Birth Trauma

Introduction: Birth trauma is any injury to a neonate that occurs during birth or after delivery. It has been reported to occur in 29 per 1000 births in the Unites States (5). Scalp injuries and clavicular fractures are the most common types of birth trauma (3). Neonatal fractures are uncommon and are typically associated with difficult deliveries (2). Risk factors include prolonged second stage of labor, instrumented delivery, fetal macrosomia, and malpresentation (5). We present a neonate with no known risk factors found to have a depressed occipital skull fracture and small subdural and epidural hemorrhages.

Case Description: A full-term male was born via spontaneous vaginal delivery to a 29-year-old G4P3 mother with a pregnancy complicated by oligohydramnios. He was delivered quickly without use of forceps or vacuum. At birth, he required respiratory support with positive pressure ventilation (PPV) weaned to continuous positive airway pressure (CPAP) and room air within 15 minutes. Apgar’s at 1, 5, and 10 minutes were 5, 6, and 7 respectively. Head circumference was 34.9cm (89th percentile) and birth weight was 3.45kg (88th percentile). He was transferred to the newborn nursery for routine care.

On initial exam, he had swelling along the right posterior occiput crossing suture lines with crepitus upon palpation. Bruising was also noted along the thoracic spinous processes. Neurologic exam was normal. A skull x-ray showed depressed occipital comminuted skull fracture.

Neurosurgery was consulted and the infant was transferred to the neonatal intensive care unit at a nearby tertiary children’s hospital for neurosurgical evaluation and monitoring. CT scan of the head without contrast showed a depressed os incus fracture with small subdural and epidural hemorrhages. MRI demonstrated similar findings. He was given a levetiracetam 40mg/kg loading dose for seizure prophylaxis. EEG and lab workup were normal. He remained clinically well without seizures. He was discharged home on day of life 3 with neurosurgery follow up.

Discussion: Cranial birth injuries like depressed skull fracture (DSF) occurs in an estimated 3.7 per 100,000 deliveries and can occur spontaneously or secondary to use forceps or a vacuum. Spontaneous DSF is thought to occur secondary to pressure on the fetal skull from maternal structures such as the sacral promontory or symphysis pubis. Infants with spontaneous DSF typically have an uncomplicated course, while cases secondary to instrumentation are often associated with intracranial injuries. Initial workup includes x-ray of the skull followed by CT to further evaluate for intracranial injury. Even with the presence of intracranial injury, prognosis is generally good with little long-term morbidity (1).

Conclusion: While birth trauma more commonly occurs secondary to identifiable risk factors, it may occur spontaneously. Pediatricians must be aware of potential birth injuries and perform thorough physical exams to detect abnormalities and manage appropriately.