KEY TAKEAWAYS
- The three scalp swellings are a classic board triple — and one is dangerous:
- Caput succedaneum: soft-tissue edema, crosses suture lines, benign.
- Cephalohematoma: subperiosteal blood, does NOT cross sutures, benign but can cause jaundice/anemia.
- Subgaleal hemorrhage: blood in the subaponeurotic space, crosses sutures, not limited by them → can cause massive blood loss and shock. This is the emergency.
- Subgaleal hemorrhage is associated with vacuum-assisted delivery — monitor for a boggy, spreading, shifting swelling and signs of hypovolemia; treat with volume/blood and coagulation support.
- Erb palsy (C5–C6) is the classic brachial plexus injury — "waiter's tip" posture; most recover spontaneously with physiotherapy; refer if no recovery by ~3–6 months (possible nerve avulsion).
- Clavicle fracture is the commonest skeletal birth injury — often an incidental crepitus/asymmetric Moro; heals spontaneously.
- Facial nerve palsy (often forceps-related) usually resolves spontaneously; protect the eye.
- Never aspirate a cephalohematoma (infection risk).
1. Clinical Overview
Clinical Overview
Birth injury is structural or functional damage to the newborn from the mechanical forces of labor and delivery. Many injuries are unavoidable even with excellent care, and the great majority are benign and self-limited. The clinical priorities are: recognize the few dangerous injuries (above all, subgaleal hemorrhage, which can exsanguinate an infant), reassure and monitor the benign ones, and arrange appropriate follow-up for nerve injuries that may need rehabilitation or, occasionally, surgery. Recognizable risk factors — macrosomia, malpresentation, instrumental delivery, shoulder dystocia, and prolonged or precipitous labor — should raise vigilance.
2. Definitions
| Term | Meaning |
|---|
| Caput succedaneum | Diffuse edema of the scalp soft tissue; crosses suture lines; present at birth. |
| Cephalohematoma | Subperiosteal blood collection; bounded by sutures (doesn't cross); appears over hours–days. |
| Subgaleal hemorrhage | Blood in the loose space beneath the galea aponeurotica; crosses sutures; can cause massive blood loss. |
| Erb palsy | Upper brachial plexus (C5–C6) injury → "waiter's tip." |
| Klumpke palsy | Lower brachial plexus (C8–T1) injury → hand/wrist weakness ± Horner syndrome. |
3. Risk Factors
Risk Factors
Macrosomia, malpresentation (breech), instrumental delivery (forceps/vacuum), shoulder dystocia, prolonged or precipitous labor, cephalopelvic disproportion, and prematurity.
4. Scalp & Cranial Injuries
Scalp & Cranial Injuries
Caput succedaneum (benign)
- Diffuse, boggy scalp edema that crosses suture lines; present at birth; from pressure/vacuum. Resolves in days. No treatment.
Cephalohematoma (usually benign)
- Subperiosteal blood collection, does NOT cross suture lines (periosteum is adherent at sutures); usually parietal, appears hours–days after birth.
- May cause hyperbilirubinemia (breakdown of extravasated blood) and mild anemia; occasionally overlies a linear skull fracture; may calcify.
- Do NOT aspirate/incise (infection risk); resolves over weeks–months.
Subgaleal hemorrhage (EMERGENCY)
- Blood in the subaponeurotic space from ruptured emissary veins; the space is large and not limited by sutures, so bleeding can be massive.
- Associated with vacuum-assisted delivery.
- Signs: a boggy, fluctuant swelling that crosses sutures, shifts with position, may extend to the neck/around the eyes; increasing head circumference; and signs of hypovolemia (pallor, tachycardia, hypotension, shock) and coagulopathy.
- Management (urgent): close monitoring (serial head circumference, vitals, hematocrit), volume resuscitation and blood transfusion, and correction of coagulopathy; NICU care. High mortality if unrecognized.
Skull fracture
- Linear (usually asymptomatic) or depressed ("ping-pong") (forceps/bony prominence); may be associated with intracranial hemorrhage — image and monitor as indicated.
| Feature (Baylor Table 13-1) | Caput succedaneum | Cephalohaematoma | Subgaleal haemorrhage |
|---|
| Relation to sutures | Crosses | Does not cross | Crosses; most prominent in dependent areas |
| Feel | Vaguely demarcated — "wet sponge" | Firm with distinct margins — "hard-boiled egg" | Diffuse, shifts to the dependent side — "water-bed" |
| Timing | At birth | Hours to days after birth | At birth or hours later |
| Blood volume | None to very little | 10–40 mL | More than 40 mL |
Subgaleal haemorrhage — the numbers that make it an emergency (Baylor Ed. 33)
- About 59 per 10,000 vacuum extractions against 4 per 10,000 spontaneous vaginal deliveries. It also follows caesarean section and prolonged pushing. Risk rises with a failed vacuum, a "rocking" motion of the cup, and multiple pulls.
