Birth injury is damage that occurs as a result of physical pressure during the birthing process, usually during transit through the birth canal.
- Many newborns have minor injuries during birth.
- Infrequently, nerves are damaged or bones are broken.
- Most injuries resolve without treatment.
A difficult delivery, with the risk of injury to the baby, may occur with extremely large fetuses. Doctors recommend cesarean delivery (C-section) when they estimate the baby weighs more than 11 pounds (more than 10 pounds when the mother has diabetes). Injury is also more likely when the fetus is lying in an abnormal position in the uterus before birth (see Figure: Position and Presentation of the Fetus).
Birth injuries are most commonly due to the natural forces of labor and delivery. In the past, when risks of cesarean delivery were high, doctors did difficult deliveries by pulling the fetus out using forceps (a surgical instrument with rounded edges that fit around the fetus’s head). However, bringing the fetus down from high in the birth canal with forceps had a high risk of causing birth injury. Today, forceps are used only in the final stages of delivery and rarely cause injury. Overall, the rate of birth injuries is much lower now than in previous decades because of improved prenatal assessment with ultrasonography, the limited use of forceps, and because doctors often do cesarean delivery if they foresee an increased risk of birth injury.
Head injury is the most common birth-related injury.
- Head molding is not an injury. Molding refers to the normal change in shape of the baby’s head that results from pressure on the head during delivery. In most births, the head is the first part to enter the birth canal. Because a fetus’s skull bones are not rigidly fixed in position, the head elongates as it is pushed through the birth canal, which allows the fetus to pass through more easily. Molding does not affect the brain and does not cause problems or require treatment. The head shape gradually becomes more rounded over several days.
- Swelling and bruising of the scalp is common but not serious and generally resolves within a few days.
- Scalp scratches can occur when instruments (such as monitor leads attached to the scalp, forceps, or vacuum extractors) are used during a vaginal delivery.
- Bleeding outside of the skull bones can lead to an accumulation of blood either above or below the thick fibrous covering (periosteum) of one of the skull bones.
- A cephalhematoma is blood accumulation below the periosteum. Cephalohematomas feel soft and can increase in size after birth. Cephalohematomas disappear on their own over weeks to months and almost never require any treatment. However, they should be evaluated by the pediatrician if they become red or start to drain liquid.
- A subgaleal hemorrhage is bleeding directly under the scalp above the periosteum covering the skull bones. Blood in this area can spread and is not confined to one area like a cephalohematoma. It can cause significant blood loss and shock, which may even require a blood transfusion. A subgaleal hemorrhage may result from the use of forceps or a vacuum extractor, or may result from a blood clotting problem.
- Fracture of one of the bones of the skull may occur before or during the birth process. Unless the skull fracture forms an indentation (depressed fracture), it generally heals rapidly without treatment.
Bleeding in and around the brain (intracranial hemorrhage) is caused by the rupture of blood vessels and may be caused by
- Birth injury
- Significant illness in the newborn that decreases delivery of blood or oxygen to the brain
- A blood clotting problem
Sometimes, intracranial hemorrhage occurs after a normal delivery in an otherwise well newborn. The cause of bleeding in these cases is unknown.
Bleeding in the brain is much more common among very premature infants. Newborns who have bleeding disorders (such as hemophilia) are also at increased risk of bleeding in the brain.
Most infants with bleeding do not have symptoms, whereas others can be sluggish (lethargic), feed poorly, and/or have seizures.
- Subarachnoid hemorrhage is bleeding below the innermost of the two membranes that cover the brain. This is the most common type of intracranial hemorrhage in newborns, usually occurring in full-term newborns. Newborns with a subarachnoid hemorrhage may occasionally have apnea (periods when they stop breathing), seizures, or lethargy during the first 2 to 3 days of life but usually ultimately do well.
- Subdural hemorrhage is bleeding between the outer and the inner layers of the brain covering. It is now much less common because of improved childbirth techniques. A subdural hemorrhage can put increased pressure on the surface of the brain. Newborns with a subdural hemorrhage may develop problems such as seizures.
- Epidural hematoma is bleeding between the outer layer (dura mater) of tissue covering the brain (meninges) and the skull. An epidural hematoma may be caused by a skull fracture. If the hematoma increases the pressure in the brain, the soft spots between skull bones (fontanelles) may bulge. Newborns with an epidural hematoma may have apnea or seizures.
- Intraventricular hemorrhage is bleeding into the normal fluid-filled spaces (ventricles) in the brain.
- Intraparenchymal hemorrhage occurs into the brain tissue itself. Intraventricular hemorrhages and intraparenchymal hemorrhages usually occur in very premature newborns and occur more typically as a result of an underdeveloped brain rather than a birth injury. Most of these hemorrhages do not cause symptoms, but large ones may cause apnea or a bluish gray discoloration to the skin, or the newborn’s entire body may suddenly stop functioning normally. Newborns who have large hemorrhages have a poor prognosis, but those with small hemorrhages usually survive and do well.
Newborns who have a hemorrhage may be admitted to a neonatal intensive care unit (NICU) for monitoring, supportive care (such as warmth), fluids given by vein (intravenously), and other treatments to maintain body function.