Cephalohematoma
Cephalohematoma refers to the accumulation of blood beneath the periosteum caused by rupture of blood vessels under the periosteum due to birth trauma. It is commonly associated with abnormal fetal positioning, cephalopelvic disproportion, vacuum extraction, or forceps-assisted delivery.
Clinical Features
The hematoma most frequently occurs on the parietal bone and is usually unilateral, although bilateral cases can occur. The hematoma gradually enlarges within hours to days after birth. As the periosteum is tightly adhered to the cranial sutures, the hematoma does not cross suture lines and has clear boundaries. It feels fluctuant under palpation, and the overlying skin typically appears normal in color. If caused by forceps or vacuum extraction, the skin may exhibit injuries or appear purplish-red. The hematoma begins to resolve through marginal calcification, forming a firm ring at its base that progresses toward the center. Complete resorption often requires 6–8 weeks, but large hematomas may take as long as 3–4 months. Increased destruction of red blood cells within the hematoma often leads to higher bilirubin levels, prolonging or worsening neonatal jaundice. Differential diagnoses include:
- Caput Succedaneum: Also known as birth swelling or scalp edema, this refers to subcutaneous edema caused by compression of the scalp during delivery, altered vascular permeability, and impaired lymphatic drainage. It typically occurs at the presenting part of the scalp, is present at birth, and has ill-defined margins. Unlike cephalohematoma, it is not restricted by suture lines, feels soft, pits on palpation, and resolves within 2–3 days. Occasionally, it coexists with a cephalohematoma, which becomes evident only after the caput succedaneum subsides.
- Subaponeurotic Hemorrhage: This involves bleeding into the loose connective tissue between the scalp's aponeurosis and the periosteum. As it is unrestricted by suture lines, the hemorrhage can cover a large area. The scalp appears diffusely swollen, fluctuant, and may cross suture lines. In severe cases, the subcutaneous tissues of the eyelids, postauricular region, and neck may exhibit purplish discoloration. It is often associated with marked hyperbilirubinemia, anemia, or even hypovolemic shock due to significant blood loss.
Management
Cephalohematomas without complications generally do not require treatment. For hematomas associated with hyperbilirubinemia reaching phototherapy thresholds, blue light phototherapy is administered. Secondary infections demand antibiotic therapy, and in severe cases, surgical incision and drainage may be necessary.
Clavicular Fracture
Clavicular fracture is the most common birth-related fracture and is associated with factors such as delivery method, fetal position during delivery, and a higher birth weight. Difficult deliveries, significant fetal repositioning, and macrosomia increase the likelihood of this injury. Most fractures occur at the outer third of the clavicle's midsection, where the clavicle is thinnest and lacks muscular attachment. When fetal shoulder delivery is obstructed, the S-shaped clavicle’s concave side may be compressed against the maternal pubic arch, resulting in fracture.
Most affected infants are asymptomatic, making the injury easy to overlook. Diagnosis is often incidental, discovered on chest X-rays performed for other reasons. Careful observation may reveal reduced movement of the infant's affected upper arm, crying during passive arm movements, localized soft tissue swelling, tenderness upon palpation, and asymmetry of the clavicles. The affected side may show a diminished or absent Moro reflex. X-ray imaging confirms the diagnosis. Greenstick fractures generally do not require treatment. Complete fractures may be managed by pediatric surgeons if needed. With growth and development, shoulder widening leads to spontaneous resolution of displacement and deformity. For support, a soft pad may be placed under the affected arm's axilla, with the arm secured to the chest using a bandage. Bone callus formation typically occurs within two weeks.
Brachial Plexus Paralysis
Brachial plexus paralysis is the most common peripheral nerve injury in neonates and often results from excessive traction on the brachial plexus during difficult deliveries, breech presentations, or shoulder dystocia. It is more frequent among full-term infants and macrosomic infants. Based on the site of injury, it is classified into three types:
- Upper Arm Type: Involves the fifth and sixth cervical nerve roots and is the most common. The affected arm hangs limp and is internally rotated, with an inability to abduct or externally rotate at the shoulder. At the elbow, the forearm is adducted, extended, and cannot supinate or flex. Wrist and finger joints are flexed, and the Moro reflex is absent on the affected side.
- Middle Arm Type: Involves the seventh cervical nerve root. Extension of the forearm, wrist, and hand is weakened or lost, while the triceps and thumb extensors exhibit partial paralysis. The Moro reflex is usually absent on the affected side.
- Lower Arm Type: Involves the eighth cervical and first thoracic nerve roots. Weakness affects wrist flexors and hand muscles, with a weak or absent grasp reflex. This type is rare. If sympathetic nerve fibers from the first thoracic root are damaged, Horner syndrome (characterized by miosis, ptosis, and narrowed palpebral fissure) may develop.
Magnetic resonance imaging (MRI) can determine the site of the lesion, while electromyography (EMG) and nerve conduction studies can aid diagnosis. The prognosis depends on the severity of the injury. Functional neurogenic paralysis often recovers completely within several weeks. Passive motion exercises and massage starting within the first week are beneficial. Most infants recover or show marked improvement within 2–3 months, but nerve tears may result in permanent paralysis.
Facial Nerve Paralysis
Facial nerve paralysis is a peripheral nerve injury often caused by compression of the fetal head against the maternal sacrum during descent through the birth canal or trauma from forceps-assisted delivery. The site of paralysis correlates closely with the fetal position and is usually unilateral. Affected infants exhibit an inability to close the eye or wrinkle the forehead on the paralyzed side. Facial asymmetry becomes more pronounced during crying, with a shallower nasolabial fold and deviation of the mouth toward the unaffected side.
Management focuses on protecting the cornea. Most cases result from compression of the facial nerve by swollen surrounding tissue and resolve spontaneously within the first month of life. Persistent facial nerve paralysis lasting beyond one year may indicate nerve rupture, in which case surgical nerve repair may be required.