- The space runs from the orbital ridges to the nuchal ridge and laterally to the temporal fascia and can hold the infant's entire blood volume — mortality 11–15%. Look for ears displaced anteriorly, periorbital swelling and ecchymosis, and a "helmet" appearance.
- Head circumference rises about 1 cm for every 40 mL of blood in the subgaleal space — measure it hourly until stable. A falling haematocrit is a late sign; do not wait for it.
- Treatment: NICU monitoring with frequent vital signs, and volume resuscitation with saline, packed red cells and fresh frozen plasma for ongoing bleeding and coagulopathy. MRI or CT — or ultrasound in experienced hands — separates it from the other swellings. Neurosurgical consultation if the infant keeps worsening despite aggressive resuscitation. Intracranial bleeds and skull fractures often accompany it; arrange long-term neurological follow-up.
The other swellings, intracranial bleeding, and falls
- Cephalohaematoma occurs in 1–2% of deliveries regardless of mode, more often with prolonged labour and instrumental delivery, and usually resorbs between 2 weeks and 3 months. It can be complicated by skull fracture (rarely), hyperbilirubinaemia, hyperkalaemia, infection or anaemia. Incision or aspiration is contraindicated — the clot is tamponading the bleed. Calcification can leave a bony swelling for months, occasionally years.
- Chignon — the artificial caput under a vacuum cup — resolves within 12–18 hours and is smaller with soft cups.
- A newborn who falls or is dropped needs immediate examination by a physician or advanced practice provider and a non-contrast head CT — intracranial haemorrhage can be present with no external trauma or skull fracture — with extended NICU monitoring considered on the findings. Most in-hospital falls are unwitnessed, at night or early morning, during co-sleeping or when a tired parent stands up holding the baby.
5. Nerve Injuries
Nerve Injuries
Brachial plexus injury
- Mechanism: lateral neck traction (shoulder dystocia, breech, macrosomia).
- Erb palsy (C5–C6, upper trunk) — most common: arm adducted, internally rotated, forearm pronated, wrist flexed ("waiter's tip"); absent biceps reflex, asymmetric Moro.
- Klumpke palsy (C8–T1, lower) — less common: hand/wrist weakness ("claw hand"); may include Horner syndrome (ptosis, miosis) with T1 involvement.
- Phrenic nerve (C3–C5) may be involved → diaphragmatic paralysis / respiratory distress.
- Management: most recover spontaneously over weeks–months; gentle physiotherapy/range-of-motion to prevent contractures; refer to specialist/surgery if no recovery by ~3–6 months (concern for root avulsion).
Facial nerve palsy
- Often from forceps or pressure; unilateral facial weakness (asymmetric crying, incomplete eye closure on the affected side).
- Usually resolves spontaneously; protect the eye (lubrication) meanwhile. Distinguish from congenital causes (e.g., Möbius, asymmetric crying facies).
Nerve injuries — numbers and practical details (Baylor Ed. 33)
- Brachial plexus injury occurs in 0.3–2 per 1000 live births (roots C5–T1). 90–95% need only physical therapy — the goal is preventing contractures while the plexus recovers. Use partial immobilization and positioning for the first 2 weeks, when traumatic neuritis is painful. Start OT/PT in hospital, and refer on discharge to a paediatric orthopaedist experienced with plexus injuries.
- Klumpke palsy may also bring dependent oedema, cyanosis and wasting of the hand, ulnar-side sensory loss, and — with T1 sympathetic involvement — Horner syndrome with delayed iris pigmentation. Rarely the whole arm is flaccid, areflexic and anaesthetic from shoulder to fingers.
- Facial palsy — peripheral vs central: in a peripheral (compression) palsy the forehead is smooth and the eye stays open on the affected side. In a central palsy from contralateral CNS injury, only the lower half to two-thirds of the face is involved. In both, the mouth pulls to the normal side on crying and the nasolabial fold is flattened. Compression palsies usually resolve within days; artificial tears protect the cornea.
- Phrenic nerve injury is rarely isolated — it usually accompanies an ipsilateral brachial plexus injury. The chest film shows a raised hemidiaphragm. Fluoroscopy shows the affected side rising and the mediastinum shifting to the normal side on inspiration. Respiratory distress may need ventilation. Most recover spontaneously; phrenic nerve stimulation can help when the palsy follows surgery.
