FIGURE 96.23 A: Caput succedaneum involves the collection of serous fluid and often crosses the suture line B: Cephalohematoma involves the collection of blood and does not cross the suture line (Reprinted with permission from Ricci SS Essentials of Maternity, Newborn, and Women’s Health Nursing 2nd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2008.) Perinatal Birth Injuries to Head and Neck Goals of Treatment Trauma during labor and delivery can be related to maternal, fetal, and obstetric factors Traumatic deliveries occur as a result of prolonged labor, large fetus, prematurity, and abnormal presentation, and as a result of assisted deliveries, for example, vacuum extraction and forceps delivery Although the majority of these injuries are diagnosed prior to discharge from the newborn nursery and are selflimiting, some are serious and potentially lethal The primary goals of management should be to recognize benign injuries and differentiate them from those caused by nonaccidental trauma and manage any acute crises, for example, acute hemorrhagic shock CLINICAL PEARLS AND PITFALLS Cephalohematomas are subperiosteal hemorrhages that not cross the suture lines They should not be routinely incised or aspirated Subgaleal hemorrhage can lead to hypovolemic shock and can present days after birth Traumatic facial nerve palsy is unilateral and will usually recover spontaneously Neck masses in a neonate need evaluation for airway proximity and compression Cephalohematoma Cephalohematoma ( Fig 96.17 ) is a subperiosteal hemorrhage occurring commonly over a parietal bone, distinguished from a caput succedaneum by the fact that the swelling never crosses suture lines ( Fig 96.23 ) It occurs in 0.4% to 2.5% of live births due to rupture of blood vessels traversing the skull to the periosteum The overlying skin is intact with no petechiae or hemorrhage Cephalohematomas often feel fluctuant and may be bordered by elevated ridges of surrounding tissue, giving a false sensation of a skull depression They may be associated with intracranial hemorrhage and 5.4% are also associated with linear skull fractures Cephalohematomas often become prominent after the immediate newborn period when scalp edema subsides Most commonly, a cephalohematoma is unilateral, but it can be bilateral They resolve slowly over to weeks, possibly with calcification and the formation of a hard bump on the scalp that may be a source of great concern to parents Occasional complications resulting from the breakdown and resorption of large hematomas are hyperbilirubinemia or anemia No therapy is required for uncomplicated lesions Routine incision or aspiration of a cephalohematoma is contraindicated due to the high risk of introducing infection Rare complications of localized infection of cephalohematoma include osteomyelitis, meningitis, and venous sinus thrombosis Subgaleal Hemorrhage Subgaleal hemorrhage (SGH) refers to hemorrhage into the soft tissue space between the galea aponeurotica and the periosteum ( Fig 96.24 ) Rupture of emissary veins within this extensive space results in hemorrhage across the whole cranial vault from the orbital ridges to the nape of the neck This space can hold up to 260 mL of blood (which could exceed the entire blood volume of a fullterm baby) and thus bleeding here can result in hemorrhagic shock Newborns with SGH have a history of difficult instrumental delivery using vacuum suction or forceps (64% to 91%) Other predisposing factors include coagulopathies (hemophilia and Christmas disease), vitamin K deficiency, macrosomia, and dystocia FIGURE 96.24 Subgaleal hemorrhage and normal caput, cephalohematoma, and intracranial hemorrhage (Reprinted with permission from Gibbs RS, Karlan BY, Haney AF, et al Danforth’s Obstetrics and Gynecology 10th ed Philadelphia, PA: Lippincott Williams & Wilkins; 2008.) FIGURE 96.25 Subgaleal hematoma Discoloration and swelling extends across suture lines onto the neck, even onto the ear, causing protuberance of the pinna (Reprinted with permission from Fletcher MA Physical Diagnosis in Neonatology Philadelphia, PA: Lippincott–Raven Publishers; 1998:185.) SGH develops insidiously and may not be apparent until several hours or even days after delivery and until blood loss is extensive Discoloration of the scalp occurs very late because blood collects deep beneath the aponeurotic layer Pallor and weakness may be the only early symptoms of SGH and may be accompanied by a rising pulse rate and increasing respiratory rate Diffuse pitting swelling of the scalp or a fluctuating mass extending from the occiput posteriorly to ecchymotic orbits anteriorly and displacing the ears is suggestive ( Fig 96.25 ) Hypoperfusion and falling hematocrit in a child who has undergone a difficult extraction should alert the clinician to the possibility of SGH even in the absence of a fluctuant mass CT scan will demonstrate presence of blood in subgaleal space and rule out associated fractures or intracranial hemorrhages ( Fig 96.26 ) Patients with significant SGH may require emergency-packed RBC transfusion, and fresh frozen plasma if PTT is prolonged Concomitant intravenous administration of vitamin K can be performed Surgical drainage can be considered as a last resort SGH with shock has a high mortality rate of 22% to 25% Facial Nerve Palsy ... associated fractures or intracranial hemorrhages ( Fig 96.26 ) Patients with significant SGH may require emergency- packed RBC transfusion, and fresh frozen plasma if PTT is prolonged Concomitant intravenous