
Diagnosis of ICH
• Doppler ultrasonography can detect any
change in cerebral circulation.
• CT scan is useful to detect cortical
• Magnetic resonance imaging (MRI) is
used to evaluate any hypoxic ischemic
• CSF analysis: Elevated RBCs, WBCs and
Management of ICH
• The baby should be nursed in quiet ,warm
and well ventilated environment.
• Maintain cleanliness of the air passage,
suction immediately after birth to remove
the secretion that occludes the pharynx.
And supply oxygen as necessary.
• Frequently monitor the baby for skin
colour, vital signs and neurological
• Feeding by nasogastric tube is advisable,
fluid balance is to be maintained, if necessary
by parenteral route.
• Administer Vitamin K 1mg IM to prevent
further bleeding due to
• Prophylactic antibiotics are to be
• Anticonvulsants like phenobarbitone,
phenytoin and diazepam can be given for
• Surgical management:
Surgical evacuation of hematoma
• Subdural tapping and extradural tapping
• Open surgical evacuation
Rarely ventricular- peritoneal shunt and
subdural-peritoneal shunt is required.
Prognosis of ICH
Prognosis depends on the severity of ICH,
brain lesions, birth weight and gestational
age of the infant. ICH is having poor
prognosis with high mortality. Survivors may
develop mental retardation and neurological
2. Soft Tissue Injuries
Soft tissue injuries are the injuries to skin,
subcutaneous tissues, muscles and visceral
organs due to some degree of disproportion
between the presenting part and the
maternal pelvis during the birth process and
also from forcep blades, vacuum extractor
cups, scalp electrodes and scalpels.
A. Injury to Skin and Subcutaneous Tissue
Erythema and abrasions: Erythema and
abrasion during birth are superficial
reddening of the skin with impaired
integrity that usually are the result of the
application of forceps, discoloration is
same configuration as the instrument.
• Petechiae: Non raised pinpoint
hemorrhages( less than 3mm in diameter)
caused by a sudden increase and then
release of pressure during passage
through birth canal are called petechiae. It
may be seen on the chest, face and head.
• Ecchymosis: Ecchymosis are small
hemorrhagic areas( greater than 10 mm in
diameter) that may occur after traumatic or
• Subconjunctival (scleral) hemorrhage:
It is defined as the collection of blood
between the sclera and conjunctiva due to
rupture of capillaries in the sclera from
pressure on the fetal head during delivery
and the most common location is the
limbus of iris.
• Spontaneous recovery occurs within 2 to 3 days.
• Abrasions and lacerations should be kept clean
• Local application of antiseptic lotion can prevent
infection of the area.
• If there is any indication of infection, medical
advice should be sought and antibiotics may be
• Deeper lacerations may require closure with
• Explain to the mother to bring the baby back if she
sees signs of local infections.
B. Muscle Trauma
Injury to muscle are those trauma to
muscle that can occur when it is torn or
when its blood supply is disrupted.
Torticollis and sternomastoid hematoma
are common muscle trauma during birth.
Torticollis or twisted neck is defined as
damage and spasm of sternomastoid
muscle during the birth of the anterior
shoulder when the fetus presents by the
vertex or during rotation of the shoulders
when the fetus is being born by breech.
The head tilts towards the affected side
constantly and the chin points towards one
One shoulder may be higher in the body
than the other shoulder.
Neck muscle swelling right after the birth.
Muscle stretching exercises and neck
The uncomplicated swelling will resolve
within 7-10 days. If it doesn't resolve even
after 6 months of muscle stretching
exercise then muscle release surgery is
2. Sternomastoid hematoma
It is sternomastoid muscle injury caused by
rupture of the muscle fibers and blood
vessels, followed by a hematoma and
cicatrical contraction and may be associated
with difficult breech delivery or attempted
delivery following shoulder dystocia or
excessive lateral flexion of the neck even
during normal delivery .
It usually appears few days after birth and is
usually situated at the mid position of the
Small moderately dense or rather small
consistency of mass of with the size of walnut
There is transient torticollis.
Muscle stretching exercises.
Surgery is indicated if hematoma fails to get
C. Visceral Injuries
• Injuries to organs like liver, spleen ,kidney,
adrenals or lungs are called visceral
• Visceral organs are commonly injured
during breech delivery.
• The most common result of the injury is
hemorrhage. The hemorrhage may remain
concealed as subcapsular hematoma or
capsule may rupture with the blood flowing
into peritoneal cavity. Prognosis is usually
Pallor , tachycardia, shock and symptoms
according to the organs being injured.
• Correction of hypovolemia, anemia and
• Management may be needed to repair injured
viscera surgically .