# Birth Injuries in the Neonate

> Birth injuries for NEET-PG Paediatrics: caput, cephalhaematoma, subaponeurotic bleed, Erb palsy, facial palsy and clavicle fracture.

- Canonical URL: https://prepelephant.com/topics/neet-pg/paediatrics/birth-injuries
- Exam / course: NEET-PG · Subject: Paediatrics
- Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team
- First published: 2026-10-02
- Last updated: 2026-10-02
- How to cite: "Birth Injuries in the Neonate", PrepElephant, https://prepelephant.com/topics/neet-pg/paediatrics/birth-injuries

## Direct answer

Birth injuries cluster around three headlines: scalp swelling, nerve injury and fracture. Caput succedaneum is subcutaneous oedema that crosses suture lines and vanishes in days; cephalhaematoma is a subperiosteal bleed limited by sutures (usually parietal) that appears after hours, may calcify and may worsen jaundice; subaponeurotic (subgaleal) haemorrhage is the dangerous one — a fluctuant swelling crossing sutures that can hide a large fraction of a neonate's blood volume and presents with shock and coagulopathy, classically after vacuum delivery. Nerve injuries are Erb palsy of C5-C6 (waiter's tip posture), Klumpke palsy of C8-T1 (claw hand, possible Horner syndrome), and facial nerve palsy from forceps or sacral pressure. Clavicle fracture is the commonest birth-associated fracture and heals without intervention.

## What you must remember

- **Scalp layers from outside in:** skin and subcutaneous tissue (caput succedaneum), aponeurosis or galea (subaponeurotic haemorrhage), periosteum (cephalhaematoma) — the layer decides whether the swelling respects sutures.
- **Subaponeurotic haemorrhage:** crosses sutures, fluctuant, spreads to the neck and ears; associated with vacuum extraction, instrumental delivery and coagulopathy or haemorrhagic disease of the newborn; treat with vigorous volume and blood product support.
- **Cephalhaematoma:** parietal bone commonest, limited by sutures, no discolouration of overlying scalp, may calcify at the edge; up to a quarter of affected neonates need phototherapy for the bilirubin load and a skull fracture (usually linear) underlies a minority.
- **Erb palsy:** C5-C6 roots; arm adducted and internally rotated, forearm pronated and extended, wrist flexed — the waiter's tip; moro reflex absent on that side, grasp preserved.
- **Klumpke palsy:** C8-T1; claw hand from intrinsic weakness, ipsilateral Horner syndrome; phrenic nerve involvement (C3-C5) causes diaphragmatic palsy with paradoxical breathing on screening ultrasound or fluoroscopy.
- **Facial palsy:** unilateral, absent nasolabial fold, eye stays open, mouth pulled to the normal side on crying; most recover within weeks — differentiate it from congenital absence of the depressor anguli oris (asymmetric crying face), where forehead and eye movements stay normal.
- **Fractures:** clavicle (mid-third, greenstick, palpable crepitus, often picked up on day 2-3 as a lump or asymmetric Moro), humerus (brachial palsy association), femur; treat with gentle handling or a splint — union is rapid in neonates.

## A typical exam case walked through

A term boy delivered by vacuum for prolonged second stage has a boggy vertex swelling crossing suture lines and reaching the left ear; by twelve hours he is pale, tachycardic at 190 per minute, the haematocrit fallen from 58 to 34 per cent. The swelling crosses sutures, so it is subaponeurotic haemorrhage in its classic vacuum setting; the loose galeal space holds volumes that can exsanguinate a three-kilogram baby. Resuscitate with saline then packed cells, correct platelets and coagulation urgently, confirm vitamin K — and note that pressing the scalp is futile. Contrast a firm parietal swelling appearing on day two, stopping at the sagittal suture in a well baby: cephalhaematoma — reassure, monitor bilirubin, no aspiration (infection risk), review for a calcified rim at two to three weeks.

For the limping arm, the sequence matters: at birth document the posture (waiter's tip points to upper roots), test grasp (intact C7-T1 suggests pure Erb), check both eyes for miosis and ptosis (Klumpke plus Horner), and get a chest radiograph or ultrasound if breathing is anomalous (phrenic palsy). Physiotherapy starts day one; over nine in ten Erb palsies recover within the year, nerve repair reserved for absent biceps function by three to six months.

## Where students slip

Two comparisons decide most questions. First, caput versus cephalhaematoma: subcutaneous oedema cannot be constrained, periosteum is attached at sutures — "crosses sutures" is caput and subgaleal, "respects sutures" is cephalhaematoma. Second, brachial palsy levels: check the hand — a clawed hand with a small pupil upgrades Erb to Klumpke. A quieter trap is subaponeurotic bleeding misread as a big caput: a falling haematocrit, tachycardia and a swelling advancing hour by hour mean exsanguination.

## Frequently asked questions

### Which birth scalp swelling crosses suture lines?

Caput succedaneum and subaponeurotic haemorrhage both cross sutures; cephalhaematoma is subperiosteal and therefore confined by sutures, typically over the parietal bone.

### Why is subaponeurotic haemorrhage dangerous?

Blood dissects freely in the loose aponeurotic space, accumulating volumes that exceed the neonatal circulating reserve — shock, severe anaemia, coagulopathy and death, the feared complication of vacuum delivery.

### What posture characterises Erb palsy?

Adduction and internal rotation at the shoulder with extension and pronation of the forearm and flexed wrist — the waiter's tip — from upper trunk C5-C6 injury, with an absent Moro but preserved grasp.

### When does a clavicle birth fracture need specific treatment?

Almost never; analgesia, careful handling and parental reassurance suffice, with callus formation within two weeks — a sling or figure-of-eight bandage is reserved for displaced painful fractures.

### How do you distinguish facial nerve palsy from asymmetric crying face?

In facial palsy the whole hemiface including forehead and eye closure is weak on the same side; in congenital absence of the depressor anguli oris only the lower lip is flat while forehead and eye movements are normal.