6. Skeletal & Soft-Tissue Injuries
Skeletal & Soft-Tissue Injuries
- Clavicle fracture — the most common skeletal birth injury; shoulder dystocia/macrosomia; often asymptomatic or with crepitus, decreased arm movement, asymmetric Moro; heals spontaneously (~7–10 days); conservative (gentle handling, occasionally immobilization).
- Humerus/femur fracture (uncommon).
- Sternocleidomastoid injury → torticollis (head tilt, SCM mass) — physiotherapy.
- Soft tissue: localized bruising/petechiae (from delivery — localized, vs generalized/progressive in a bleeding disorder), subconjunctival hemorrhage, subcutaneous fat necrosis.
Instrument marks, lacerations and scalp electrodes (Baylor Ed. 33)
- Forceps marks can hide nerve, soft-tissue or bony injury. Periorbital bruising → ophthalmology to look for hyphema or vitreous haemorrhage. Ear injury → ENT, because it may accompany inner-ear haemorrhage and temporal bone fracture.
- Caesarean lacerations most often involve the scalp, buttocks and thighs. Close superficial wounds with adhesive strips and suture deeper or bleeding ones. Consider plastic surgery for the face and ophthalmology for eye lacerations. Keep the wound clean and notify obstetrics.
- Fetal scalp electrode sites can show lacerations, haematomas or abrasions, and usually need only local care. If an abscess develops, evaluate for sepsis.
Fractures — how to immobilize and when to escalate (Baylor Ed. 33)
- Clavicle — fractured in 0.2–16% of vaginal deliveries, usually unilateral and greenstick, and most have minimal findings in the first days. An X-ray can document that the fracture was present at birth. For pain, pin the sleeve to the chest with the elbow flexed at 90°; stop once callus forms and the pain settles, usually at 7–10 days.
- Humerus — the second commonest, usually diaphyseal; a complete fracture gives an immobile arm with an absent Moro reflex, and a greenstick may go unnoticed until callus appears. Immobilize in adduction for 2–4 weeks, hand on hip, with a triangular splint or Velpeau bandage. Union is usually by 3 weeks; arrange orthopaedic follow-up.
- Femur — uncommon, mid-shaft and transverse, with deformity, swelling, pain and an immobile leg. Treat with a spica cast or simple splint for up to 3–4 weeks (traction-suspension for some shaft fractures) and involve orthopaedics.
- Skull — uncommon, because the skull is compliant and the sutures open. Linear fractures heal over months; a leptomeningeal cyst rarely follows. Depressed fractures (often after forceps) need a CT for intracranial injury, and neurosurgery when the depression is more than 1 cm or there is an intracranial lesion — these usually need surgery.
7. Diagnostic Approach
Diagnostic Approach
- Examination distinguishes the scalp swellings (cross sutures? → caput/subgaleal vs cephalohematoma) and identifies nerve/skeletal injury (Moro symmetry, arm posture, crepitus, facial symmetry).
- Serial head circumference, vitals, and hematocrit if subgaleal hemorrhage is suspected.
- Imaging: ultrasound/X-ray for clavicle; skull imaging for suspected fracture/intracranial hemorrhage; CT/MRI for significant head trauma.
- Bilirubin monitoring with cephalohematoma/bruising.
- Coagulation studies if bleeding seems excessive.
8. Management (principles)
Management (principles)
- Reassure and observe benign injuries (caput, cephalohematoma, clavicle fracture, most facial palsies).
- Treat subgaleal hemorrhage as an emergency (monitor, transfuse, correct coagulopathy).
- Rehabilitate nerve injuries (physiotherapy) and refer persistent brachial plexus palsy.
- Monitor for jaundice (cephalohematoma/bruising) and treat per nomogram.
- Protect the eye in facial nerve palsy.
9. Monitoring
Monitoring
- Subgaleal: serial head circumference, vitals, hematocrit, coagulation until stable.
- Cephalohematoma/bruising: bilirubin trend.
- Nerve injuries: serial neuro exam and functional recovery; developmental/rehab follow-up.
- Skeletal: healing and function.
10. Complications
Complications
- Subgaleal hemorrhage: hypovolemic shock, DIC, death.
- Cephalohematoma: hyperbilirubinemia, anemia, calcification, rare underlying fracture.
- Brachial plexus: persistent weakness/contracture, root avulsion; phrenic palsy → respiratory compromise.
- Skull fracture: intracranial hemorrhage.
- Facial palsy: corneal exposure if the eye isn't protected.
11. Safety Warnings
Safety Warnings
- ⚠️ Subgaleal hemorrhage can exsanguinate a newborn — after vacuum delivery, watch for a spreading, boggy, shifting scalp swelling and signs of shock; monitor and transfuse.
