Caput succedaneum

This is an oedematous swelling under the scalp and above the periosteum (Fig. 33.1 and Box 33.1). A ‘false’ caput succedaneum can also occur if a vacuum extractor cup is used; the resulting oedematous deformity is known as a ‘chignon’.

Fig. 33.1: Caput succedaneum.

The baby will usually experience some discomfort.

Other injury

When the face presents, it becomes congested and bruised, and the eyes and lips become oedematous. In a breech presentation the fetus will develop bruised and oedematous genitalia and buttocks.

Uncomplicated oedema and bruising usually resolve within a few days of life. However, if there is significant trauma during a vaginal breech birth, there can be serious complications such as:

Torticollis

Excessive traction or twisting can cause tearing to one of the sternomastoid muscles during the birth of the anterior shoulder of a fetus with a cephalic presentation, or during rotation of the shoulders when the fetus is being born by vaginal breech. A small lump can be felt on the affected sternomastoid muscle. It appears painless for the baby. The muscle length is shortened; therefore the neck is twisted on the affected side.

The management of torticollis involves stretching of the affected muscle, achieved under the guidance of a physiotherapist. The swelling will usually resolve over several weeks.

Facial nerve

Damage to the facial nerve usually results from its compression against the ramus of the mandible by a forceps blade, resulting in a unilateral facial palsy. The eyelid on the affected side remains open and the mouth is drawn over to the normal side. If the baby cannot form an effective seal on the breast or teat, there may be some initial feeding difficulties. Spontaneous resolution usually occurs within 7–10 days.

Brachial plexus

Trauma to this group of nerves usually results from excessive lateral flexion, rotation or traction of the head and neck during vaginal breech birth or when shoulder dystocia occurs. These injuries can be unilateral or bilateral. There are three main types of injury:

All types of brachial plexus trauma will require further investigations such as X-ray and ultrasound scanning (USS), and assessment of the joints. Passive movements of the joints and limb can then be initiated under the direction of a physiotherapist. At approximately 1 month of age, magnetic resonance imaging (MRI) can offer specific data on nerve damage.

Spontaneous recovery within days to weeks is expected for most babies. Follow-up is recommended. Babies with no functional recovery by 6 months of age may require surgical repair.

Cephalhaematoma

A cephalhaematoma is an effusion of blood under the periosteum that covers the skull bones (Fig. 33.2 and Box 33.2). During a vaginal birth, if there is friction between the fetal skull and the maternal pelvic bones, such as in cephalopelvic disproportion or precipitate labour, the periosteum is torn from the bone, causing bleeding underneath. Cephalhaematomas can also be caused during vacuum-assisted births. More than one bone may be affected, causing multiple cephalhaematomas to develop (Fig. 33.3).

Fig. 33.2: Cephalhaematoma.