Neonatal soft tissue injuries
Soft tissue injuries of the scalp in infants are mostly caused by shearing forces during vacuum or forceps delivery.
Epidemiology & Risk Factors
- Operative vaginal delivery: Vacuum extraction (highest risk for subgaleal hemorrhage), forceps delivery.
- Fetal factors: Macrosomia / Large for gestational age (LGA), infant of diabetic mother (IDM), abnormal presentation (face, brow, breech), shoulder dystocia.
- Maternal/Labor factors: Primiparity, prolonged second stage of labor, precipitous delivery, cephalopelvic disproportion (CPD).
- Iatrogenic: Fetal scalp electrode (FSE) placement, intrauterine pressure catheter (IUPC).
Clinical Features
- Caput Succedaneum:
- Subcutaneous serosanguinous fluid accumulation superficial to the periosteum.
- Crosses suture lines, soft, pitting, poorly demarcated margins.
- Present at delivery; resolves spontaneously within 2–3 days.
- Cephalohematoma:
- Subperiosteal hemorrhage (rupture of subperiosteal blood vessels).
- Does NOT cross suture lines (limited by cranial sutures/periosteum).
- Firm, fluctuant with well-demarcated edges; may enlarge over hours to days.
- Resolves over weeks to months; may undergo central liquefaction or peripheral calcification (“eggshell” rim).
- Subgaleal Hemorrhage (Emergent): c
- Rupture of emissary veins leading to blood accumulation in the loose connective tissue between the epicranial aponeurosis (galea) and periosteum.
- Crosses suture lines and cranial ridges; diffuse, fluctuant, progressive swelling spreading across the entire scalp, neck, and behind ears (ecchymosis).
- Systemic signs: Tachycardia, hypotension, pallor, rapid drop in hematocrit, lethargy, expanding head circumference (1 cm increase ≈ 30–40 mL of blood loss).
- Congenital Muscular Torticollis (Fibromatosis Colli):
- SCM injury/hematoma with fibrous contracture due to intrauterine crowding or birth trauma.
- Palpable, nontender, mobile SCM mass/olive noted at 2–4 weeks of life.
- Head tilted toward affected SCM and chin rotated away to the contralateral side.
- Subcutaneous Fat Necrosis:
- Firm, non-tender, violaceous/erythematous nodules or plaques on the back, buttocks, cheeks, or shoulders.
- Occurs days-to-weeks after birth trauma, asphyxia, or therapeutic hypothermia.