- ⚠️ "Crosses sutures" distinguishes the swellings — caput/subgaleal cross; cephalohematoma doesn't.
- ⚠️ Never aspirate a cephalohematoma (infection).
- ⚠️ Refer persistent brachial plexus palsy (~3–6 months) — don't assume all recover.
- ⚠️ Protect the eye in facial nerve palsy.
- ⚠️ Consider phrenic nerve injury (respiratory distress) with brachial plexus palsy.
12. Common Mistakes
Common Mistakes
- Mistaking subgaleal hemorrhage for a benign swelling and missing evolving shock.
- Aspirating a cephalohematoma.
- Failing to monitor bilirubin with cephalohematoma/bruising.
- Assuming all brachial plexus palsies recover without follow-up.
- Missing Horner syndrome / phrenic involvement in plexus injury.
- Neglecting eye protection in facial palsy.
- Confusing localized delivery petechiae with a bleeding disorder (or vice versa).
13. Clinical Pearls
Clinical Pearls
- 💡 Does it cross the sutures? Caput and subgaleal yes; cephalohematoma no.
- 💡 Vacuum + boggy shifting scalp + shock = subgaleal hemorrhage — act fast.
- 💡 "Waiter's tip" = Erb (C5–C6); claw hand ± Horner = Klumpke (C8–T1).
- 💡 Clavicle fracture heals itself — gentle handling, done.
- 💡 Cephalohematoma makes bilirubin — watch for jaundice.
- 💡 No recovery by a few months? Refer the plexus — think avulsion.
14. Summary Table
Summary Table
| Injury | Key feature | Danger | Management |
|---|
| Caput succedaneum | Edema, crosses sutures, present at birth | Benign | Observe |
| Cephalohematoma | Subperiosteal, no cross sutures, hours–days | Jaundice/anemia; don't aspirate | Observe; monitor bilirubin |
| Subgaleal hemorrhage | Boggy, crosses sutures, shifts; ↑HC; shock | Massive blood loss — emergency | Monitor, transfuse, correct coags |
| Erb palsy (C5–C6) | "Waiter's tip," asymmetric Moro | Contracture/avulsion | Physiotherapy; refer by ~3–6 mo |
| Klumpke (C8–T1) | Claw hand ± Horner | Avulsion | Physiotherapy; refer |
| Facial nerve palsy | Unilateral facial weakness (forceps) | Corneal exposure | Eye protection; usually resolves |
| Clavicle fracture | Crepitus, asymmetric Moro | Minimal | Conservative; heals ~7–10 d |
15. Step-by-Step Bedside Algorithm
NEWBORN after delivery (esp. macrosomia, instrumental, shoulder dystocia, breech)
│
▼
SCALP SWELLING? → does it CROSS suture lines?
├─ Crosses + soft, present at birth → CAPUT (benign, observe)
├─ Does NOT cross (bounded by sutures), appears hours–days → CEPHALOHEMATOMA
│ → observe; DON'T aspirate; monitor BILIRUBIN/anemia
└─ Crosses + boggy + SHIFTS + ↑ head circumference (esp. after VACUUM) → SUBGALEAL HEMORRHAGE
→ EMERGENCY: serial HC/vitals/hematocrit → VOLUME + BLOOD TRANSFUSION +
correct coagulopathy → NICU
│
▼
ARM MOVEMENT / MORO asymmetric?
├─ "Waiter's tip," absent biceps reflex → ERB palsy (C5–C6)
├─ Claw hand ± Horner → KLUMPKE (C8–T1)
│ → physiotherapy/ROM; check phrenic (respiratory distress); refer if no recovery ~3–6 mo
└─ Crepitus over clavicle → CLAVICLE FRACTURE → conservative, heals ~7–10 d
│
▼
FACIAL asymmetry (forceps)? → FACIAL NERVE PALSY → protect eye; usually resolves
│
▼
Bruising/petechiae: localized (delivery) vs generalized/progressive (bleeding disorder → workup)
Monitor bilirubin where relevant; arrange rehab/follow-up for nerve injuries
16. References to Verify
Confirm each against the primary source before clinical or published use.
- 1.Overview: Birth Injuries in Neonates. Pediatrics in Review. 2016;37(11):451. (AAP) (Verify classification/management.)
- 2.Subgaleal hemorrhage: references on vacuum-associated subgaleal hemorrhage, monitoring, and transfusion. (Verify.)
- 3.Brachial plexus: obstetric brachial plexus injury natural history and referral timing (~3–6 months). (Verify.)
- 4.Cephalohematoma vs caput vs subgaleal: standard distinguishing features (suture lines). (Verify.)
- 5.Facial nerve palsy / clavicle fracture: management references. (Verify.)