Approach to birth injury (pediatrics): Clinical sciences

Birth injury refers to any physical harm to a newborn that occurs during labor or delivery. Many birth injuries result from prolonged labor or a precipitous delivery; a difficult or instrumental delivery; macrosomia; or fetal malpresentation. Common birth-related injuries include head injuries, nerve damage, bone fractures, and soft tissue injury.

When a pediatric patient presents with a chief concern suggesting a birth injury, first perform an ABCDE assessment to determine if they are stable or unstable. If unstable, stabilize their airway, breathing, and circulation, and consider intubation for ineffective respirations or apnea. Next, obtain intravenous access or perform an umbilical venous catheterization, and consider starting IV fluids or transfusing packed red blood cells. Then, place your patient on continuous vital sign monitoring, and provide supplemental oxygen if needed.

Once you’ve initiated acute management, perform a focused history and physical examination. History might reveal risk factors such as preterm delivery, prolonged labor, or instrumental delivery. As far as the physical exam goes, you’ll often notice an altered level of consciousness and tachycardia. These findings should make you consider the possibility of a hemorrhage. Proceed with your evaluation by assessing the scalp for progressive edema.

If progressive edema is present, consider a subgaleal hemorrhage. In this case, birth history often reveals that the delivery required vacuum assistance. The physical exam will reveal a boggy scalp with edema that crosses the suture lines, that manifests in the first few hours after birth, and moves posteriorly to the level of the ears, often pushing the ears outward and extending to the nape of the neck. The occipital-frontal head circumference will also be increased.

Now, due to the potential for massive blood loss, in addition to tachycardia, these patients often develop tachypnea and hypotension, as well as pallor and eventually jaundice. To confirm the diagnosis, obtain a CBC and head ultrasound. If the hemoglobin and hematocrit are low, and imaging reveals bleeding between the periosteum and the aponeurosis of the scalp, diagnose subgaleal hemorrhage.

On the other hand, if there is no progressive scalp edema, consider the possibility of an intracranial hemorrhage. In this case, history often reveals risk factors like prolonged labor and instrumental delivery; and the neonate may present with seizures, apnea, or irritability.

Meanwhile, the physical examination might reveal a concavity of the skull that resembles an indented ping-pong ball, which is highly suggestive of a depressed skull fracture. Less commonly, there might be signs suggesting a basilar fracture, like bloody drainage from the nose or ears. With these findings, your next step is to obtain a head ultrasound or CT scan to look for an intracranial hemorrhage.

Now let’s look at imaging results. If ultrasound or CT reveals a hyperdense crescent-shaped lesion in the subdural space, diagnose subdural hematoma, which is the most common intracranial injury seen in newborns.

Here’s a clinical pearl! Keep in mind that any subdural hematoma beyond the immediate newborn period should make you suspect abusive head trauma!

However, if imaging identifies a hyperdense layering along the convexities of the cerebral cortex, diagnose subarachnoid hemorrhage. Although infants with subarachnoid hemorrhage often have no clinical symptoms, in rare cases, those with an underlying arteriovenous malformation can develop a catastrophic intracranial hemorrhage.

Here’s another clinical pearl! Other types of intracranial hemorrhage that can occur in newborns include epidural hematoma, retinal hemorrhage, and intraventricular hemorrhage. However, intraventricular hemorrhage is more closely associated with prematurity and very low birthweight, and it’s not usually caused by birth trauma.

Okay, now let’s return to the ABCDE assessment and discuss some stable patients. Begin with a focused history and physical examination. History will often reveal risk factors for birth injury, such as prolonged labor, instrumental delivery, malpresentation, macrosomia, shoulder dystocia, and preterm delivery.

The physical exam might demonstrate scalp edema or focal neurologic deficits, while the skin exam may reveal ecchymoses or abrasions. Also look for signs suggesting a fracture, such as palpable crepitus, deformity, or swelling.

First, let’s assess the scalp for the presence of edema. If scalp edema is present, assess its relationship to the suture lines.

Let’s look at scalp edema that does not cross the suture lines. If you see a well-circumscribed fluctuant area of ecchymosis and edema that develops over the first few hours of life, diagnose cephalohematoma, which is caused when blood vessels beneath the periosteum rupture. The bleeding doesn’t cross suture lines since the bleeding is confined to a single cranial plate.

Now let’s look at scalp edema that crosses the suture lines. In this case, you’ll usually see diffuse, fluctuant ecchymosis and edema at the time of delivery. This indicates caput succedaneum, where edema, composed of blood and serum, accumulates above the periosteum, just below the skin.

Here’s another clinical pearl! While caput succedaneum and subgaleal hemorrhage both present with scalp edema that crosses suture lines, newborns with caput succedaneum are generally well-appearing and hemodynamically stable. In contrast, those with subgaleal hemorrhage lose a substantial amount of blood into the subgaleal space, which can lead to hypovolemic shock. Due to the high mortality associated with this condition, early recognition is crucial!

Now, once your scalp assessment is complete, move on to assess for focal nerve deficits.